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1Quach A, et al. BMJ Global Health 2021;6:e006804. doi:10.1136/bmjgh-2021-006804
Assessing the quality of care for children attending health facilities: a systematic review of assessment tools
Alicia Quach,1,2 Shidan Tosif,1,3 Herfina Nababan,4 Trevor Duke,1,3 Stephen M Graham,1,5 Wilson M Were,6 Moise Muzigaba,6 Fiona M Russell1,2
Original research
To cite: Quach A, Tosif S, Nababan H, et al. Assessing the quality of care for children attending health facilities: a systematic review of assessment tools. BMJ Global Health 2021;6:e006804. doi:10.1136/bmjgh-2021-006804
Handling editor Seye Abimbola
► Additional material is published online only. To view please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjgh- 2021- 006804).
Received 3 July 2021Accepted 9 September 2021
For numbered affiliations see end of article.
Correspondence toDr Alicia Quach; alicia. quach@ mcri. edu. au
© Author(s) (or their employer(s)) 2021. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.
ABSTRACTIntroduction Assessing quality of healthcare is integral in determining progress towards equitable health outcomes worldwide. Using the WHO ‘Standards for improving quality of care for children and young adolescents in health facilities’ as a reference standard, we aimed to evaluate existing tools that assess quality of care for children.Methods We undertook a systematic literature review of publications/reports between 2008 and 2020 that reported use of quality of care assessment tools for children (<15 years) in health facilities. Identified tools were reviewed against the 40 quality statements and 510 quality measures from the WHO Standards to determine the extent each tool was consistent with the WHO Standards. The protocol was registered in PROSPERO ID: CRD42020175652.Results Nine assessment tools met inclusion criteria. Two hospital care tools developed by WHO- Europe and WHO- South- East Asia Offices had the most consistency with the WHO Standards, assessing 291 (57·1%) and 208 (40·8%) of the 510 quality measures, respectively. Remaining tools included between 33 (6·5%) and 206 (40·4%) of the 510 quality measures. The WHO- Europe tool was the only tool to assess all 40 quality statements. The most common quality measures absent were related to experience of care, particularly provision of educational, emotional and psychosocial support to children and families, and fulfilment of children’s rights during care.Conclusion Quality of care assessment tools for children in health facilities are missing some key elements highlighted by the WHO Standards. The WHO Standards are, however, extensive and applying all the quality measures in every setting may not be feasible. A consensus of key indicators to monitor the WHO Standards is required. Existing tools could be modified to include priority indicators to strengthen progress reporting towards delivering quality health services for children. In doing so, a balance between comprehensiveness and practical utility is needed.PROSPERO registration number CRD42020175652.
INTRODUCTIONEnding preventable child deaths by 2030 is a major focus for the Sustainable Development Goals (SDGs).1 A crucial factor to achieving
this is Universal Health Coverage (UHC) which ensures that all people, including children, have access to quality essential healthcare services without being pushed
Key questions
What is already known? ► There are no universally agreed indicators to assess quality of health care.
► Previous reviews on quality of health care for children in low- income and middle- income countries (LMICs) tend to concentrate on system input measures such as physical infrastructure, availability of essential medicines, equipment and human resources.
► There has been no systematic review of existing as-sessment tools for quality of health care for children in health facilities.
What are the new findings? ► This is the first systematic review to compare ex-isting quality of care assessment tools against the WHO ‘Standards for improving the quality of care for children and young adolescents in health facilities’, and found that they do not adequately assess the WHO Standards in its current format.
► Most assessment tools were more comprehensive in assessing provision of care and available human and physical resources, but deficient in assessing experience of care.
► Most assessment tools focused more on input and process measures than outcome measures.
What do the new findings imply? ► There is no existing assessment tool that can com-prehensively assess all the indicators in the ‘WHO Standards’, however, the indicators are extensive and may not be feasible for LMICs to comprehen-sively assess.
► Future endeavours should focus on identifying and obtaining consensus on a selection of key indicators in the assessment of quality of health care for chil-dren in health facilities. Harmonisation of key indica-tors embedded within existing assessment tools will enable regular monitoring and comparable data in order to report progress in the quality of health care for children at local and national levels.
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into financial hardship. Quality healthcare is defined by WHO as health services which are ‘effective, efficient, accessible, patient centred, equitable and safe’.2 To further reduce child deaths, many countries will need to find ways to increase UHC with quality healthcare for children.
Determining progress in quality of healthcare delivery for children requires monitoring and tracking of measur-able indicators. However, there are no universally agreed indicators for quality of care (QoC). To better under-stand the complex multidimensional nature of quality healthcare, WHO developed a framework to identify domains to assess, improve and monitor the quality of paediatric care in health facilities, an extension of the earlier framework for improving maternal and newborn care in health facilities.3 4 The framework encompasses three broad categories of QoC: (A) provision of care—evidence- based practices, effective information systems and referral pathways; (B) experience of care—effec-tive communication, recognition of child rights and appropriate emotional and psychological support; and (C) available human and physical resources to meet the best interests of children. The broad categories are subdivided into eight domains to provide a structured approach when addressing QoC at all levels of the health system (online supplemental appendix A). These eight domains reflect the eight quality standards (QSd) in the WHO ‘Standards for improving the QoC for children and young adolescents in health facilities’ which are further detailed in 40 priority statements and 510 measurable indicators.4 The WHO Standards can, therefore, be used as a standard point of reference when assessing QoC for children in a healthcare facility.
Historically, various tools have been developed to assess QoC for children. We sought to understand if these tools adequately assess all aspects of QoC as outlined by the WHO Standards for children and young adolescents. A recent review identified and compared five existing assess-ment tools to the WHO ‘Standards for improving quality of maternal and newborn care in health facilities’.5 6 The percentage of indicators outlined in the WHO Standards that the five tools were able to assess ranged from 12% to 62%.6 There has been no systematic review of existing assessment tools for QoC for children <15 years. There is an urgent need to better understand the capacity of readily available tools to assess the QoC for children, in order to meet the SDG targets for child health.
The aim of this systematic literature review is to identify existing tools used to assess QoC for children and young adolescents in health facilities and assess the extent to which they represent the domains in the WHO QSd.
METHODSSearch strategy and selection criteriaA systematic review of the literature was undertaken in August 2020 using Preferred Reporting Items for System-atic Reviews and Meta- Analyses reporting guidelines, to
identify assessment tools available globally that evaluate QoC for children attending health facilities.7 MEDLINE (Ovid) database was searched using Medical Subject Heading terms and/or keywords. PubMed was searched using keywords, to retrieve items not indexed on MEDLINE. The PubMed search strategy was adapted for use in Global Health (Commonwealth Agricultural Bureaux direct) database and the International Journal for Quality in Health Care. Additional peer- reviewed publications were identified through handsearching of reference lists of key articles. Grey literature was iden-tified by conducting a keyword search using the World Bank and WHO library databases. The search strategies and results yielded are available from online supple-mental appendix B.
The inclusion criteria for eligibility included publi-cations/reports that: reported the use of an assessment tool to evaluate QoC in a primary, secondary or tertiary level healthcare facility. The assessment tool was deemed eligible if used by more than one country; and included at least one module/component evaluating QoC in chil-dren. A child was defined as aged 0–14 years, to align with the definition of ‘birth up to 15 years’ used in the WHO Standards. To identify tools more likely to be in current use and available globally, the search period was limited to ten years preceding the publication of the WHO Standards to present time (2008–2020), and to those published in English language. Exclusion criteria included publications/reports of assessment tools that: evaluated only newborns (<1 month old) or only adoles-cents (10–19 years old); were developed only for research purposes; evaluated QoC for a specific disease; or a niche component of QoC (eg, antimicrobial prescribing prac-tice). For any assessment tools not publicly available, authors and/or the original developers of the tool were contacted.
