Health Care Quality Improvement in Emerging Markets: Measure and Manage Performance

By Tej Maini, M.D.

Top-notch patient care, safety and satisfaction is the goal of health care organizations around the world, but getting there can be a difficult process – particularly for hospitals in emerging markets. The leaders of institutions in many of these countries often face the same three obstacles: an unclear understanding of what quality care and safety really mean; the lack of a systematic, organization-wide focus on quality; and an inadequate metrics-based system to measure and manage performance.

To define quality, and set the standards to be met, the most powerful research tool – and improvement impetus – is the hospital accreditation process. While nearly all U.S. hospitals have met the rigorous standards for Joint Commission accreditation, only about 200 institutions in the rest of the world have been accredited by its sister organization, the Joint Commission International (JCI). JCI’s “core measures” for the monitoring and treatment of key medical events and illnesses are the place to start, as well as standards set by specialty accreditation or membership in organizations such as the College of American Pathologists and the National Surgical Quality Improvement Project (NSQIP), among others.

Some benefits of the accreditation process are its effectiveness across cultures with very different health care systems, the continuous improvement imperative it imposes, resulting cost efficiency gains, enhancement of staff recruiting and satisfaction, and education of key audiences outside the hospital, including health care regulators and the public.

Developing a systematic, organization-wide focus on quality requires a commitment and intense oversight from leadership, which must cascade down to the entire staff, through the Chief Operating Officer and the Chief Medical Officer – and a dedicated Chief Patient Quality and Safety Officer who reports to the Chief Executive Officer. Bringing the physician staff on board is the biggest challenge, requiring education, collaborative decision-making, a defined set of quality-related responsibilities and performance evaluation accountability – and a great deal of patience and persistence. The challenge becomes easier by recruiting the right type of physicians. Additionally, the entire nursing and other hospital staff need to understand that quality and patient safety are an integral part of the culture of the organization.

Transparency is also a prerequisite for effective organizational response to quality issues. There must be clear, non-punitive avenues for reporting incidents, expressing concern or dissenting on patient care and safety issues – independent of hospital power hierarchies. And it must be a team effort, akin to the U.S. group practice model that is “foreign” to health care systems in much of the rest of the world. Transparency on care and safety is equally important beyond the hospital doors: it will build goodwill, and even influence policy, with health care regulators; and it will educate and enhance the satisfaction ratings of patients.

Building an effective metrics-based system to measure and manage performance is both a people and technology challenge in emerging markets. First, your leadership team needs to decide exactly what to measure. While treatment outcomes are obvious, your system should also address structural and organizational resources and effectiveness, as well as the adequacy of hospital processes. A non-biased (not departmental based) data collection and analysis team should be set up, and research done to settle on areas of concentration (with a focus on what’s “broken). While obvious on its face, physician and support staff must be trained and constantly “nagged” to collect and record case information.

On the technology side, an electronic medical records system is an absolute prerequisite – one with the capability to build automated alerts and reminders of treatment protocols based on patients’ diagnoses. Information systems software effective enough to analyze and generate useful reports on staff actions and case outcomes can be more problematical, and it may be necessary – at least in the early stages of system building – to train and deploy dedicated staff to “query” patient medical records directly in order to generate the necessary data. (The use of evidence-based medicine will be the subject of another blog.)

Developing effective performance measurement and management systems can be a long, incremental and labor-intensive process that comes with considerable expense – but it will partly pay for itself in more cost-efficient hospital operations, and will definitely pay dividends through care quality and patient safety improvements. And that will move the needle on the most meaningful measure of all: patient and public satisfaction with their local hospital.

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