Quality Monitoring
Even in environments with limited resources, systematic methods are available to regularly monitor the quality of healthcare. Quality monitoring is a process for the regular collection and analysis of a core set of health indicators. In order to develop trust and involve staff, quality monitoring emphasizes measuring and analyzing processes rather than individuals. Too often, individuals are held accountable for poorly designed systems and processes. Seeking a culprit for poor outcomes is not the objective of quality monitoring. Instead, quality monitoring enables healthcare providers to assess a health facility or program’s overall performance to ensure that desired outcomes are achieved.
This section discusses the following topics related to quality monitoring:
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The Systems View
A systems view provides a comprehensive framework for quality monitoring by facilitating the structured analysis of quality issues and the identification of explicit links among inputs, processes, and outcomes. The systems view helps to identify process elements that are often overlooked and explore the causes of poor performance.The table below illustrates the systems view for three primary care programs: a training session for community health workers, a diarrhea control program, and drug supply.
Systems View of Health-Related Programs
|
INPUTS |
PROCESSES |
OUTCOMES |
Training of community health workers (CHWs) |
Community health workers
Trainers
Training material
|
Training session |
Competent CHWs
|
Diarrhea control program |
Trained CHWs
Oral rehydration salts |
Education sessions for the mothers |
Children treated with oral rehydration therapy
|
Drug supply |
Pharmacist
Drugs |
Stock management |
Drugs available in health facilities
|
The outcomes of one system can become the inputs of another. For example, competent community health workers are the outcomes of training and also the inputs of the diarrhea control program. The availability of drugs at the health facility is the outcome of the drug supply system and also the input for all programs involving pharmaceutical treatment.Quality monitoring is especially challenging in hospital settings. Hospitals are complex systems, with many interdependent parts and processes that interact to deliver an outcome. Quality monitoring in a hospital setting must take into account the interrelationship between all of the services and departments that make up a hospital system. The figure below depicts the core processes and support systems that typically are involved in providing hospital care.
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Hospital Core Processes
Most patients will experience all or most of these processes during an in-patient stay. Some of the processes can be defined as "supportive" inasmuch as they are not direct care. For example, the admission process and medical records system are needed to support patient care and treatment. Nursing care is another core process in the hospital system, as are complementary services such as dietary, pharmacy, and physical therapy.
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Foundations of Quality Monitoring
The foundations of a quality monitoring system are standards—the guidepost for achieving quality. Standards appear in a variety of forms, such as administrative policies, procedures, guidelines, and clinical pathways. Standards should be realistic (able to be followed with available resources), valid (based on scientific evidence or other acceptable experience), and clear (understood in the same way by everyone concerned and not subject to misinterpretation). In hospital settings, developing standards using multidisciplinary teams that cross departments helps to ensure that standards of care are consistent throughout the hospital. The data collected through monitoring provide a way to compare performance with standards, both at a specific point in time and over a period of time, and also with the performance of other healthcare facilities. The results of quality monitoring also help to determine causes for deviation from standards and identify areas for improvement.In an effective quality monitoring system:
- Data collection is a routine activity integrated into daily tasks
- Data are collected regularly and over time, so trends in the indicators can be monitored
- Data are used to identify the presence and causes of system problems that can result in poor performance
- Data are used to guide management decisions
A quality monitoring system not only collects information on inputs (structure) and outcomes, but also focuses on processes to determine if services meet defined standards.
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Ongoing Monitoring versus Spot Checks
Some quality indicators may be important enough to measure frequently and regularly (e.g., monthly); this concept is referred to as trending. However, because it is often not feasible to measure the hundreds of standards that are expected to be followed in a given health facility or program, spot checks may be conducted to measure specific standards during a defined period of time. A spot check may be done on a one-time basis or may involve monitoring a set of indicators for a particular service for a specific period (e.g., six months).
To avoid becoming overwhelmed with data collection and analysis, the best way to establish a quality monitoring system is to proceed incrementally. Start with a simple system focused on one or a few services and expand it as experience and resources permit.Initially, the scope of quality monitoring may be limited by selecting a few key indicators that are of the highest priority. High volume, high-risk, and problem-prone processes are frequently given highest priority. High-risk processes have a potential of resulting in harm to the patient or staff. Problem-prone processes are those that have been recognized by the authorities or staff as having poor outcomes. Priority indicators in a hospital setting typically include surgical infection rates, medical error rates, and mortality rates, since these indicators relate to every hospitalized patient and yield grave outcomes if standards are not met. Once a quality monitoring system is in place, the process can be expanded to include additional indicators.