The screening process was performed independently by two reviewers using Covidence systematic review soft-ware.8 Titles and abstracts were screened and excluded if inclusion/exclusion criteria were not met. Full texts of remaining publications/reports were assessed for eligi-bility. The assessment tools from full texts were retrieved and further assessed to ensure that they met eligibility criteria. The assessment tools that were identified in multiple reports were grouped together as one unique tool for analysis. Conflicts in determining whether an article/assessment tool met eligibility criteria were resolved by discussion between the two reviewers. If consensus was not reached, a third reviewer was consulted.
Data analysisEach quality assessment tool included was compared against the WHO ‘Standards for improving QoC for chil-dren and young adolescents in health facilities’.4 The WHO Standards comprises of eight overarching ‘QSd’, each one correlating to one domain of the framework for improving quality of paediatric care. Each QSd is composed of priorities or ‘Quality Statements (QSt)’
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(total of 40) for improving QoC for children. The QSt further subdivided into 510 ‘Quality Measures (QM)’, comprised of 235 input, 169 process/output and 106 outcome measures (figure 1). A full list of the QSd, QSt and QM are listed in online supplemental appendix C.
For each assessment tool, we used the most updated version in English in its generic format. Each tool was composed of various modules to assess quality (eg, direct clinical observations, health worker interviews, inventory checklists). We evaluated all modules and excluded those not relevant to our review (eg, antenatal care services). For the remaining modules, we reviewed each question/statement and matched them if applicable to the relevant QM in the WHO Standards. Two paediatricians (AQ and ST) performed the matching process independently to decrease the risk of bias. Any conflicts were discussed between the two reviewers and a third reviewer was consulted for any unresolved conflicts.
We used a similar scoring system as the review of facility assessment tools on maternal and newborn QoC in health facilities performed by Brizuela et al.6 A ques-tion/statement from the tool was considered a match to a WHO QM if any component of the QM was included. If a WHO QM was matched, a score of 1 was allocated. Although multiple questions could match the same QM, each QM could only score a maximum of 1. For a QM that consisted of more than one subcomponent, a ques-tion/statement from the assessment tool only had to fulfil one subcomponent to be considered a match. For example, QM 1.1.1: ‘health facility maintains an up- to- date 24 hours staff duty roster, with a functioning contact mechanism for finding additional support, which ensures that staff responsible for paediatric triage are available at all times’; would be matched by a question asking if
the health facility has a 24- hour staff roster.4 Conversely, a single question/statement could also be matched to more than one QM. For example, an assessment tool with a checklist of available antibiotics in the health facility would match the WHO QM detailing adequate supplies of antibiotics to treat pneumonia (QM 1.3.3), sepsis (QM 1.5.4), neonatal infections (QM 1.2.2); while also matching the QM detailing adequate stocks of essential medicines (QM 8.4.4).
Descriptive statistics were used to calculate the percentage of matched QM, QSt and QSd for each assess-ment tool. The assessment tools were ranked according to the total percentage of WHO QM assessable. Assess-ment tools were also categorised according to whether they were able to completely assess (100%), partially assess (1%–49% and 50%–99%), or not assess (0%) any of the QSd and QSt.
Patient and public involvementNo patients or public were involved in this study.
RESULTSThe search strategy identified 1180 publications/reports, after duplicates were removed (figure 2). The screening process excluded 1035 publications/reports. The remaining 145 full- text manuscripts were assessed for eligibility, with 39 publications/reports being deemed eligible. These publications/reports were further evalu-ated to collate duplications of assessment tools, with 10 unique tools identified as eligible. One tool was not accessible from the author, leaving nine unique assess-ment tools for analysis (figure 2).
Table 1 summarises the nine assessment tools and the modules that were evaluated as part of our analysis. All tools were developed for use in low- income and middle- income countries (LMICs), except for the Child Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).9 All tools were available in English, but could be adapted/translated to local context. All tools were structured questionnaires/interviews with checklist style questions, but varied in length and compo-sition of modules. The shortest tool was the HCAHPS with 62 multichoice questions. Others such as the Service Provision Assessment (SPA) and the WHO Hospital Care assessment tools were detailed with over 100 pages, had multiple modules, with over 100 questions/checklist items per module.10–12
Table 2 summarises the percentages of WHO QM within each QSd assessable by each tool. Overall, QM related to the domains of provision of care and available human and physical resources were more widely assessable than experience of care. QSd 1: ‘Every child receives evidence- based care and management of illness according to WHO guidelines’ was most comprehensively assessable across all tools, apart from the Child HCAHPS which did not assess it at all.4 9 QSd 6: ‘All children and their families are provided with educational, emotional and psychosocial
Figure 1 Structure of the WHO ‘Standards for improving the quality of care for children and youngadolescents in health facilities’.
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support that is sensitive to their needs and strengthens their capability’ was absent from five of the nine included tools.4 All assessment tools were able to partially assess QSd 7 (staff availability) and QSd 8 (health facility phys-ical infrastructure, waste management, supplies and equipment).
Overall, the tools were more comprehensive at assessing the input QM (median 32·8%, IQR (16·4%–45·3%)) and process/output QM (median 21·3%, IQR (12·4–41·7%)) compared with the outcome QM (median 16·0%, IQR (3·8%–28·3%)). Table 3 summarises the proportion of QSt that had at least one each of input, process and outcome QM within each QSd. No single tool was able to fulfil this for all 40 WHO QSt. The percentages of QM that was assessable within each of the 40 QSt are summarised
in figure 3. The WHO (Europe regional office) ‘Hospital care for children: quality assessment and improvement tool’ was the only tool able to partially assess every QSt. Of the remaining tools, 5–27 of 40 QSt were not assess-able at all. The SPA and the Health Resources Available Mapping System (HeRAMS) were the only tools able to assess 100% of any one QSt. The HeRAMS, however, failed to assess any QM of 15 other QSt.
Figure 4 shows the overall percentage of QM assess-able by each tool. The WHO- Europe tool was the most comprehensive with 291 (57·1%) of the 510 WHO QM being assessable.11 The remaining tools varied from 6·5% to 40·8% in their capacities to assess the QM. Table 4 shows the percentage of assessable QM in each QSt. Most tools assessed less than half the QM in any single QSt. The
Figure 2 PRISMA flow diagram for the selection of assessment tools. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta- Analyses.
