Publications:Technical Reports

Malawi Field Study: Comparison of Methods for Assessing Quality of Health Worker Performance Related to Management of Ill Children: This study reports the strengths, weaknesses, and costs, as well as guidelines for use, of four methods for assessing the quality of healthcare provider performance: observation, exit interviews with patients/caretakers, record review, and interviews with providers. Data were collected at Under Five clinics at 14 health facilities in Malawi, where 436 provider-patient encounters were observed. The report concludes that exit interviews reliably reflect provider-patient encounters and provides other insights on the reliability of each of the four methods. In terms of costs, provider interviews proved least expensive and record reviews require the least time.
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The Niger Country Report: Tahoua Project: This final report describes QAP technical assistance activities in the Tahoua Region of Niger during the period April 1993 through March 1997.
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Download report, Part 2

Niger Measles Initiative Phase II Final Report: This report describes the results of the second phase of the Niger Measles Initiative Project. Download report (37 pages)

Strengthening the Capacity of African Institutions for Improving the Quality of Nutrition Programs: Final Report of the Greater Horn of Africa Initiative: Major investments in nutrition programs have shown little effectiveness in alleviating malnutrition. Strengthening the capacity of program managers/implementers to optimize service delivery to ensure effectiveness is critical and requires examination of processes and application of problem-solving techniques. This report examines two child survival interventions (growth monitoring/promotion and Vitamin A administration) in Kenya and Tanzania, respectively. The process adapted in designing/implementing the assessment/improvement activities focused on building regional capacity for design/implementation for other nutrition programs.
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Asia

Internal Quality Assurance: Lessons Learned from the PKMI Hospital Pilot Program in Indonesia: Starting in May 1992, the Indonesian Association for Secure Contraception (PKMI) developed and pilot tested an internal QA program in the family planning units of 16 hospitals. The program complemented an existing external QA system that PKMI had supported since 1984 and that consisted of periodic meetings to review activity reports. The hope for the new program was that staff would assume greater responsibility for service quality. After a manual on QA for certain contraceptive methods was developed and training provided, teams formed to identify, prioritize, and analyze problems. Improvements included reductions in the number of clients who were not served, in post-operative infections, and in incomplete medical records and an increase in the percentage of clients learning of sterilization. Provides a 20-page overview of the entire program followed by 1- to 5-page summaries of the experiences of 11 hospitals.
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Reducing Treatment Default Among Tuberculosis Patients in the Philippines: The QA Project partnered with the Tuberculosis Control Service in the mid-1990s to compare two methods to improve patient compliance with a medical regimen for TB: a flip chart with drawings and text that health workers kept on their desks and the technique of having health workers establish a contract with TB patients promising the to abide the regimen, the latter of which leveraged an aspect of Philippine culture that gives import to those in authority. While the results of both interventions were disappointing, the report provides interesting insight into behavior change education. Tools: 10-page flip chart with drawings and text explaining a then-current TB regimen and the contract, including a certificate of completion of therapy.
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Global

The Evidence Base for Programming for Children Affected by HIV/AIDS in Low Prevalence and Concentrated Epidemic Countries. This working paper is the result of collaboration between the United Nations Children’s Fund (UNICEF) and URC’s Quality Assurance and Workforce Development Project (QAP). Worldwide, the commitment to protect and support children affected by HIV/AIDS is growing, and countries with low level or concentrated epidemics are increasingly developing and putting in place special programs to support these children. The goal of the working paper was to summarize and weigh the evidence on a myriad of challenges faced by children affected by HIV/AIDS in low prevalence and concentrated epidemic countries in order to facilitate evidence-based programming.
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The Global Polio Laboratory Network: A Model for Good Laboratory Practice: This report provides a framework to guide laboratories and health programs in assessing their performance. It describes seven quality principles demonstrated by the Global Polio Laboratory Network that have contributed to its success in adhering to good laboratory practice and reducing polio: leadership commitment, network-wide communication, use of QA methods, accreditation, capacity building, documentation standards, and responsible allocation of program resources.
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HIV and Infant Feeding: A Compilation of Programmatic Evidence: This document is intended for professionals involved in 1) updating infant feeding guidelines or adapting them to local settings or 2) developing or scaling up programs to prevent mother-to-child transmission of HIV. Editors at QAP and UNICEF teamed up to identify, summarize, analyse, and synthesize reports on programs aimed at preventing the transmission of HIV through infant feeding. The result provides two-to-four page summaries of over 40 programs that addressed HIV and infant feeding. Most of the programs took place in a single country, mostly Africa, although three are multi-country programs. Six discussing heat-treating milk or safe water are not connected to any particular country. Program countries include: Botswana, Cote D’Ivoire, Honduras, India, Kenya, Myanmar, Nigeria, Rwanda, South Africa, Swaziland, Tanzania, Thailand, Uganda, Zambia and Zimbabwe.
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Latin America & the Caribbean

