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raghavan-gilbert/vw 1
A MANAGEMENT PERSPECTIVE
raghavan-gilbert/vw 2
QUALITY OF CARE & SERVICEA MANAGEMENT PERSPECTIVE PROGRAMME JUSTIFICATION FOR QUALITY• Demographic approach & unmet needs• Is quality the missing link?• Target free approach• Reward system and donors• Wasted resources & opportunity costs• Programme sustainability• Stakeholders
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HEALTH & SOCIAL JUSTIFICATION FOR QUALITY
Direct relationship between high fertility and maternal & child deaths
Access to and use of FP Services is critical
Determinants of fertility known Attitudinal & socio-psychological
variables Decision-making processes in human
reproductive behaviour
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MORAL & ETHICAL OBLICATIONS
Ethical concerns
Heightened Expectations
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Societal
andIndividual
Factors
Value andDemand
for
Children
FP Demand Spacing Limiting
OtherIntermediateVariables
ContraceptivePractice
Fertility Wanted Unwanted
Other Healthand Social
Improvements
ServiceUtilization
Service Outputs Access
QualityImage/Acceptability
DevelopmentPrograms
FamilyPlanningSupply Factors
Conceptual Framework of Family Planning ProgrammeImpact on Fertility in the Context of Supply and Demand
Source: Bertrand, et.al, 1992
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Larger Societaland PoliticalGovernanceFactors
ExternalDevelopmentAssistance FP
OrganizationalStructure Service
Infrastructure SectoralIntegration DeliveryStrategies Public-PrivatePartnership
Political andAdministrativeSystem Political
Support ResourceAllocations Legal Code/Regulations
Operations ManagementandSupervision Training CommodityAcquisition/Distribution I-E-C Research andEvaluation
Conceptual Framework ofFamily Planning Supply Factors
Family Planning Supply Factors
Source: Bertrand, et.a., The Evaluation Project 1992)
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Schematic presentation of links between quality
of f amily planning services and f ert ility (f rom J ain, 1989)
Hypothesizedeff ects
Q ualityofServices Choice I nformation to
users Provider
competence Client/ Provider
relations Follow- up Appropriate
constellationof services
Otherfactorsincluding demand
Acceptance
Continuation
Contraceptiveprevalence
Otherproximate
determinants
Fertility
Knowneff ects
Source:J ain, A. , 1989
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KEY SYSTEMIC FEATURES OF A FP PROGRAMME
High interdependence Complex service delivery system Large information gaps between the
entities No consensus on output measure
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SPECIAL INTEREST GROUPS IN FP PROGRAMME
Religious and cultural groups
Political mistrust
Human rights groups
Feminists groups
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Family Planning Service Delivery and Stakeholders
PO LI CYMAKERS& DO N O RS
Providers
T echnicalT eam
S upportT eam
Communityawareness
S erviceProcess
Community
CLI EN T
I MPA CT
ProgramorFieldManagers
or ganisat ional cont ex t communit y cont ex t
PQ A Tactshere
S o u rce : R a g h a va n -G ilb ert, 1 99 7
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WHY?
Reduces wastage of scarce resources
Provides a fuller understanding of the
problem
Prevents recurrence of a problem
Doing it Right the First Time (DRIFT)
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DEFINITION OF QUALITYISO 8402 (1986) ON QUALITY
VOCABULARY
The definition advanced by the ISO draws attention to three key embedded concepts: “Quality is the totality of features and characteristics of a product or service that bears on its ability to satisfy stated or implied needs”. This definition of quality encapsulates its complexity and multidimensionality.
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INDUSTRIAL QUALITY MODEL
Quality is conformance to specifications that relate to customer satisfaction.