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Tab
le 1
S
umm
ary
of a
sses
smen
t to
ols
revi
ewed
for
qua
lity
of c
are
for
child
ren
in h
ealth
faci
litie
s
Too
lD
evel
op
men
t/so
urce
Typ
e o
f he
alth
fac
ility
to
ol d
esig
ned
fo
rP
op
ulat
ion
and
ser
vice
s to
ol d
esig
ned
fo
rK
ey t
op
ics
asse
ssed
b
y to
ol
Co
untr
ies
that
hav
e us
ed t
oo
l*Ve
rsio
n as
sess
edM
od
ules
incl
uded
in
asse
ssm
ent
Ser
vice
Pro
visi
on
Ass
essm
ent10
US
AID
-
ME
AS
UR
E
Eva
luat
ion
All
heal
th fa
cilit
y ty
pes
All
ages
Fam
ily p
lann
ing,
mat
erna
l an
d c
hild
hea
lth s
ervi
ces,
co
mm
unic
able
and
non
- co
mm
unic
able
dis
ease
s,
bas
ic s
urge
ry
►
Ava
ilab
ility
of h
ealth
se
rvic
es
►S
ervi
ces
read
ines
s of
he
alth
faci
litie
s
►E
xten
t se
rvic
es fo
llow
ac
cep
ted
sta
ndar
ds
of c
are
►
Sat
isfa
ctio
n le
vels
of
clie
nts
and
ser
vice
p
rovi
der
s
Afg
hani
stan
, B
angl
ades
h, C
ongo
D
R, E
gyp
t, E
thio
pia
, G
hana
, Gua
tem
ala,
G
uyan
a, H
aiti,
Ken
ya,
Mal
awi,
Nam
ibia
, N
epal
, Rw
and
a,
Sen
egal
, Tan
zani
a,
Uga
nda,
Zam
bia
2012
►
Inve
ntor
y
►C
linic
al
obse
rvat
ion—
sick
ch
ild
►E
xit
inte
rvie
w—
care
take
r of
sic
k ch
ild
►H
ealth
wor
ker
inte
rvie
w
Rap
id H
ealth
Fac
ility
A
sses
smen
t32U
SA
ID- M
EA
SU
RE
E
valu
atio
nP
rimar
y he
alth
care
fa
cilit
ies
Wom
en a
nd c
hild
ren
Mat
erna
l, ne
onat
al a
nd
child
hea
lth s
ervi
ces
►
Ass
essm
ent,
d
iagn
osis
and
tr
eatm
ent
of c
omm
on
child
hood
illn
esse
s
►S
ervi
ce r
ead
ines
s of
he
alth
faci
litie
s
►Q
ualit
y of
m
anag
emen
t p
roce
sses
in h
ealth
fa
cilit
ies
Nig
eria
, Sou
th S
udan
2008
►
Clin
ical
ob
serv
atio
n—si
ck
child
►
Exi
t in
terv
iew
—ca
reta
ker
of s
ick
child
►
Hea
lth w
orke
r in
terv
iew
and
re
cord
rev
iew
►
Hea
lth fa
cilit
y ch
eckl
ist
Ser
vice
Ava
ilab
ility
and
R
ead
ines
s A
sses
smen
t19W
HO
All
heal
th fa
cilit
y ty
pes
All
ages
Mat
erna
l and
chi
ld h
ealth
se
rvic
es, c
omm
unic
able
an
d n
on- c
omm
unic
able
d
isea
ses,
sur
gica
l car
e
►
Ser
vice
ava
ilab
ility
- in
fras
truc
ture
, cor
e he
alth
per
sonn
el,
serv
ice
utili
satio
n
►G
ener
al s
ervi
ce
read
ines
s- b
asic
eq
uip
men
t, a
men
ities
, in
fect
ion
pre
vent
ion,
d
iagn
ostic
cap
acity
, es
sent
ial m
edic
ines
►
Ser
vice
- sp
ecifi
c re
adin
ess
Ban
glad
esh,
Ben
in,
Bur
kina
Fas
o,
Cam
bod
ia, C
ongo
D
R, C
ote
D’Iv
oire
, D
jibou
ti, G
hana
, Hai
ti,
Ind
ia, K
enya
, Lao
PD
R,
Lib
ya M
adag
asca
r, M
aurit
ania
, Mya
nmar
, N
amib
ia, N
iger
, R
wan
da,
Sen
egal
, S
ierr
a Le
one,
Som
alia
, S
outh
Sud
an T
anza
nia,
To
go, U
gand
a V
ietn
am,
Zam
bia
, Zim
bab
we
2015
►
Sta
ffing
►
Infr
astr
uctu
re
►A
vaila
ble
ser
vice
s
►D
iagn
ostic
s
►M
edic
ines
and
co
mm
oditi
es
Con
tinue
d
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Too
lD
evel
op
men
t/so
urce
Typ
e o
f he
alth
fac
ility
to
ol d
esig
ned
fo
rP
op
ulat
ion
and
ser
vice
s to
ol d
esig
ned
fo
rK
ey t
op
ics
asse
ssed
b
y to
ol
Co
untr
ies
that
hav
e us
ed t
oo
l*Ve
rsio
n as
sess
edM
od
ules
incl
uded
in
asse
ssm
ent
Hea
lth F
acili
ty S
urve
y-
usin
g In
tegr
ated
M
anag
emen
t C
hild
hood
Ill
ness
as
clin
ical
gu
idel
ines
33
WH
OP
rimar
y le
vel o
utp
atie
nt
heal
th fa
cilit
ies
All
child
ren
Out
pat
ient
car
e fo
r si
ck
child
ren
►
Qua
lity
of c
ase
man
agem
ent
rece
ived
b
y si
ck c
hild
ren
►
Qua
lity
of c
ouns
ellin
g of
car
etak
ers
►
Ava
ilab
ility
of k
ey
heat
h sy
stem
su
pp
orts
- ed
icin
es,
equi
pm
ent,
su
per
visi
on, r
efer
ral
syst
em
►B
arrie
rs t
o ef
fect
ive
inte
grat
ed c
ase
man
agem
ent
Bot
swan
a, C
amb
odia
, G
uate
mal
a, K
enya
, Z
amb
ia, A
fgha
nist
an,
Rw
and
a, C
hina
, M
alaw
i, M
ongo
lia,
Nig
eria
, Pap
ua N
ew
Gui
nea,
Phi
lipp
ines
, V
ietn
am, K
irib
ati,
Lao
PD
R, S
olom
on Is
land
s
2003
►
Clin
ical
ob
serv
atio
n—si
ck
child
►
Exi
t in
terv
iew
—ca
reta
ker
of s
ick
child
►
Re-
exam
inat
ion
of
sick
chi
ld
►E
qui
pm
ent
and
su
pp
ly c
heck
list
Ass
essm
ent
Tool
for
Hos
pita
l Car
e (W
HO
- SE
A
sia
Offi
ce)12
WH
O- S
E A
sia
Offi
ceA
ll ho
spita
lsW
omen
and
chi
ldre
nM
ater
nal,
neon
atal
and
ch
ild h
ealth
ser
vice
s
►
Ser
vice
ava
ilab
ility
an
d r
ead
ines
s-
infr
astr
uctu
re, h
osp
ital
sup
por
t sy
stem
s,
staf
fing,
ess
entia
l m
edic
ines
and
d
iagn
ostic