Diagnóstico de la Situación de la Tuberculosis en Dieciséis Municipios Priorizados de Bolivia: In early 2007, QAP and the Gestión y Calidad en Salud (GCS) Project managed by John Snow, Inc. (JSI) initiated, with USAID support, an improvement collaborative with the National Tuberculosis Control Program of Bolivia and 16 municipal health networks, aimed at expanding the coverage and quality of DOTS and increasing TB cure rates. To identify opportunities for improvement and needs of the specific municipal health networks, QAP and GCS/JSI staff conducted a rapid assessment of the current TB program in the municipal health networks, located in the Departments of La Paz, Cochabamba, and Santa Cruz. Data for the rapid assessment were collected through site visits to the 16 municipalities between November 2006 and January 2007 and drawn from the National Health Information System and epidemiological reports. The assessment found wide variations in program quality among the 16 municipalities and widespread problems with low case detection, lack of follow-up of contacts, limited use of DOTS follow, and low cure rates. These findings were used to develop the interventions implemented through the improvement collaborative.
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Evaluación de competencias en la atención del embarazo, parto, posparto, recién nacido y sus complicaciones, Junio – Septiembre 2005: In 2005, QAP assisted the Ministry of Health of Nicaragua to carry out a national competency assessment of skilled birth attendants to identify gaps and weaknesses that would be addressed through in-service training and supervision. The assessment included Ministry of Health hospitals (20) and health centers (44) drawn from each of the country's 17 health areas. A total of 1,358 physicians and nurses who attend deliveries were evaluated through a written knowledge test. From this group, 580 providers participated in skills tests related to the prevention and management of obstetric and neonatal complications. Anatomical models were used for the skill assessment. While the assessment found moderate to high levels of knowledge in several functional areas, clinical skills were generally weaker. The skill assessment found that only 51% of the personnel assessed were able to adequately fill out a partogram; 46% correctly performed active management of third stage of labor; 51%, manual extraction of the placenta; 46%, bimanual uterine compression; 71% immediate newborn care; and 55%, neonatal resuscitation. The report was published in 2006 by the Ministry of Health of Nicaragua, QAP, PAHO, CARE, and UNICEF.
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Maximizing Quality of Care through Health Sector Reform: The Role of Quality Assurance Strategies: The Quality Assurance Project and the Pan American Health Organization collaborated to develop this conceptual framework for how to incorporate quality assurance (QA) within health sector reform. The report springs from the shift in health sector reform (HSR) progress in Latin America and the Caribbean, which is focusing less on efficiency and more on wider issues, such as fairness in financing and responsiveness to client expectations. The report first notes differences between HSR and QA: The former works at the macro-level, seeking to shape an environment conducive to quality and thereby enabling quality indirectly. The later works at the operational level, assuring that all determinants of quality are in place and performing. The report discusses how specific QA strategies complement HSR initiatives related to health sector steering (e.g., regulation), financing mechanisms, healthcare guarantees, and delivery. During 2004, the Quality Assurance Project reviewed the framework document with national health authorities in Jamaica and Nicaragua. The present document is a revision of an earlier paper published jointly by PAHO and QAP, reflecting changes made in the framework based on feedback from health officials in the two countries.
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Maximización de la calidad de la atención mediante la reforma del sector salud: La función de las estrategias de garantía de calidad

Quality-Oriented Health Sector Reform Training Module: Instructor Notes and Quality-Oriented Health Sector Reform Training Module: Participant Manual: These companion documents outline a half-day training course that provides an overview of the conceptual framework for incorporating quality assurance strategies within health sector reform.
Download Instructor Notes (14 pages)
Download Participant Manual (14 pages)