Five quality dimensions relate to customer satisfaction in industrial quality. Quality measurement in industry necessarily reflects these dimensions. They are:
• specification (preservice expectation)
• conformance (in relation to the expectation)
• reliability (over time)
• cost (value)
• delivery (timeliness)
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QUALITY IN HEALTH CARE
Self regulation
External Regulation
Medical Audits
Quality in FP
Bruce QOC Model
Other Models
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Quality of Care Framework – Bruce
ANTECEDENTS, ELEMENTS and OUTCOMES OFFAMI LY PLANNI NG SERVI CES
Enabling systems forService Delivery
Elements of Quality of Care I mpact
Resources available
Management structureand capacity
Logistics
Training
MI S
1. Choice of Methods
2. Technical competence
3. I nforming and counseling clients
4. I nterpersonal relations
5. Mechanisms to encourage continuity
6. Appropriateness and acceptability
I nformed decision- making aboutreproductive health options
Client health
Client knowledge
Client satisfaction
Contraceptive use
Acceptance
Continuity
adapted f rom Bruce by the Subcommittee on Quality I ndicators 1990
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SERVICE CHARACTERISTICS
Intangible Experience Co-production Simultaneity of production and
consumption Client decides the continuation of the
relationship Deficiencies, evident during
transaction or even later affects perception of quality
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SERVICE CHARACTERISTICS
Quality service requires that critical ‘behind-the-scene’ activities meet quality critieria before the first client-provider interaction and service experience occurs.This can happen only if organizational processes are predetermined and quality standards preset for the organization, which providers can strive to reach in service production and delivery
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Professionaljudgement
People’sbehaviour
Physicalprocess
A Conceptual Model of Service Quality(Haywood - Farmer)
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The Service Quality Model – Gronroos
Expectedservice
Perceivedservice
Image
Technicalquality
Functionalquality
What? How?
Traditional marketingactivities (advertising,field selling, publicrelations, pricing); andexternal influence bytraditions, ideologyand word-of-mouth
From: Gronroos. 199 0, A S ervice Quality Model and its Marketing Implications
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DIFFICULTIES IN MEASUREMENT OF SERVICE QUALITY
Client’s mental model Courtesy bias Empowerment of the customers Diversity of Perspectives on Quality
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INTERPERSONAL PROCESS
‘The virtues’ of the interpersonal process of privacy, confidentiality, informed choice, concern, empathy, honesty, tact and sensitivity identified by Donabedian (1988) be applied as programmatic guidelines to assess and improve services in the QOC model
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HEALTH CARE MANAGER’S PERSPECTIVE
The production and maintenance of
high quality service
Non-physician manager
Clinician manager
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HEALTHCARE MANAGER’S PERSPECTIVE
Managers tend to feel that technical competence, efficiency, access and effectiveness are the most important dimensions of quality (Brown et al., 1993). Less importance is given to the interpersonal dimensions of service.
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HEALTH CARE PROVIDER’S PERSPECTIVE
Management enabling the internal customers
Commitment & motivation depends on the organization enabling them
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HEALTH CARE PROVIDER’S PERSEPCTIVE
Providers tend to focus on technical competence, effectiveness and of course, safety. This is for good clinical, ethical and legal reasons. They need and expect effective and efficient technical, administrative and supportive services in providing high quality service. Providers tend to underestimate the importance of the role they play and the attitudes they and other front-line staff have in shaping the interpersonal experience of the client and her perception of quality.
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DONOR/FUNDER PERSPECTIVE
Major donor interests in family planning, until recently, have been driven mostly by concerns related to reaching numerical targets to measure impact, efficiency and equity, and to a lesser extent by considerations of ethics
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CLIENT PERSPECTIVE
Family planning clients and communities in developing countries often focus on interpersonal process, geographic and financial accessibility, effectiveness of method, continuity of provider and physical amenities as the most important dimensions of quality. May clients in developing countries cannot adequately assess technical competence because power and knowledge asymmetries between provider and client are too large
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SERVICE QUALITY MODELQuality of service is when client’s perception of service received conforms to client’s expectation of service
Tangibles: the physical facilities, equipment, appearance of personnel
Reliability: the ability to perform the desired service dependably, accurately and consistently
Responsiveness: the willingness to provide prompt service and help customers
Assurance: employees’ knowledge, courtesy and ability to convey trust and confidence
Empathy: the provision of caring, individualised attention to customer
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Service- qualityimprovement
eff orts
UnitManagers
(FieldManagers)
Intermediateservice
providers(Support-
services team)
Customer-contact
personnel(providers)
Customers(FP clients)
Adapted from: Berry and Parasuraman, 1990, The Service Quality Puzzle
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TOTAL QUALITY MANAGEMENT (TQM)
Systems model of a Quality Loop
Market research & specifications Quality management system Quality control system Internal quality assurance systems External quality assurance systems
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Program Q uality A ssessment Model
PO LI CY & donorinterests
Enabling S ystems
O RGA N I Z A T I O N A LRO UT I N ES
HUMA N RES O URCESstaffi ng & training
F. P. T ECH N O LO GY
& clinical procedures
FA CI LI T I ES
I . E. & C.