s
►Q
ualit
y of
med
ical
ca
re p
rovi
ded
for
mat
erna
l, ne
onat
al
and
chi
ld h
ealth
se
rvic
es
►S
atis
fact
ion
leve
ls o
f cl
ient
s an
d s
ervi
ce
pro
vid
ers
Ind
ones
ia, N
epal
2016
►
Gen
eral
hos
pita
l in
form
atio
n
►P
aed
iatr
ic c
are
►
Car
egiv
er in
terv
iew
►
Hea
lth w
orke
r in
terv
iew
►
Pos
tal
que
stio
nnai
re
Tab
le 1
C
ontin
ued
Con
tinue
d
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Quach A, et al. BMJ Global Health 2021;6:e006804. doi:10.1136/bmjgh-2021-006804 7
BMJ Global Health
Too
lD
evel
op
men
t/so
urce
Typ
e o
f he
alth
fac
ility
to
ol d
esig
ned
fo
rP
op
ulat
ion
and
ser
vice
s to
ol d
esig
ned
fo
rK
ey t
op
ics
asse
ssed
b
y to
ol
Co
untr
ies
that
hav
e us
ed t
oo
l*Ve
rsio
n as
sess
edM
od
ules
incl
uded
in
asse
ssm
ent
Hos
pita
l car
e fo
r ch
ildre
n:
qua
lity
asse
ssm
ent
and
im
pro
vem
ent
tool
(WH
O-
Eur
ope
Offi
ce)11
WH
O- E
urop
e O
ffice
All
hosp
itals
All
child
ren,
exc
lud
ing
new
bor
nsP
aed
iatr
ic s
ervi
ces,
ex
clud
ing
neon
atal
he
alth
care
►
Ser
vice
ava
ilab
ility
an
d r
ead
ines
s-
infr
astr
uctu
re, h
osp
ital
sup
por
t sy
stem
s,
heal
th m
anag
emen
t in
form
atio
n sy
stem
s,
staf
fing,
ess
entia
l m
edic
ines
and
eq
uip
men
t
►Q
ualit
y of
med
ical
ca
re p
rovi
ded
fo
r co
mm
on
child
hood
illn
esse
s an
d e
mer
genc
y p
rese
ntat
ions
►
Hos
pita
l pol
ices
and
gu
idel
ines
- inf
ectio
n p
reve
ntio
n, t
rain
ing,
ac
cess
, pat
ient
’s
right
s
►S
atis
fact
ion
leve
ls o
f cl
ient
s an
d s
ervi
ce
pro
vid
ers
Kyr
gyst
an, T
ajik
ista
n,
Eth
iop
ia, A
ngol
a,
Mal
awi,
Moz
amb
ique
2015
►
Hos
pita
l sup
por
t se
rvic
es
►C
ase
man
agem
ent
►
Pol
icie
s an
d
orga
nisa
tion
of
serv
ices
►
Inte
rvie
ws
Hea
lth R
esou
rces
A
vaila
bili
ty M
app
ing
Sys
tem
34
WH
OH
uman
itaria
n an
d
Em
erge
ncy
Res
pon
se
sett
ings
All
ages
Ess
entia
l tra
uma
care
, ch
ild h
ealth
and
nut
ritio
n,
com
mun
icab
le d
isea
ses,
m
enta
l hea
lth, s
exua
l and
re
pro
duc
tive
heal
th
►
Ava
ilab
ility
of h
ealth
fa
cilit
ies
and
ser
vice
s
►R
esou
r ces
for
serv
ice
del
iver
y- in
fras
truc
ture
, hu
man
res
ourc
es,
com
mun
icat
ions
, in
fect
ion
cont
rol
►
Rea
sons
for
gap
s in
se
rvic
e av
aila
bili
ty
Sud
an, U
gand
a20
17
►H
osp
itals
as
sess
men
t to
ol
►H
ealth
cen
tres
as
sess
men
t to
ol
Tab
le 1
C
ontin
ued
Con
tinue
d
on Novem
ber 23, 2021 by guest. Protected by copyright.
http://gh.bmj.com
/B
MJ G
lob Health: first published as 10.1136/bm
jgh-2021-006804 on 4 October 2021. D
ownloaded from
8 Quach A, et al. BMJ Global Health 2021;6:e006804. doi:10.1136/bmjgh-2021-006804
BMJ Global Health
Too
lD
evel
op
men
t/so
urce
Typ
e o
f he
alth
fac
ility
to
ol d
esig
ned
fo
rP
op
ulat
ion
and
ser
vice
s to
ol d
esig
ned
fo
rK
ey t
op
ics
asse
ssed
b
y to
ol
Co
untr
ies
that
hav
e us
ed t
oo
l*Ve
rsio
n as
sess
edM
od
ules
incl
uded
in
asse
ssm
ent
Hea
lth R
esul
ts B
ased
Fi
nanc
ing
imp
act
eval
uatio
n to
olki
t35
Wor
ld B
ank
All
heal
thca
re fa
cilit
ies
(Pro
gram
me
eval
uatin
g th
e im
pac
t of
hea
lth-
rela
ted
res
ults
- bas
ed
finan
cing
ince
ntiv
es)
All
ages
with
focu
s on
w
omen
and
chi
ldre
nM
ater
nal,
neon
atal
an
d c
hild
hea
lth,
com
mun
icab
le d
isea
ses
►
Qua
ntity
of h
ealth
se
rvic
es d
eliv
ered
►
Qua
lity
of h
ealth
se
rvic
es p
rovi
ded
►
Hea
lth o
utco
mes
►
Res
ourc
e m
anag
emen
t at
hea
lth
faci
litie
s
►Im
pac
t on
non
- res
ults
b
ased
fina
ncin
g se
rvic
es d
eliv
ered
►
Dis
aggr
egat
ion
of
imp
act
by
pro
vid
er
and
pop
ulat
ion
char
acte
ristic
s
Tajik
ista
n, B
urki
na
Faso
, Con
go D
R,
Rw
and
a, B
enin
, Le
soth
o, K
yrgy
zsta
n,
Cam
eroo
n, C
entr
al
Afr
ican
Rep
ublic
, The
G
amb
ia,
2012
►
Hea
lth fa
cilit
y as
sess
men
t
►H
ealth
wor
ker
ind
ivid
ual
►
Exi
t in
terv
iew
- ca
regi
ver
for
child
un
der
5
Hos
pita
l Con
sum
er
Ass
essm
ent
of H
ealth
care
P
rovi
der
s an
d S
yste
ms-
C
hild
Ver
sion
9
Bos
ton
Chi
ldre
n’s
Hos
pita
lA
ll ho
spita
lsA
ll ch
ildre
nA
ll p
aed
iatr
ic in
pat
ient
he
alth
ser
vice
s
►
Qua
lity
of
com
mun
icat
ion
with
car
egiv
ers
and
p
atie
nts
►
Att
entio
n to
saf
ety
and
co
mfo
rt
►H
osp
ital e
nviro
nmen
t
Bel
gium
, Can
ada,
U
SA
, Arg
entin
a20
14
►E
ntire
sur
vey
(62
item
s)
*Onl
y in
clud
es c
ount
ries
with
rep
orts
/dat
a p
ublic
ly a
vaila
ble
.
