District-Level Activities for Improving Quality Health Services PDF

District-level activities for improving quality health services Before starting this section, review the introductory and national level sections. This section should also be read with the facility- level section. Introduction The health district is an essential...

District-level activities for improving quality health services Before starting this section, review the introductory and national level sections. This section should also be read with the facility- level section. Introduction The health district is an essential element of a national health system. Interpretation of the term ‘district’ varies depending on country and local contexts. For this planning guide, the term refers to a clearly defined administrative area, where there are local government and administrative structures that take over many of the Box 6. responsibilities from the national government and where there is a general hospital for referral. Activities at the Who is taking action at the district district level influence implementation of quality health level? services at the facility and community levels, and should be carefully considered in national-level strategic direction District management leadership on quality. The district level is the key interface between and teams facilitate and ensure that health facilities and higher levels, and is responsible for quality of care activities is prioritized, operationalizing national strategic direction on quality. It supported and delivered at the is at this level that planning, implementation, monitoring point of care. Engagement of other and supervision of activities to improve quality of health stakeholders at the district level services in facilities and communities are carried out. – including health providers, civil society and communities, academic and professional associations, The focus of this section cooperating partners and other decentralized services such as WASH This section describes activities that staff at the district and housing authorities – is critical level (particularly district health leadership and teams) for quality health services. Further, can do to improve quality of health services. Activities stakeholders involved in the national at the district level should be coordinated with national health sector planning process should and facility-level authorities to ensure coherence and be attentive to activities, challenges strengthening in the delivery of quality health services and competences at the district level. designed to meet the needs of people. Quality health services: a planning guide 23 DISTRICT-LEVEL START-UP ACTIVITIES This section describes a range of activities to improve quality of health services that can be initiated more readily by district-level actors. These activities are clustered around district commitment, structures and operational planning, and orientation of facilities. DISTRICT COMMITMENT TO NATIONAL QUALITY GOALS AND PRIORITIES The district level should commit to deliver on national quality goals and priorities by developing, aligning and implementing operational plans with clear actions for district-level actors, that aim to improve the quality of health services delivered at the subnational level. Where there is no clearly defined national strategic direction on quality, the district level can demonstrate through implementing, sharing results and advocating for quality at all levels. Key activities ƒ Internalize and commit to the district aims and targets in support of the overall national goals and priorities for quality health services. ƒ Commit structures and resources (both financial and human) to support the needs of health facilities. ƒ Commit to creating an enabling environment for QI, reflecting on the elements of a culture of quality (see Box 4). ƒ Commit to and facilitate documentation and sharing of learning within and across districts, and with the national level. ƒ Facilitate sharing of national strategic goals and priorities with facilities and relevant programmes. ƒ Ensure national quality strategic direction is informed by health service realities encountered at the district level. ƒ Ensure effective dialogue with the national level, facilities and communities in planning and coordination. 24 Quality health services: a planning guide  DISTRICT QUALITY STRUCTURES AND OPERATIONAL PLAN District-level structures and operational plans play an important role in setting out implementation of quality health service activities. District-level structures help clarify governance and implementation arrangements for quality. Operational plans at the subnational level help to identify and prioritize tasks, timelines, responsible stakeholders, resource requirements and measurement/monitoring parameters. Understanding current quality interventions being applied at the district level and adapting any existing national quality interventions is critical for operational planning. Key activities ƒ Review and map existing quality health service activities, partners and resources. ƒ Map existing quality interventions applied within the district and identify whether a set of national- level quality interventions exists. ƒ Examine district-level quality health service data to set priorities and guide the process of selecting aims. ƒ Identify district aims in support of national level goals and priorities. ƒ Establish appropriate structures and mechanisms to support quality of care activities at the facilities level. ƒ Build capacity for QI support among district staff. ƒ Consult with and introduce the related quality programme to district, facility and community stakeholders. ƒ Work with facilities and communities in identifying improvement aims to support district-level quality goals and priorities (aligned with equivalent national goals and priorities). ƒ Develop and share district operational plan, outlining activities, timelines, budgets and responsible actors. ƒ Establish coordination and collaboration mechanisms with other programmes working on quality health service delivery. ORIENT FACILITIES ON KEY QUALITY CONCEPTS AND ACTIVITIES Quality care happens in health facilities and communities. Any new or renewed effort to improve quality of care requires that facility health workers and leadership be brought on board to