S ERVI CEELEMEN T S
CommunityI nterests
CLI EN T
I MPA CT
Resources &
Management
or ganisat ional cont ex t communit y cont ex t
Q uality- of - CareEvaluation
Q
U
A
L
I
T
Y
M
A
N
A
G
E
M
E
N
T
ProgramQ uality
A ssessment
S o u r c e : R a g h a v a n -G ilb e r t , A P H A 1 9 9 1
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T he Discrepancy or Gap model f or Q uality A ssessment
3 Local Adaptation
2Decision toAssess(PQ AT )
1
Stakeholders
Perf ormanceStandards
(W hat should be)
Other
Actions
4T raining
5 Assessment (what is)
6 Follow- up action(to reach ‘should be’)
YES
FieldManagementFeedback
Policy & StrategyFeedback
PQAT
.S o u r c e : R a g h a v a n -G ilb e r t 9 7
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MANAGEMENT AND QUALITY ASSURANCE
Finding & fixing problems in processes
of work
Identify performance gap
Cyclical continuous activity
Role of Leadership
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Selected Quality Assessment Tools Case Follow-up Client Satisfaction Studies Clinic Management System Competency testing Consumer/Client Intercept Studies Counselor Training Evaluation Demographic and Health Survey Oversample Focus Group Discussions Hypothetical Cases Management Information Systems Matrix (CEDPA) Matrix (Enterprise) Monitoring Voluntary Surgical Contraception Procedures Observation
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Selected Quality Assessment Tools(cont’d)
Operations Research Panel Studies Patient/Client Flow Analysis Peer Review Programme Quality Assessment Tool (PQAT) Quality Definition and Assessment Record Review Self-Assessment Simulated/Mystery Client Studies Situation Analysis Structured Interviews/Surveys Supervision Tool (CARE) SWOT Analysis Use and Discontinuation Studies
Source: Katz et,al.1993
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The Service Performance GapFactors aff ecting workforcewillingness & ability to perform
Management factorsaff ecting performance
Role Conflict
Unclear roles and responsibilities
Poor fi t among elements of provider’s job
Lack of managementspecifications f or servicequality
I nadequate role support
Hiring practices,
Training programs
Support services
Neglecting the internal customer
Lack of management clarity andcommitment
I nadequate role environment
Organizational climate
Culture
Reward
Recognition
Lack of management concernabout workers morale
These create the service performance gap These are responsible for theservice performance gap
Adapted from Berry et al., 1990
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Program qualityindicators inPQAT
Criteria examined Quality linked Issues Activity targeted forimprovement
Competence Training SOP use Knowledge Interpersonal
Imported technologies Technology transfer andintegration
Case management Practice Communication Supervision
Choice Range available Method mix
Options Coercion Paternalism
Commodities acquisition Provider training Supervision
Safety Infection control Commodities storage
Invasive procedures Method failure
Training Management support Supervision
Medical backup Technical backup Emergency protocols Organizational routines
Adequacy ofcommodities
Written inventory Unbroken supply Training Organizational routines
Adequacy ofexpendables
Written inventory SOP application Training Organizational routines
Adequacy ofequipment
Written inventory Safe practice Training Organizational routines
ANALYSIS AND JUSTIFICATION OF PQAT CONTENT
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Programqualityindicators inPQAT
Criteria examined Quality linked Issues Activity targetedfor improvement
Physicalfacilities
Appearance Privacy Ventilation Water available Toilet/WC Signs and directions Client flow
Consumerpreferences Client needs Client satisfaction
Upgradefacilities Managementtraining Supervision
Guidelines &Protocols
Clinical guidelines Infection controlguidelines Management SOP Current literature
Specify currentstandard Technical practice Managementpractice
Managementsupport Training Supervision