Tab
le 1
C
ontin
ued
on Novem
ber 23, 2021 by guest. Protected by copyright.
http://gh.bmj.com
/B
MJ G
lob Health: first published as 10.1136/bm
jgh-2021-006804 on 4 October 2021. D
ownloaded from
Quach A, et al. BMJ Global Health 2021;6:e006804. doi:10.1136/bmjgh-2021-006804 9
BMJ Global Health
Tab
le 2
P
erce
ntag
e of
WH
O Q
ualit
y S
tand
ard
s as
sess
able
by
each
qua
lity
asse
ssm
ent
tool
Per
cent
age
of
Qua
lity
Mea
sure
s as
sess
able
fo
r ea
ch Q
ualit
y S
tand
ard
WH
O- E
uro
pe
WH
O- S
E A
sia
SPA
HR
BF
HeR
AM
Sr-
HFA
SA
RA
HFS
- IM
CI
HC
AH
PS
- Chi
ld
Sta
ndar
d 1
: Eve
ry c
hild
rec
eive
s ev
iden
ce- b
ased
ca
re a
nd m
anag
emen
t of
illn
ess
acco
rdin
g to
WH
O
guid
elin
es. (
n=22
2)
59%
55%
49%
27%
39%
24%
23%
18%
0%
Sta
ndar
d 2
: The
hea
lth in
form
atio
n sy
stem
ens
ures
th
e co
llect
ion,
ana
lysi
s an
d u
se o
f dat
a to
ens
ure
early
, ap
pro
pria
te a
ctio
n to
imp
rove
the
car
e of
ev
ery
child
. (n=
29)
52%
52%
48%
38%
0%24
%0%
10%
10%
Sta
ndar
d 3
: Eve
ry c
hild
with
con
diti
on(s
) tha
t ca
nnot
be
trea
ted
effe
ctiv
ely
with
the
ava
ilab
le
reso
urce
s re
ceiv
es a
pp
rop
riate
, tim
ely
refe
rral
, with
se
amle
ss c
ontin
uity
of c
are.
(n=
28)
39%
18%
36%
39%
43%
7%7%
18%
0%
Sta
ndar
d 4
: Com
mun
icat
ion
with
chi
ldre
n an
d t
heir
fam
ilies
is e
ffect
ive,
with
mea
ning
ful p
artic
ipat
ion
and
res
pon
ds
to t
heir
need
s an
d p
refe
renc
es.
(n=
45)
53%
22%
29%
24%
9%7%
0%16
%27
%
Sta
ndar
d 5
: Eve
ry c
hild
’s r
ight
s ar
e re
spec
ted
, p
rote
cted
and
fulfi
lled
at
all t
imes
dur
ing
care
, w
ithou
t d
iscr
imin
atio
n. (n
=44
)
45%
11%
20%
14%
7%5%
5%2%
9%
Sta
ndar
d 6
: All
child
ren
and
the
ir fa
mili
es
are
pro
vid
ed w
ith e
duc
atio
nal,
emot
iona
l and
p
sych
osoc
ial s
upp
ort
that
is s
ensi
tive
to t
heir
need
s an
d s
tren
gthe
ns t
heir
cap
abili
ty. (
n=32
)
66%
9%3%
0%0%
0%0%
0%19
%
Sta
ndar
d 7
: For
eve
ry c
hild
, com
pet
ent,
mot
ivat
ed,
emp
athi
c st
aff a
re c
onsi
sten
tly a
vaila
ble
to
pro
vid
e ro
utin
e ca
re a
nd m
anag
emen
t of
com
mon
ch
ildho
od il
lnes
ses.
(n=
44)
70%
34%
52%
59%
2%25
%7%
16%
7%
Sta
ndar
d 8
: The
hea
lth fa
cilit
y ha
s an
ap
pro
pria
te,
child
frie
ndly
phy
sica
l env
ironm
ent,
with
ad
equa
te w
ater
, san
itatio
n, w
aste
man
agem
ent,
en
ergy
sup
ply
, med
icin
es, m
edic
al s
upp
lies
and
eq
uip
men
t fo
r ro
utin
e ca
re a
nd m
anag
emen
t of
co
mm
on c
hild
hood
illn
esse
s. (n
=66
)
56%
50%
41%
39%
35%
20%
32%
3%8%
Red
box
es in
dic
ate
that
the
ass
essm
ent
tool
did
not
ass
ess
any;
ora
nge
box
es in
dic
ate
less
tha
n ha
lf an
d y
ello
w b
oxes
ind
icat
e eq
ual t
o or
mor
e th
an h
alf o
f the
qua
lity
mea
sure
s w
ere
asse
ssab
le in
the
ass
ocia
ted
Qua
lity
Sta
ndar
d.
HC
AH
PS
, Hos
pita
l Con
sum
er A
sses
smen
t of
Hea
lthca
re P
rovi
der
s an
d S
yste
ms;
HeR
AM
S, H
ealth
Res
ourc
es A
vaila
bili
ty M
app
ing
Sys
tem
; HFS
- IM
CI,
Hea
lth F
acili
ty S
urve
y—us
ing
Inte
grat
ed
Man
agem
ent
of C
hild
hood
Illn
ess
clin
ical
gui
del
ines
; HR
BF,
Hea
lth R
esul
ts B
ased
Fin
anci
ng im
pac
t ev
alua
tion
tool
kit;
n, n
umb
er o
f Qua
lity
Mea
sure
s w
ithin
the
ass
ocia
ted
Qua
lity
Sta
ndar
d;
r- H
FA, r
apid
Hea
lth F
acili
ty A
sses
smen
t; S
AR
A, S
ervi
ce A
vaila
bili
ty a
nd R
ead
ines
s A
sses
smen
t; S
PA, S
ervi
ce P
rovi
sion
Ass
essm
ent.
;
on Novem
ber 23, 2021 by guest. Protected by copyright.
http://gh.bmj.com
/B
MJ G
lob Health: first published as 10.1136/bm
jgh-2021-006804 on 4 October 2021. D
ownloaded from
10 Quach A, et al. BMJ Global Health 2021;6:e006804. doi:10.1136/bmjgh-2021-006804
BMJ Global Health
Tab
le 3
P
rop
ortio
n of
WH
O Q
ualit
y S
tate
men
ts w
ith a
t le
ast
one
each
of i
nput
, pro
cess
and
out
put
Qua
lity
Mea
sure
ass
essa
ble
by
each
qua
lity
asse
ssm
ent
tool
Per
cent
age
of
Qua
lity
Mea
sure
s as
sess
able
fo
r ea
ch Q
ualit
y S
tand
ard
WH
O- E
uro
pe
WH
O- S
E A
sia
SPA
HR
BF
HeR
AM
Sr-
HFA
SA
RA
HFS
- IM
CI
HC
AH
PS
- Chi
ld
Sta
ndar
d 1
: Eve
ry c
hild
rec
eive
s ev
iden
ce- b
ased
ca
re a
nd m
anag
emen
t of
illn
ess
acco
rdin
g to
WH
O
guid
elin
es. (
QS
t=15
)
7/15
7/15
6/15
2/15
1/15
0/15
0/15
1/15
0/15
Sta
ndar
d 2
: The
hea
lth in
form
atio
n sy
stem
ens
ures
th
e co
llect
ion,
ana
lysi
s an
d u
se o
f dat
a to
ens
ure
early
, ap
pro
pria
te a
ctio
n to
imp
rove
the
car
e of
eve
ry c
hild
. (Q
St=
3)
2/3
3/3
2/3
2/3
0/3
1/3
0/3
0/3
0/3
Sta
ndar
d 3
: Eve
ry c
hild
with
con
diti
on(s
) tha
t ca
nnot
be
trea
ted
effe
ctiv
ely
with
the
ava
ilab
le r
esou
rces
rec
eive
s ap
pro
pria
te, t
imel
y re
ferr
al, w
ith s
eam
less
con
tinui
ty o
f ca
re. (
QS
t=3)
1/3
0/3
1/3
2/3
1/3
0/3
0/3
0/3
0/3
Sta
ndar
d 4
: Com
mun
icat
ion
with
chi
ldre
n an
d t
heir
fam
ilies
is e
ffect
ive,
with
mea
ning
ful p
artic
ipat
ion,
and
re
spon
ds
to t
heir
need
s an
d p
refe
renc
es (Q
St=
4)
2/4
1/4
1/4
2/4
0/4
0/4
0/4
0/4
1/4
Sta
ndar
d 5
: Eve
ry c
hild
’s r
ight
s ar
e re
spec
ted
, p
rote
cted
and
fulfi
lled
at
all t
imes
dur
ing
care
, with
out
dis
crim
inat
ion.