understand their roles in improving care. Orientation of health facilities and health workers to improve health care quality is therefore an essential component of strengthening capacity and building interest to deliver effective, safe and people-centred care. Quality health services: a planning guide 25  Key activities ƒ Identify who will be involved in the orientation. ƒ Based on the emerging national strategic direction, operational plan and set of quality interventions, develop a district orientation package for – and in consultation with – facilities and communities. The district-level orientation package includes key quality concepts, a set of quality interventions adapted to the district context and key activities to be operationalized. ƒ Identify other activities to be undertaken alongside the orientation. For example, periodic capacity building on the foundational requirements identified (i.e. on-site support, measurement, sharing and learning, stakeholder and community engagement and management), alongside any quality intervention training. ƒ Deliver the orientation and continuously refine it based on feedback. 26 Quality health services: a planning guide DISTRICT-LEVEL ONGOING ACTIVITIES This section describes activities that may be currently ongoing at the district level or long-term processes to support quality of care programmes. A number of these areas also contribute to the start-up of quality health service activities at the district level. These activities at the operational district level inform and contribute to overall policy or strategy direction put forth by national authorities and serve as a support to health facilities in rolling out activities aligned with the district-level aims and objectives. RESPOND TO FACILITY NEEDS IN REACHING SELECTED AIMS A key function for leadership at the district level is the support to health facilities in achieving stated aims. Key activities ƒ Identify ways the district level can help in reaching selected aims at the facility level. ƒ Identify what types of support may be needed from the district level, informed by consideration of foundational requirements for quality at the district level (see page 33). ƒ Map out existing capacities at the district level to respond to facility needs. ENSURE FUNCTIONING MECHANISMS TO SUPPORT QUALITY HEALTH SERVICE DELIVERY District-level leadership should ensure that the foundational requirements to support quality health services are functional. Where lacking, district leadership should provide support to build this. On-site support and management are needed to build and sustain a culture of continuous quality improvement. District managers overseeing quality activities need data to determine whether planned activities to improve quality of health services are happening and whether they are leading to better care. Learning within the district can be either collaborative – bringing a multidisciplinary team, from different health facilities to work through an improvement aim and improve systems performance or, working with one individual facility to improve a weak area identified by district and facility leadership. Stakeholder and community engagement are pivotal to building trust within the health system and ensuring that service delivery is centred on people. Quality health services: a planning guide 27  Key activities On-site support ƒ Ensure that each facility has assigned coaches to provide refresher trainings/orientation to facility health workers and support overall quality improvement efforts. ƒ Support coaches to build QI skills. ƒ Keep track of QI support visits and help facilities to solve problems. ƒ Collect data on facility QI projects, review to identify successes and identify facilities needing support. ƒ Incorporate mentoring and supportive supervision as part of activities to improve health worker performance. ƒ Identify gaps and develop an advocacy and communication plan to address gaps, targeting both district and national stakeholders. ƒ Based on identified gaps at facility level, address specific challenges, or coordinate with national level to get necessary support. Measurement ƒ Collect data pertaining to patient outcome measures and process measures at the facility level. ƒ Collect district-level performance measures based on aggregate data from facilities. ƒ Analyse data emerging from both the facility and district levels to inform facility-level support and district-level planning. ƒ Share emerging data on quality of health services with community stakeholders and into national- level reporting systems. Learning ƒ Establish exchange visits between health facilities and between health districts to understand how improvement activities were conducted. ƒ Develop simple tools and resources to facilitate sharing of data and stories. ƒ Identify key learning about what works to improve care in the district, record good practices that should be scaled up, and learn from failures. ƒ Include capacity building on data collection and story-writing/sharing as part of regular supervision visits, in order to enable health workers to capture key elements of improvement. ƒ Host peer-to-peer learning opportunities. Examples at the district level can include district review meetings, quarterly sharing meetings, district newsletters or bulletins and other routine meeting opportunities. ƒ Include a measure on learning in periodic assessments and feed emerging information to the national level. Stakeholder and community engagement ƒ Engage relevant stakeholders and the community in the design, planning, implementation and monitoring of district-level activities to improve quality of health services. ƒ Jointly plan and produce quality health service activities with relevant stakeholders and communities. 