IEC Hospital outreach Community outreach Teaching aids Informational materials
Parallel activity Communication
Program policy Organizationalroutines
MIS Records and forms Service statistics
Reliable client data Reliable programdata
Program policy Training Supervision
Supervision Project supervision Clinic supervision Supervisory tools Supervisory workplan
Close supportivesupervision Structuredsupervision
Managementsupport Training Supervisorysystems
ANALYSIS AND JUSTIFICATION OF PQAT CONTENT-cont’d
raghavan-gilbert/vw 39
Programquality
indicators inPQAT
Criteria examined Quality linked Issues Activity targetedfor improvement
Monitoring Program performance Program feedback
Intrinsic rewards Motivation
Management, field, and trainerlinkages
Client followup system
Defaulter tracing Appointment system
Program continuity Method continuity
Program policy changes
Accessibility Cost Distance Waiting time Cultural barriers Functional access
Program use Program non-use Methoddiscontinuation
Program design Program redesign
ANALYSIS AND JUSTIFICATION OF PQAT CONTENT-cont’d
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Program Quality Indicator Source of data Assessment score
Criteria to be fulfilledStandard to be met
Interview Obser-vation
Adequate NotAdequate
Explain score‘The WHY?”
Recommendationsfor improvement
TECHNICALCOMPETENCE (indicator)
IN
1. Have the technical staffreceived a minimum of twoweeks of pure FP trainingbefore certification (Criteria)(If less than 2 weeks thenmark not adequate)(Standard)
X X IN Many sources oftraining supportover the years
To build statelevel training database to enableplanning forprioritized trainingneeds
2. Were clinical staffrequired to do 10 IUDinsertions training prior tocertification(Criteria)(If less than 10 IUDinsertions under trainingthen mark not adequate)(Standard)
X X IN The standarddiffered withsource oftraining support
For closer on-the-job training andsupervision bystate trainingteams andsupervisors.
An Example of PQAT use from FHS Nigeria 1990-Clinic 7
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Program Quality Indicator Source of data Assessment score
Criteria to be fulfilledStandard to be met
Interview Obser-vation
Adequate NotAdequate
Explain score‘The WHY?”
Recommendationsfor improvement
TECHNICALCOMPETENCE (indicator)
IN
3. Have technical staff hadrefresher training within thelast 3 years?(Criteria)(If within 3 years then markadequate) (Standard)
X X IN Last trainingreceived byprovider wasabout 4 years ago.Has depended onnational and statetraining capacity
To be addressed asa priority by thecurrent trainingplans of the Statetraining teams.
4. Are infection controlguidelines & protocols (ICP)followed? (Criteria)(If absent, then mark notadequate) (Standard)
X IN Breaches in ICPobserved. ICPsupplies inshortage due tocentral problems.Errors in aseptictechniques. SOPsnot providedcentrally
To improve thecentral logisticssupport systems ofICP suppliesCloser OJT andsupervision in ICPby clinic and statelevel supervisorsFHS to expeditethe provision ofcentrallydevelopmentSOPs
An Example of PQAT use from FHS Nigeria 1990-Clinic 7 (cont’d)
raghavan-gilbert/vw 42
Program Quality Indicator Source of data Assessment score
Criteria to be fulfilledStandard to be met
Interview Obser-vation
Adequate NotAdequate
Explain score‘The WHY?”
Recommendationsfor improvement
TECHNICALCOMPETENCE (indicator)
IN
5. Are guidelines andprotocols used correctly incase management? (Criteria)(If correct then markadequate) (Standard)
X IN Provider hasoutdatedinformationabout oral pillsand clientselection. Lackof FP knowledgeweakenscounseling,causesunnecessarymethodswitching
To be addressedthrough trainingand on-the-jobsupervision. To beimproved throughthe provision ofSOPs forreference.
6. Are guidelines andprotocols used correctly inon-the-job training andsupervisory training?(Criteria)(If used then mark adequate)(Standard)
X X IN Not developedand providedfrom HQ
Central action isurgently needed toassist the trainersand supervisors toprovide bettersupport.