The Law for the Provision of Free Maternity and Child Care in Ecuador: The Law for the Provision of Free Maternity and Child Care is a major piece of health sector reform legislation in Ecuador that guarantees access to free prenatal care, labor and delivery, family planning, and other basic maternal and child health services for all women and children under five. Designed to reduce the economic barrier that prevents access to care, the Law also incorporated a number of innovative reforms to the health system in its design and implementation, including separating the functions of financing/paying for health services and healthcare delivery, and transferring funds for healthcare to municipalities, with oversight by local management committees as opposed to solely by the Ministry of Public Health. This report describes the development and key features of the Free Maternity Law, which offers important lessons for countries interested in integrating quality assurance within health sector reform strategies.
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la Ley de Maternidad Gratuita y Atención a la Infancia (LMGYAI) en el Ecuador

Scaling Up and Institutionalizing Continuous Quality Improvement in the Free Maternity and Child Care Program in Ecuador: The mechanisms employed by the Free Maternity and Child Care Law have become increasingly important tools for the improvement of healthcare coverage and quality of services in Ecuador. Among such mechanisms are the publication of clinical guidelines, reimbursement to facilities based on production, implementation of a continuous quality improvement system with practical tools to measure and improve quality and attainment of goals, management agreements with municipalities for co-management of facilities, and the organization of users’ committees to monitor service quality. This document reports the findings of an operations research study to document the process of institutionalizing the continuous quality improvement (CQI) mechanism within the Free Maternity Program in Ecuador and reports on the CQI program’s impact on healthcare quality through early 2005. The 10 annexes to the report—documents in Spanish that were developed to support the institutionalization of continuous quality improvement within the Free Maternity Program in Ecuador—may also be downloaded and can be requested in modifiable format for adaptation in other Spanish-speaking countries (contact qapdissem@urc-chs.org).
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Expansión e Institucionalización del la Mejora Continua de la Calidad en la ley de Maternidad
Gratuita en el Ecuador

Download Annex 1: Sistema de Mejoramiento Continuo de la Calidad de las prestaciones que contempla la Ley de Maternidad Gratuita y Atención a la Infancia. Estándares e indicadores/Etapa Uno

Download Annex 2:

Manual de capacitación para equipos de Mejoramiento Continuo de la Calidad: Introducción

Manual de capacitación para equipos de Mejoramiento Continuo de la Calidad: Unidad Uno: Bases para el Mejoramiento Continuo de la Calidad

Manual de capacitación para equipos de Mejoramiento Continuo de la Calidad: Unidad Dos: Medición de la calidad: Estándares e indicadores

Manual de capacitación para equipos de mejoramiento continuo de la calidad: Unidad Tres: Mejoramiento Continuo de la Calidad a través de ciclos rápidos

Manual de capacitación para equipos de mejoramiento continuo de la calidad: Unidad Cuatro: Mejoramiento Continuo de la Calidad y satisfacción de usuarias / os

Download Annex 3:

Instructivos e instrumentos de recolección de información para indicadores/Etapa Dos

Estándares e indicadores/Etapa Dos

Download Annex 4:

Presentación de PowerPoint: Unidad Uno

Presentación de PowerPoint: Unidad Dos

Presentación de PowerPoint: Unidad Tres

Presentación de PowerPoint: Unidad Cuatro

Download Annex 5: Formato para informe de los ciclos rápidos para el mejoramiento de la calidad

Download Annex 6: Manual del usuario de la página web Mortalidad Materna, www.mortalidadmaterna.org

Download Annex 7 (need Microsoft Excel to view): Matriz de reporte de la medición del cumplimiento de estándares e indicadores de calidad para la atención materno infantil y de cuidado obstétrico esencial: País: Ecuador

Download Annex 8: Subsistema de monitoreo de la calidad de las prestaciones de la Ley de MGYAI. Documento Borrador

Download Annex 9: Guía para el aseguramiento de la calidad de las prestaciones de la Ley de Maternidad Gratuita y Atención a la Infancia por los Comités de Gestión

Download Annex 10: Premio a la Calidad de la atención que ofrecen las unidades de salud del Ministerio de Salud Pública en prestaciones cubiertas por la Ley de Maternidad Gratuita y Atención a la Infancia. Documento Borrador