28 Quality health services: a planning guide Management ƒ Ensure and build management capacity for quality improvement at the district and facility levels. ƒ Hold regular management meetings to ensure coordination of QI efforts. ƒ Communicate effectively between district and national staff, relevant stakeholders and communities. ƒ Ensure resources to support activities are in place. UPDATE DISTRICT QUALITY HEALTH SERVICE OPERATIONAL PLANS AND ACTIVITIES BASED ON LEARNING District leadership should periodically review operational plans against emerging learning from facilities and the district to adjust as needed. Key activities ƒ Regular review of quality activities. ƒ Based on learning from facilities, refine district-level plans. ƒ Participate in national-level learning activities and learn from experiences in other districts. MAINTAIN ENGAGEMENT WITH NATIONAL LEVEL District management should interact regularly with the national level to convey their progress and outline how district-level goals and priorities are contributing to the overall national strategic direction on quality. Engagement between national, district and the facility levels is a cross-cutting function across all levels of the health system, which helps foster the positive environment required for successful implementation. Key activities ƒ Share data on progress with national level. ƒ Identify specific problems that the district needs help with. ƒ Share any key learnings about how best to organize such an effort at a district level. ƒ Ensure progress and activities on quality are discussed at periodic meetings with national-level leadership. Quality health services: a planning guide 29  FOSTER POSITIVE ENVIRONMENT FOR QUALITY HEALTH SERVICE DELIVERY A key role of the district level is to cultivate an environment for improving quality of health services. Supporting and sustaining a culture for everyday quality is key to improving health outcomes. District leadership can influence how quality is perceived and acted upon by cultivating and institutionalizing quality considerations across all governance structures within the district. Key activities ƒ Recognize and celebrate successes of health facilities. ƒ Establish health facility and health workers forums to share learning about quality. ƒ Develop strategies to build motivation to improve quality of health services. ƒ Engage with health facility leadership to ensure quality is prioritized and staff are supported. ADAPT QUALITY INTERVENTIONS AT THE DISTRICT LEVEL Quality interventions can vary greatly depending on the context and surrounding health systems environment at the district level. At the national level, authorities are responsible for prioritizing a set of quality interventions to drive health systems towards the stated national level objectives for quality of care. District health teams may adapt these prioritized quality interventions to achieve the desired district-level goal(s) in support of the national-level objective. Key activities ƒ Identify and map existing quality interventions that aim to improve the health systems environment, reduce harm, improve clinical care and engage patients, families and communities. ƒ Prioritize and adapt quality interventions to use at the district level. ƒ Align the district-level set of quality interventions with the national-level set of quality interventions. ƒ Roll out the prioritized quality interventions within the district. ƒ Decide on measures to periodically evaluate the effectiveness of the applied interventions in the district. ƒ Learn from application of quality interventions and refine the district-level set of quality interventions. ƒ Review foundational requirements to support application of the quality interventions at the district level. 30 Quality health services: a planning guide  Key questions to consider when adapting quality interventions at the district level ƒ What quality interventions are currently being applied at the district level? ƒ Of these interventions, which ones have yielded positive results? ƒ What national-level interventions need to be prioritized and adapted to the district-level context, and at what cost? ƒ What value can the district health authority add to the implementation of the quality interventions? For practical tools and resources on district health management, ƒ What resources are required from the district and the national visit Chapter 6, page 30 of levels to adapt and implement the prioritized interventions? the WHO Recovery Toolkit: Supporting countries to achieve ƒ What foundational requirements are needed to support health service resilience (17). implementation of quality activities at the district level? FURTHER CONSIDERATIONS FOR ADAPTING QUALITY INTERVENTIONS AT THE DISTRICT LEVEL For systems environment interventions, district leadership have the role of managing and ensuring allocation of adequate human and financial resources – in terms of both quality and quantity – as well as adapting guidance on processes of care emerging from the national level. Foundations of care, including governance and accountability structures, health workforces, essential medicines, tools and commodities, and health management information systems are all essential to have in place and are central to how quality of care is delivered at the facility level (4). As an example, district leaders are responsible for public reporting and comparative benchmarking to facilitate sharing of information between health facilities and promoting transparency and accountability in reporting. In addressing health workforce competence, supervision, coaching and mentoring of health facility QI teams can promote health system leadership and build local capacity to lead and sustain QI efforts. District leadership can improve facility readiness by ensuring that health workers and health facilities/ institutions meet the minimum criteria when conducting periodic assessment visits. Reducing harm to patients, health workers and the community should be at the core of service delivery and a key pillar of any district-level operational support. Key activities that can be considered for district-level leadership can include inspection of institutions for minimum safety standards to ensure there is baseline capacity and resources to maintain a safe clinical environment. This includes ensuring that minimum requirements for WASH infrastructure, IPC and energy/power supply are all available and maintained. Considering the differences between districts – for example those in urban and rural settings – adaptation and capacity building related to safety protocols and checklists may be required for sustained uptake of safety interventions. Support will be needed from district-level leadership to facilitate improvements in clinical care. Types of support that may be considered at the district level include: ƒ Adaptation of clinical standards, pathways, guidelines