An Example of PQAT use from FHS Nigeria 1990-Clinic 7 (cont’d)
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Findings from Nigeria 1990
Findings byclinic
OYO OYO OYO KADUNA KADUNA KADUNA BENDEL BENDEL BENDEL BENDEL
Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8 Clinic 9 Clinic 10
Competence IN IN IN IN IN IN IN IN IN IN
I EC IN IN IN IN IN IN IN IN IN IN
ManagementIN IN
MIS IN IN IN IN Supervision IN IN IN IN
Monitoring IN IN IN IN Clientfollow up
IN IN IN IN IN IN IN IN
CommoditiesIN IN IN IN
ExpendablesIN IN IN IN IN IN IN IN IN IN
Equipment IN IN IN IN IN IN IN
Access IN IN IN
Physicalfacilities
IN IN IN
IN = Inadequate quality
raghavan-gilbert/vw 44
Findings from the Solomon I slands 1991
SOLOMONI SLANDS
Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6
Competence I N I N I N I NChoice I N I NSafety I N I N I N I NMedicalBackup
I N I N
Commodities I N I N I NConsumables I N I N I N I N
Equipment I N I N I NPhysicalFacility
I N I N I N I N
Access I N I N I N I N I NStd. andprotocols
I N I N I N I N I N I N
I EC I N I N I N I N I NMIS I N I N I N I N I N I NSupervision I N I N I N I N I NMonitoring I N I N I N I N I N I NClientfollow- up
I N I N I N I N I N I N
IN = Inadequate qualityBlank box = Adequate quality
raghavan-gilbert/vw 45
Findings from VANUATU 1991
VANUATU Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5
Competence I N I N I N
Choice I N I N I N
Safety I N I N
Medical Backup
Commodities I N I N I N I N I N
Consumables I N I N I N I N I N
Equipment I N I N I N I N I N
Physical Facility I N I N
Access I N I N
Std. &protocols
I N I N I N I N
I EC I N I N I N I N I N
MI S I N I N I N I N I N
Supervision I N I N I N I N
Monitoring I N I N I N I N
Client follow- up I N I N I N I N I N
IN= Inadequate quality; Blank box = Adequate quality
raghavan-gilbert/vw 46
Findings from FI J I 1991
FI J I Cl1
Cl 2µ
ANC
Cl3
Cl4
Cl5
Cl6
Cl7
Cl8
Cl9
Competence I N I N I N I N I N I N I N I N
ChoiceSafetyMedicalBackupCommodities I N
ConsumablesEquipmentPhysicalFacility
I N I N I N I N I N
Access I N I N
Std. &protocols
I N I N I N I N I N I N I N I N I N
I EC I N I N I N I N I N I N I N I N I N
MI S I N I N I N I N I N I N
Supervision I N I N I N I N I N I N
Monitoring I N I N I N I N
Client follow-up
I N I N I N I N I N I N I N
IN = Inadequate qualityBlank box = Adequate quality
µ= Only motivation, no clinical services
raghavan-gilbert/vw 47
“Would you tell me please, which way I ought to go from here?”
“That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where,” said Alice.“Then it doesn’t matter which way you go,” said the Cat.“So long as I get somewhere,” Alice added as an
explanation.“Oh, you’re sure to do that,” said the Cat, “If you only walk long enough”.
Lewis Carroll, Alice in Wonderland
raghavan-gilbert/vw 48
1. P.Raghavan-Gilbert, 1997 Service Quality Management in Family Planning: The Program Quality Assessment model, a multipurpose management tool, Doctoral Thesis, University of Exeter
2. Berry, L.L, Parasuraman, A, Zeithaml, V.A.1990 Quality Counts in Services too. In: Clark G (ed), Managing Service Quality. An IFS Executive Briefing, IFS Publications, UK
3. Bruce, J. 1989 Fundamental elements of quality of care: A Simple Framework, The Population Council, Working Papers (1).
4. Network FHI, Vol. 14 No. 1 1993 Quality of Care - Ways to Improve Care Focusing on Clients.
Key References: Quality of Care
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