Approaches to Healthcare Quality Regulation in Latin America and the Caribbean: Regional Experiences and Challenges: Through regulatory approaches, governments establish expectations for the competence of healthcare providers and institutions and for the quality of services these provide. Three main approaches to quality regulation have been used by governments and professional bodies to ensure, maintain, and improve the quality of healthcare: licensing, certification, and accreditation. This paper was commissioned to examine experiences in the Latin American and Caribbean region with these approaches to quality regulation of both providers and facilities, to derive lessons and implications for future policy development, programming, and research. The report also discusses challenges facing efforts in the region to effectively regulate quality of healthcare, including enforcement, monitoring and evaluation of the impact of quality regulation, incentives for maintaining quality of care, and regulating the growing private sector. An annex to the report provides more detailed descriptions of experiences with quality regulation in Argentina, Brazil, the Caribbean Community, Colombia, the Dominican Republic, and Honduras.
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Baseline Assessments of Essential Obstetric Care: Bolivia, Ecuador, and Honduras: This report describes the QA Project's contribution to the Latin America and Caribbean Regional Initiative to Reduce Maternal Mortality (LAMM). Responsible for supporting process redesign and quality improvement teams seeking to improve essential obstetric care, the QA Project conducted a baseline assessment at facilities in selected areas of three countries. Performance according to standard was measured through 21 indicators; data were collected through medical record review, structured observation of deliveries, and a questionnaire completed by healthcare workers.
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Health Care Sector Reform and Quality Assurance in Costa Rica: Results of Process Improvement Teams Working in Health Facilities Managed by the Costa Rican Social Security Institute: Starting in 1993, Costa Rica's Social Security Institute sought to strengthen management and planning of healthcare and improve quality, while responding to the country's depressed economic conditions. Its QA methodology was based on the premise that continuous quality improvement can be convincingly demonstrated by systematically resolving problems identified as important by health workers. Two hospitals, four clinics, and one health district addressed patient rejection, long waiting times, delays in retrieving records, long lines, and similar problems. The results and extensive documentation (some in Spanish) are provided in a lengthy appendix.
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Maximizing Quality of Care through Health Sector Reform: The Role of Quality Assurance Strategies: The Quality Assurance Project and the Pan American Health Organization collaborated to develop this broad discussion of the intersection of health sector reform (HSR) and quality assurance (QA). The draft report springs from the shift in health sector reform progress, which is focusing less on efficiency and more on wider issues, such as fairness in financing and responsiveness to client expectations. The report first notes the difference between HSR and QA: The former works at the macro-level, seeking to shape an environment conducive to quality and thereby enabling quality indirectly. The later works at the operational level, assuring that all determinants of quality are in place and performing. They intersect and complement each other in several initiatives, such as accreditation, licensing, and certification. Maximizing the impact of the complementariness is explained with the aid of a graphic showing the point of maximum equity in the distribution of services. That explanation is followed by a discussion of stewardship and steering (e.g., regulation), financing mechanisms, healthcare guarantees, and delivery. The draft report includes recommendations for moving forward with HSR and QA, including urging country leaders to take a “hard look” at their data while developing healthcare initiatives: The body of the report may guide them in doing so. Activities/tools: Dimensions of quality, determinants of quality of care, QA triangle, Venn diagram of the intersection of HSR and QA, and Equitable Distribution of Services graphic.
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Maximización de la calidad de la atención mediante la reforma del sector salud: La función de las estrategias de garantía de calidad

Making a Commitment to Quality: Development of a National Quality Assurance Program in Chile 1991-1998: This report covers the first four years of QA Project work in Chile. The Project provided technical assistance to the Chilean Ministry of Health in the early 1990s, helping local health professionals develop a national QA program and build local QA expertise. The goals, largely achieved, were to raise awareness of the importance of quality throughout the health system, develop a structure to support QA activities, achieve measurable improvements in the quality of care, and improve patient satisfaction. When the report was written, the National Program for the Evaluation and Improvement of Quality was operating in nearly all of Chile's 29 decentralized Health Services and was independent of external financing or technical assistance.
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Middle East

Egypt Country Report: This report details the QA Project in Egypt from its start in July 1993 to its closure in November 1995, when it was integrated into a cost-recovery project. Quality assurance was institutionalized at both the facility and national levels to decentralize and improve facility management, upgrade facilities and equipment, and improve services. Tools: Appendices provide the operating policy that QAP/Egypt developed at one facility and includes, for example, the emergency room QA improvement plan; the QA committee operating policy; and clinical practice guidelines in a few areas, such as pneumonia.
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Poland

Poland: Improving Quality of Care in Eight Polish Hospitals. This report describes the results of a project's initial phase in which quality management methods and tools were used to solve one problem at a time.
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Russia