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Establishing a Quality Monitoring System
There are three major steps in establishing a quality monitoring system: (a) decide what information you need, (b) collect the data, and (c) use the information and results. The detailed steps in designing and implementing a quality monitoring system are shown in the figure below.
The Steps in Quality Monitoring
Step one: Decide what information you need
- Select health services to be monitored. A given health system provides a large number of services, not all of which can be monitored. Monitoring should focus on those services which are considered to have the highest priority.
- Describe the process of care. The healthcare process to be monitored must be made explicit by listing the critical activities that must be conducted for the correct delivery of the service or management of the health condition. A flowchart may be a useful tool for mapping the main steps of the care process.
- Draw a systems view of the services. A systems perspective of the services that will be monitored will help to better understand the processes to be monitored and to identify the critical inputs and expected outcomes.
- Make critical standards explicit. Standards must be defined for each critical system component whose performance is to be monitored.
- Develop performance indicators. Indicators to measure performance according to each standard are then developed. Such indicators measure the gap between observed and expected performance according to standards.
Step two: Collect the data
- Choose appropriate data collection methods. Quality monitoring data may be collected through a variety of methods, including direct observation, patient exit interview, interview with healthcare providers, and record review. Each method has its advantages and disadvantages, and none is adequate for all situations. Using a combination of methods is usually more reliable. The right combination of methods will depend on the resources available (including time), the familiarity of the data collectors with the method, and the specific performance indicators of interest.
- Design the monitoring tools. Forms to collect date and tabulate findings must be developed and data collectors trained in their use. Using structured forms helps to decrease variation in the results obtained by different observers.
- Test the monitoring tools. Data collection forms should be reviewed with the intended users of the forms and field-tested to verify their appropriateness.
- Select the monitoring strategy. The monitoring strategy involves determining whose performance will be monitored, the optimal frequency for data collection, how existing information and monitoring systems will be used for quality monitoring purposes, and how the accuracy and validity of data will be ensured.
- Collect data. Implementing the quality monitoring system requires planning to prepare and mobilize data collectors. Data collection may be carried out by teams specifically organized for this purpose or may be collected by supervisors as part of routine supervision.
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Step three: Use the information and results
- Tabulate results. After the data have been collected, they must be tabulated and used to calculate the performance indicators. Disaggregated indicators may be used to present the observed frequency of performance of specific tasks. Aggregated indicators, characterizing overall performance over several related tasks, are sometimes helpful to provide an overall measure of healthcare provider adherence to standards.
- Analyze the information. Data analysis seeks to determine the overall performance level of the providers or facilities being monitored, identify best and worst performers, and identify patterns or trends in performance. To decrease the perceived threat associated with quality monitoring, it may be helpful to involve healthcare providers whose performance was assessed in the analysis and interpretation of the results.
- Interpret and use results. The data obtained through quality monitoring are then used to identify performance gaps and the root causes of poor performance.
- Design a data storage and retrieval system. Once data are collected regularly, they must be stored in an accessible form and location that allows for regular updating of monitoring data.
- Disseminate information. Information obtained through quality monitoring should be shared first with the staff whose performance was assessed. Dissemination workshops, management meetings, newsletters, and other informational methods may be used to disseminate monitoring results to internal and external audiences.
The QA Project has published two Health Manager’s Guides that describe in more detail the systematic approach to implementing quality monitoring. Monitoring the Quality of Primary Care explains how to establish a monitoring system to assess the quality of primary care by measuring how providers and facilities perform according to standards of care. Each element of the quality monitoring approach is illustrated using a running example of the design of a quality monitoring system for the case management of acute respiratory infections.
Monitoring the Quality of Hospital Care describes how to systematically implement quality monitoring in a hospital setting. The guide explains how to take a systems view of a hospital and provides step-by-step methods for monitoring quality: one method for organizations that have no monitoring system and one for organizations where standards have been established and the monitoring of a few indicators is working. Extensive appendices provide examples of quality monitoring tools and resource materials.
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