(QS
t=5)
2/5
0/5
1/5
0/5
0/5
0/5
0/5
0/5
0/5
Sta
ndar
d 6
: All
child
ren
and
the
ir fa
mili
es a
re p
rovi
ded
w
ith e
duc
atio
nal,
emot
iona
l and
psy
chos
ocia
l sup
por
t th
at is
sen
sitiv
e to
the
ir ne
eds
and
str
engt
hens
the
ir ca
pab
ility
. (Q
St=
3)
3/3
0/3
0/3
0/3
0/3
0/3
0/3
0/3
0/3
Sta
ndar
d 7
: For
eve
ry c
hild
, com
pet
ent,
mot
ivat
ed,
emp
athi
c st
aff a
re c
onsi
sten
tly a
vaila
ble
to
pro
vid
e ro
utin
e ca
re a
nd m
anag
emen
t of
com
mon
chi
ldho
od
illne
sses
. (Q
St=
3)
3/3
2/3
2/3
2/3
0/3
1/3
0/3
1/3
0/3
Sta
ndar
d 8
: The
hea
lth fa
cilit
y ha
s an
ap
pro
pria
te,
child
frie
ndly
phy
sica
l env
ironm
ent,
with
ad
equa
te
wat
er, s
anita
tion,
was
te m
anag
emen
t, e
nerg
y su
pp
ly,
med
icin
es, m
edic
al s
upp
lies
and
eq
uip
men
t fo
r ro
utin
e ca
re a
nd m
anag
emen
t of
com
mon
chi
ldho
od il
lnes
ses.
(Q
St=
4)
1/4
1/4
2/4
2/4
0/4
1/4
1/4
0/4
0/4
Tota
l Qua
lity
Sta
tem
ents
=40
21/4
014
/40
15/4
012
/40
2/40
3/40
1/40
2/40
1/40
Red
box
es in
dic
ate
that
the
ass
essm
ent
tool
did
not
incl
ude
any;
ora
nge
box
es in
dic
ate
less
tha
n ha
lf; y
ello
w b
oxes
ind
icat
e eq
ual t
o or
mor
e th
an h
alf a
nd g
reen
box
es in
dic
ate
that
all
of t
he
Qua
lity
Sta
tem
ents
with
in t
he a
ssoc
iate
d Q
ualit
y S
tand
ard
had
at
leas
t on
e ea
ch o
f inp
ut, p
roce
ss a
nd o
utco
me
Qua
lity
Mea
sure
ass
essa
ble
.H
CA
HP
S, H
osp
ital C
onsu
mer
Ass
essm
ent
of H
ealth
care
Pro
vid
ers
and
Sys
tem
s; H
eRA
MS
, Hea
lth R
esou
rces
Ava
ilab
ility
Map
pin
g S
yste
m; H
FS- I
MC
I, H
ealth
Fac
ility
Sur
vey—
usin
g In
tegr
ated
M
anag
emen
t of
Chi
ldho
od Il
lnes
s cl
inic
al g
uid
elin
es; H
RB
F, H
ealth
Res
ults
Bas
ed F
inan
cing
imp
act
eval
uatio
n to
olki
t; Q
St,
num
ber
of Q
ualit
y S
tate
men
ts w
ithin
the
ass
ocia
ted
Qua
lity
Sta
ndar
d; r
- HFA
, rap
id H
ealth
Fac
ility
Ass
essm
ent;
SA
RA
, Ser
vice
Ava
ilab
ility
and
Rea
din
ess
Ass
essm
ent;
SPA
, Ser
vice
Pro
visi
on A
sses
smen
t.;
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BMJ Global Health
WHO- Europe tool and the WHO- SE Asia were the most comprehensive, able to assess more than half the QM in 23 and 13 of the 40 QSt, respectively. The HCAHPS- Child tool had the largest number of gaps, leaving 27 QSt
completely unassessed, but was able to assess 9 (69%) of the 13 QM for QSt 4.1, that is, effective communication given to children and their carers, which is a key objective of the tool.
DISCUSSIONThis is the first systematic review to compare QoC assess-ment tools against the current WHO Standards for chil-dren and young adolescents in health facilities. Three of the nine assessment tools included questions from all eight of the WHO QSd, but only one (WHO- Europe Hospital Care assessment tool) was able to address all 40 QSt. Despite being the most comprehensive tool, the WHO- Europe Hospital Care assessment tool still only included about half of all QM. QSd that included evidence- based management, staffing and physical infra-structure and resources (QSd 1,7 and 8) were more widely covered across the tools than those which encompassed health information systems (HIS), referral processes, communication, psychosocial support and child rights (QSd 2–6).
Previous assessments of QoC in LMICs have often centred on input measures as these are seen to be more tangible, objective measures.6 13–15 This was reflected in this review with most tools assessing more input measures and less process or outcome measures, and no tool assessing at least one input, process and outcome measure in all 40 QSt. Mortality data were largely absent from almost all tools. The Donabedian quality framework describes the relationship between the three components on input/structure, process and outcomes.16 Although structural, input measures are important to healthcare delivery, the flow- on effects to processes such as appro-priate care delivery and adequate communication, and outcome measures such as morbidity and mortality data, and patient satisfaction, determine how successful a health facility is. Including all three components is there-fore crucial for assessing the level of QoC that is being provided for children in hospitals.
The WHO Standards for improving QoC for children and young adolescents were used in this review as a refer-ence standard for assessing QoC for children attending health facilities. They are comprehensive and include all three components of the Donabedian quality framework, while aligning with the SDG emphasis on equity. They have been developed as a resource for healthcare profes-sionals and managers at the health facility level through to government bodies and technical partners responsible for policy and programme development at the national level, to support quality improvement practices for chil-dren.4 How the WHO Standards are implemented in practice and what tools to use when assessing quality of healthcare for children, are to be decided within the local context. However, it is unlikely that a single tool could encompass all 510 QM and be feasible in most settings in LMICs.
Figure 3 Percentage of WHO Quality Statements* assessable by each quality assessment tool. *‘Quality Statements’ are 40 concise statements of the priorities for improving quality of care for children as documented in the WHO Standards. Each quality statement contains from 6 to 22 quality measures.4 Not assessable = the assessment tool did not assess any quality measures in the quality statement. Partially assessable = the assessment tool assessed at least one of the quality measures in the quality statement. Completely assessable = the assessment tool assessed all of the quality measures in the quality statement. HRBF, Health Results Based Financing impact evaluation toolkit; HeRAMS, Health Resources Availability Mapping System; HFS- IMCI, Health Facility Survey—using Integrated Management of Childhood Illness clinical guidelines; HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems; r- HFA, rapid Health Facility Assessment; SPA, Service Provision Assessment. SARA, Service Availability and Readiness Assessment.
