Methods & Tools
In the QA Triangle, Measuring Quality consists of quantifying the current level of performance according to expected standards. It is the systematic identification of the current level of quality the facility or system is achieving. The QA approach to Measuring Quality is inextricably linked with Defining Quality, since the indicators for quality measurement are derived from the specific definition or standard under scrutiny. Quality cannot be measured without a clear definition or standard. Likewise, Measuring Quality leads directly to the identification of areas for improvement or enhancementthe first step in Improving Quality. Successful improvement ultimately contributes to attaining quality care, the goal of quality assurance.
QA activities that are part of Measuring Quality include:
Quality assessment is the measurement of the quality of healthcare services. A quality assessment measures the difference between expected and actual performance to identify opportunities for improvement. Performance standards can be established for most Dimensions of Quality, such as technical competence, effectiveness, efficiency, safety, and coverage. Where standards are explicit, a quality assessment measures the level of performance according to those standards. For dimensions of quality where standards are more difficult to identify, such as continuity of care or accessibility, a quality assessment describes the current level of performance with the objective of improving it.
A quality assessment frequently combines various data collection methods to overcome the intrinsic biases of each method alone. These methods typically involve either some form of direct observation of health worker performance or indirect assessment of performance, such as through testing of providers, patient interview, or record review. Examples of such methods include:
- Observation of service delivery (by expert observers, peers, supervisors)
- Mystery client method
- Audit of individual patient records
- Review of data from automated information system
- Testing (written tests, simulation with standardized patients, computer-based testing)
- Health worker interview
- Patient exit interview
Some methods are more intrusive than others. Quality assessment methods are subject, to varying degrees, to the "observation effect," wherein subjects are thought to perform better or possibly worse than they might in everyday practice or provide answers they perceive the interviewer wants to hear because they are aware that their performance is being assessed. The nature of the bias introduced by the observation effect is usually thought to be in the direction of overestimating performance, assuming that health workers might be performing at their very best when they think their performance is being observed. This is not always the case, however, since the presence of observers might also have the effect of making health workers nervous and undermine their performance. The mystery client method, wherein trained individuals pose as clients seeking health services unbeknownst to the providers and observe whether the providers perform certain predetermined tasks, has been cited as a promising method for reducing observation bias.
Another issue in quality assessment is the fact that health providers’ performance may vary from one patient to the next or from day to day, depending on patient characteristics (e.g., disease severity, cultural factors) and other situational factors (e.g., total number of patients, presence of other providers, availability of drugs and supplies). Multiple measurements of provider-patient interaction or performance of the same task are needed to obtain a reliable indication of usual performance. The cost of applying the different performance assessment methods also varies widely in terms of the cost incurred to produce each unit of observation.
Quality assessment is often an initial step in a larger QA process which may include providing feedback to health workers on performance, training and motivating staff to undertake quality improvements, and designing solutions to bridge quality gaps.
The QA Project has published several Case Studies on Quality Assessment that describe the methods and results obtained in actual quality assessments implemented in developing countries.
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