Situational Analysis of TB-HIV Co-infection in Russia and Four QAP Project Regions: Samara, Saratov, Orenburg, and St. Petersburg: The Quality Assurance Project is seizing a unique opportunity to strengthen the Russian healthcare system’s capacity for addressing TB-HIV co-infection and to develop and implement the functional integration of TB and HIV services. Working with health authorities and service providers, the QA Project/Russia is designing a model system of treatment, care, and support for TB patients as part of international efforts to control the dual epidemics of tuberculosis and HIV/AIDS. As a first step, QAP conducted a situational analysis in four regions. This report of its findings covers the epidemiology of TB-HIV, efforts of various Russian and international organizations, and health system mechanisms for dealing with co-infection. It presents recommendations for effectively addressing the issues of support and adherence to drug therapies by people infected with TB and HIV.
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Health Care Quality Glossary: This document provides, in English and Russian, definitions and translations of terms in the field of healthcare quality. Terms are organized under sections addressing "common concepts and terms," "health and related factors and conditions," "health care," "health care economics," and "health care quality."
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Improving Care for Women Suffering from Pregnancy-Induced Hypertension Intended for use by midwives, obstetricians/gynecologists, anesthesiologists/resuscitators, and general physicians, this report provides the clinical guideline, developed in Tver Oblast, Russia, for treating women with pregnancy-induced hypertension (PIH). A US-Russia collaborative team developed the guideline using quality improvement principles and evidence-based medicine. (Results from implementing the guideline are in other publications, including the Report Improving the System of Care for Women Suffering from Pregnancy-Induced Hypertension in Tver Oblast and the Case Study Developing Evidence-Based Standards for Pregnancy-Induced Hypertension in Russia).
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Russian

Improving the System of Care for Neonates Suffering from Respiratory Distress Syndrome in Tver Oblast: This is a summary of the work by the QA Project alongside Russian partners in addressing care for neonates with respiratory distress syndrome, first at five hospitals and later at 42. This paper lists the key changes made to the care system (e.g., creating a central referral neonatal ICU and an ambulance system) and the results of those changes, including a drop in early neonatal mortality from 10.8/l000 in 1998 to 5.3/1000 in 2001.
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Improving the System of Care for Patients Suffering from Arterial Hypertension: Arterial hypertension (AH) is a major cause of mortality in Tula Oblast, Russia, where 27 percent of the population is believed to have the condition but only 10 percent have been diagnosed. In addition to the human suffering and loss, the toll on the healthcare system was burdensome. A US-Russia team of oblast leaders, healthcare providers, and quality assurance experts examined the then-current system, proposed evidence-based changes that were introduced gradually and monitored for their effect, and revised the system so that AH could be identified early and people with AH could learn healthy behaviors. This report presents the guideline that serves as part of that system; results are included in the Report Improving the System of Hypertension Care in Tula Oblast.
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Russian

Improving the System of Care for Women Suffering from Pregnancy-Induced Hypertension in Tver Oblast: This report summarizes QA Project/Russia work related to pregnancy-induced hypertension in Tver Oblast, Russia, from January 1999 to December 2001. Three facilities participated; run charts present the results relating to PIH diagnoses and hospitalizations.
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Improving the System of Hypertension Care in Tula Oblast: This report summarizes work by the QA Project and its Russian partners in improving care in Tula for people with arterial hypertension (AH). A guideline was developed using quality improvement principles and evidence-based medicine. The steps taken and results are presented here, including run charts showing increases in the number of patients identified as having AH and decreases in the number of hospitalizations.
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Quantifying the Economic Impact of Using Evidence-Based Clinical Guidelines for Pregnancy-Induced Hypertension in Two Hospitals in Tver Oblast: This report of a before-after cost analysis suggests that efforts to improve quality can coincide with reducing costs, including long-term costs. Costs analyzed included drugs, hospitalization, and clinical tests: All dropped when the new guideline was introduced, reducing average total cost per patient by 41 percent.
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(Re)Designing the System of Care for Neonates Suffering from Respiratory Distress Syndrome: This clinical guideline addresses all stages of the management of newborns with respiratory distress syndrome (RDS). A US-Russia collaborative team developed the guideline using quality improvement principles and evidence-based medicine. (Results from implementing the guideline are in the Report Improving the System of Care for Neonates Suffering from Respiratory Distress Syndrome in Tver Oblast.).
Download report (49 pages)
Russian report

The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development (USAID) under Contract Number GPH-C-00-02-00004-00.