Figure 4 Overall percentage of WHO Quality Measures* assessable by each quality assessment tool. HRBF, Health Results Based Financing impact evaluation toolkit; HeRAMS, Health Resources Availability Mapping System; HFS- IMCI, Health Facility Survey—using Integrated Management of Childhood Illness clinical guidelines; HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems; r- HFA, rapid Health Facility Assessment; SPA, Service Provision Assessment; SARA, Service Availability and Readiness Assessment.
on Novem
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ownloaded from
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BMJ Global Health
Tab
le 4
P
erce
ntag
e of
WH
O Q
ualit
y S
tate
men
ts a
sses
sab
le b
y ea
ch q
ualit
y as
sess
men
t to
ol
Per
cent
age
of
Qua
lity
Mea
sure
s as
sess
able
in e
ach
Qua
lity
Sta
tem
ent
WH
O- E
uro
pe
WH
O- S
E A
sia
SPA
HR
BF
HeR
AM
Sr-
HFA
SA
RA
HFS
- IM
CI
HC
AH
PS
- Chi
ld
Sta
ndar
d 1
: Eve
ry c
hild
rec
eive
s ev
iden
ce- b
ased
car
e an
d m
anag
emen
t o
f ill
ness
acc
ord
ing
to
WH
O g
uid
elin
es
Sta
tem
ent
1.1
All
child
ren
are
tria
ged
and
pro
mp
tly
asse
ssed
for
emer
genc
y an
d p
riorit
y si
gns
to d
eter
min
e w
heth
er t
hey
req
uire
res
usci
tatio
n an
d r
ecei
ve
app
rop
riate
car
e ac
cord
ing
to W
HO
gui
del
ines
. (n=
19)
63%
58%
68%
16%
63%
26%
16%
16%
0%
Sta
tem
ent
1.2
All
sick
infa
nts,
esp
ecia
lly s
mal
l new
bor
ns,
are
thor
ough
ly a
sses
sed
for
serio
us b
acte
rial i
nfec
tion
and
rec
eive
ap
pro
pria
te c
are
acco
rdin
g to
WH
O
guid
elin
es (n
=19
)
37%
79%
42%
11%
11%
16%
16%
11%
0%
Sta
tem
ent
1.3
All
child
ren
with
cou
gh o
r d
ifficu
lt b
reat
hing
are
cor
rect
ly a
sses
sed
, cla
ssifi
ed a
nd
inve
stig
ated
and
rec
eive
ap
pro
pria
te c
are
and
/or
antib
iotic
s fo
r p
neum
onia
, acc
ord
ing
to W
HO
gui
del
ines
. (n
=18
)
83%
83%
61%
17%
61%
39%
28%
33%
0%
Sta
tem
ent
1.4
All
child
ren
with
dia
rrho
ea a
re c
orre
ctly
as
sess
ed a
nd c
lass
ified
and
rec
eive
ap
pro
pria
te
rehy
dra
tion
and
car
e, in
clud
ing
cont
inue
d fe
edin
g,
acco
rdin
g to
WH
O g
uid
elin
es. (
n=19
)
74%
68%
68%
32%
74%
53%
16%
42%
0%
Sta
tem
ent
1.5
All
child
ren
with
feve
r ar
e co
rrec
tly
asse
ssed
, cla
ssifi
ed a
nd in
vest
igat
ed a
nd r
ecei
ve
app
rop
riate
car
e ac
cord
ing
to W
HO
gui
del
ines
.(n
=19
)
58%
68%
58%
37%
47%
42%
32%
26%
0%
Sta
tem
ent
1.6
All
infa
nts
and
you
ng c
hild
ren
are
asse
ssed
for
grow
th, b
reas
tfee
din
g an
d n
utrit
ion,
and
th
eir
care
rs r
ecei
ve a
pp
rop
riate
sup
por
t an
d c
ouns
ellin
g,
acco
rdin
g to
WH
O g
uid
elin
es. (
n=12
)
83%
75%
50%
33%
17%
25%
17%
25%
0%
Sta
tem
ent
1.7
All
child
ren
at r
isk
for
acut
e m
alnu
triti
on
and
ana
emia
are
cor
rect
ly a
sses
sed
and
cla
ssifi
ed a
nd
rece
ive
app
rop
riate
car
e ac
cord
ing
to W
HO
gui
del
ines
. (n
=16
)
75%
88%
44%
38%
56%
25%
31%
25%
0%
Sta
tem
ent
1.8
All
child
ren
at r
isk
for
TB a
nd/o
r H
IV
infe
ctio
n ar
e co
rrec
tly a
sses
sed
and
inve
stig
ated
and
re
ceiv
e ap
pro
pria
te m
anag
emen
t ac
cord
ing
to W
HO
gu
idel
ines
. (n=
17)
47%
29%
47%
65%
41%
18%
41%
0%0%
Con
tinue
d
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ber 23, 2021 by guest. Protected by copyright.
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ownloaded from
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BMJ Global Health
Per
cent
age
of
Qua
lity
Mea
sure
s as
sess
able
in e
ach
Qua
lity
Sta
tem
ent
WH
O- E
uro
pe
WH
O- S
E A
sia
SPA
HR
BF
HeR
AM
Sr-
HFA
SA
RA
HFS
- IM
CI
HC
AH
PS
- Chi
ld
Sta
tem
ent
1.9
All
child
ren
are
asse
ssed
and
che
cked
for
imm
unis
atio
n st
atus
and
rec
eive
ap
pro
pria
te v
acci
natio
ns
acco
rdin
g to
the
gui
del
ines
of t
he W
HO
exp
and
ed
pro
gram
me
on im
mun
isat
ion.
(n=
12)
17%
58%
100%
75%
42%
50%
58%
58%
0%
Sta
tem
ent
1.10
: All
child
ren
with
chr
onic
con
diti
ons
rece
ive
app
rop
riate
car
e, a
nd t
hey
and
the
ir fa
mili
es a
re
suffi
cien
tly in
form
ed a
bou
t th
eir
cond
ition
(s) a
nd a
re
sup
por
ted
to
optim
ise
thei
r he
alth
, dev
elop
men
t an
d
qua
lity
of li
fe. (
n=12
)
42%
0%33
%8%
17%
0%25
%0%
0%
Sta
tem
ent
1.11
All
child
ren
are
scre
ened
for
evid
ence
of
mal
trea
tmen
t, in
clud
ing
negl
ect
and
vio
lenc
e, a
nd r
ecei
ve
app
rop
riate
car
e. (n
=7)
29%
0%0%
0%29
%0%
0%0%
0%
Sta
tem
ent
1.12
: All
child
ren
with
sur
gica
l con
diti
ons
are
scre
ened
for
surg
ical
em
erge
ncie
s an
d in
jurie
s an
d
rece
ive
app
rop
riate
sur
gica
l car
e. (n
=12
)
33%
17%
17%
8%25
%8%
17%
0%0%
Sta
tem
ent
1.13
: All
sick
chi
ldre
n, e
spec
ially
tho
se
who
are
mos
t se
rious
ly il
l, ar
e ad
equa
tely
mon
itore
d,
reas
sess
ed p
erio
dic
ally
and
rec
eive
sup
por
tive
care
ac
cord
ing
to W
HO
gui
del
ines
. (n=
14)
93%
50%
36%
0%21
%7%
7%0%
0%
Sta
tem
ent
1.14
: All
child
ren
rece
ive
care
with
sta
ndar
d
pre
caut
ions
to
pre
vent
hea
lth c
are-
asso
ciat
ed in
fect
ions
. (n
=14
)
64%
50%
50%
57%
43%
21%
36%
7%0%
Sta
tem
ent
1.15
: All
child
ren
are
pro
tect
ed fr
om
unne
cess
ary
or h
arm
ful p
ract
ices
dur
ing
thei
r ca
re. (
n=12
)67
%33
%17
%0%
0%0%
0%8%
0%
Sta
ndar
d 2
: The
hea
lth
info
rmat
ion
syst
em e
nsur
es t
he c
olle
ctio
n, a
naly
sis
and
use
of
dat
a to
ens
ure
earl
y, a
pp
rop
riat
e ac
tio
n to
imp
rove
the
car
e o
f ev
ery
child
Sta
tem
ent
2.1:
Eve
ry c
hild
has
a c
omp
lete
, acc
urat
e,
stan
dar
dis
ed, u
p- t
o- d
ate
med
ical
rec
ord
, whi
ch is
ac
cess
ible
thr
ough
out
thei
r ca
re, o
n d
isch
arge
and
on
follo
w- u
p. (
n=13
)
62%
38%
23%
15%
0%23
%0%
8%0%
Sta
tem
ent
2.2:
Eve
ry h
ealth
faci
lity
has
a fu
nctio
nal
mec
hani
sm fo
r d
ata
colle
ctio
n, a
naly
sis
and
use
as
par
t of
its
activ
ities
for
mon
itorin
g p
erfo
rman
ce a
nd q
ualit
y im
pro
vem
ent.