and protocols to fit the local district context(s). ƒ Clinical skills mentoring, coaching and skills development. ƒ Periodic assessment of health facilities for appropriate implementation of standards. ƒ Development of locally appropriate tools and resources (electronic or print-/paper-based) to support decision-making processes at the facility level. ƒ Co-development of feedback mechanisms on clinical practice with health facilities, stakeholders and communities. Quality health services: a planning guide 31 ƒ Periodic learning reviews with health facilities and with other districts. ƒ Learning reviews to weigh effectiveness of interventions and costs to inform future operational planning. ƒ Development of plans and mechanisms for occupational health and safety, including the provision of adequate personal protective equipment for health workers. Similar to the national level, engaging and empowering patients, family and communities (16) at the district level can increase participation in district-level planning and ensure that activities proposed at the district level are tailored to the needs of the community. Representation of community and patients on district health boards can create the open space needed to feed emerging community needs into district planning and increase community participation in district-level health outreach programmes. A strong link between community and district leadership creates the dialogue needed to ensure that emerging national policy/plans/strategies are grounded in community needs, and can in turn help operationalize emerging policy and plans at the district level. District leadership is well-placed to tap into the wisdom of relevant stakeholders (e.g. facilities, partners, civil societies, communities, professional bodies etc.) to improve health care quality. Each stakeholder will need to be engaged within the planning cycle of the district as well as the continued design, implementation and monitoring of district level plans and quality improvement activities. As part of this engagement, key insights and learning from frontline experiences need to be identified and harvested collaboratively with relevant stakeholders. This learning needs to feed into local QI efforts, and best practices shared to ensure scale up and uptake of proven interventions. As part of the convening power of district leadership, emerging issues relating to resources, clinical management, administration and QI can be discussed, and actions identified in periodic learning fora. This collaborative approach can improve communication between district-level stakeholders and promote coordination and harmonization of efforts to support quality of service delivery. 32 Quality health services: a planning guide  Driving foundational requirements for quality from the district level Quality health services at the point of care rely upon several actions at the district level. Key considerations for district actors as they look to develop and sustain foundational requirements for quality are outlined in Table 2. Table 2. Key considerations district-level stakeholders FOUNDATIONAL REQUIREMENT EXAMPLES OF DISTRICT-LEVEL KEY CONSIDERATIONS ƒ What is required from the district level for the QI on-site support system? ƒ How can district-level leadership support facilities in moving forward on quality health service delivery? ƒ What resources are required from the district level to support facility- Onsite support level improvements? ƒ What sources of data and tools are used for QI at the district level? ƒ What data should be collected from the facility and district levels? ƒ How should quality health services data be reported and used? ƒ What measures are needed to manage quality-related activities? ƒ How can the district level support data quality and transparency? Measurement ƒ How can district-level leadership support measurement capacity- building in facilities and across the district health management team? ƒ What is required for health data to be able to monitor effectiveness of care and cost of quality interventions at the district level? ƒ What tools and resources are available at the district level to support learning around quality health service activities? ƒ How should learning on quality be documented? Sharing and ƒ What information is needed to support learning on quality? learning ƒ How should data emerging from the facilities be shared within and beyond the district? ƒ How should learning opportunities be organized within the district? ƒ What relevant stakeholders need to be engaged in district-level design, planning, implementation and monitoring for quality health service delivery? Stakeholder and community ƒ How can stakeholders be engaged within design, planning, engagement implementation and monitoring efforts on quality at the district-level? ƒ What existing mechanisms are being used for community engagement within the district? ƒ What are the ways the community can be engaged at the district level in improving quality of health services? ƒ What does the management system for quality health services look like at the district level? Management ƒ What is required to support management for quality health services? ƒ What additional resources are needed to support district-level aims and goals for quality health services? ƒ What do mechanisms to review performance of QI interventions look like? What stakeholders are involved in these mechanisms? Quality health services: a planning guide 33 SUMMARY OF ACTIONS DISTRICT LEVEL Improving quality of health services requires several actions at the district level. After reading this chapter you should know how to address the following interconnected actions. Align district commitment to national quality goals and priorities Develop district quality structures and operational plan, and where they already exist, update district quality operational plans based on learning from health facilities and emerging national strategic direction on quality Orient health facilities to district- and national- level quality goals and priorities Respond to facility needs in reaching selected aims and ensure functioning support systems for quality health services Maintain engagement with the national level on quality health services Adapt quality interventions to district-level contexts 34 Quality health services: a planning guide