(n=
9)
44%
67%
78%
56%
0%44
%0%
0%0%
Sta
tem
ent
2.3:
Eve
ry h
ealth
faci
lity
has
a m
echa
nism
fo
r co
llect
ing,
ana
lysi
ng a
nd p
rovi
din
g fe
edb
ack
on t
he
serv
ices
pro
vid
ed a
nd t
he p
erce
ptio
n of
chi
ldre
n an
d t
heir
fam
ilies
of t
he c
are
rece
ived
. (n=
7)
43%
57%
57%
57%
0%0%
0%29
%43
%
Tab
le 4
C
ontin
ued
Con
tinue
d
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ownloaded from
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BMJ Global Health
Per
cent
age
of
Qua
lity
Mea
sure
s as
sess
able
in e
ach
Qua
lity
Sta
tem
ent
WH
O- E
uro
pe
WH
O- S
E A
sia
SPA
HR
BF
HeR
AM
Sr-
HFA
SA
RA
HFS
- IM
CI
HC
AH
PS
- Chi
ld
Sta
ndar
d 3
: Eve
ry c
hild
wit
h co
ndit
ion(
s) t
hat
cann
ot
be
trea
ted
eff
ecti
vely
wit
h th
e av
aila
ble
res
our
ces
rece
ives
ap
pro
pri
ate,
tim
ely
refe
rral
, wit
h se
amle
ss
cont
inui
ty o
f ca
re
Sta
tem
ent
3.1:
Eve
ry c
hild
who
req
uire
s re
ferr
al r
ecei
ves
app
rop
riate
pre
refe
rral
car
e, a
nd t
he d
ecis
ion
to r
efer
is
mad
e w
ithou
t d
elay
. (n=
10)
30%
30%
30%
50%
40%
0%0%
20%
0%
Sta
tem
ent
3.2:
Eve
ry c
hild
who
req
uire
s re
ferr
al r
ecei
ves
seam
less
, coo
rdin
ated
car
e an
d r
efer
ral a
ccor
din
g to
a
pla
n th
at e
nsur
es t
imel
ines
s. (n
=12
)
33%
0%17
%42
%17
%8%
8%25
%0%
Sta
tem
ent
3.3:
For
eve
ry c
hild
ref
erre
d o
r co
unte
r-
refe
rred
with
in o
r am
ong
heal
th fa
cilit
ies,
the
re is
ap
pro
pria
te in
form
atio
n ex
chan
ge a
nd fe
edb
ack
to
rele
vant
hea
lthca
re s
taff.
(n=
6)
67%
33%
83%
17%
100%
17%
17%
0%0%
Sta
ndar
d 4
: Co
mm
unic
atio
n w
ith
child
ren
and
the
ir f
amili
es is
eff
ecti
ve, w
ith
mea
ning
ful p
arti
cip
atio
n an
d r
esp
ond
s to
the
ir n
eed
s an
d p
refe
renc
es
Sta
tem
ent
4.1
All
child
ren
and
the
ir ca
rers
are
giv
en
info
rmat
ion
abou
t th
e ch
ild’s
illn
ess
and
car
e ef
fect
ivel
y,
so t
hat
they
und
erst
and
and
cop
e w
ith t
he c
ond
ition
and
th
e ne
cess
ary
trea
tmen
t. (n
=13
)
85%
23%
38%
31%
0%15
%0%
23%
69%
Sta
tem
ent
4.2
All
child
ren
and
the
ir ca
rers
exp
erie
nce
coor
din
ated
car
e, w
ith c
lear
, acc
urat
e in
form
atio
n ex
chan
ge a
mon
g re
leva
nt h
ealth
and
soc
ial c
are
pro
fess
iona
ls a
nd o
ther
sta
ff. (n
=9)
22%
11%
11%
11%
0%0%
0%0%
0%
Sta
tem
ent
4.3
All
child
ren
and
the
ir ca
rers
are
ena
ble
d t
o p
artic
ipat
e ac
tivel
y in
the
chi
ld’s
car
e, in
dec
isio
n m
akin
g,
in e
xerc
isin
g th
e rig
ht t
o in
form
ed c
onse
nt a
nd in
mak
ing
choi
ces,
in a
ccor
dan
ce w
ith t
heir
evol
ving
cap
acity
. (n
=10
)
80%
10%
10%
20%
0%0%
0%0%
20%
Sta
tem
ent
4.4
All
child
ren
and
the
ir ca
rers
rec
eive
ap
pro
pria
te c
ouns
ellin
g an
d h
ealth
ed
ucat
ion,
acc
ord
ing
to t
heir
cap
acity
, ab
out
the
curr
ent
illne
ss a
nd p
rom
otio
n of
the
chi
ld’s
hea
lth a
nd w
ell-
bei
ng. (
n=13
)
23%
38%
46%
31%
31%
8%0%
31%
8%
Sta
ndar
d 5
: Eve
ry c
hild
’s r
ight
s ar
e re
spec
ted
, pro
tect
ed a
nd f
ulfi
lled
at
all t
imes
dur
ing
car
e, w
itho
ut d
iscr
imin
atio
n
Sta
tem
ent
5.1
All
child
ren
have
the
rig
ht t
o ac
cess
he
alth
care
and
ser
vice
s, w
ith n
o d
iscr
imin
atio
n of
any
ki
nd. (
n=9)
78%
11%
44%
22%
11%
0%0%
11%
0%
Tab
le 4
C
ontin
ued
Con
tinue
d
on Novem
ber 23, 2021 by guest. Protected by copyright.
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lob Health: first published as 10.1136/bm
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BMJ Global Health
Per
cent
age
of
Qua
lity
Mea
sure
s as
sess
able
in e
ach
Qua
lity
Sta
tem
ent
WH
O- E
uro
pe
WH
O- S
E A
sia
SPA
HR
BF
HeR
AM
Sr-
HFA
SA
RA
HFS
- IM
CI
HC
AH
PS
- Chi
ld
Sta
tem
ent
5.2
All
child
ren
and
the
ir ca
rers
are
mad
e aw
are
of a
nd g
iven
info
rmat
ion
abou
t ch
ildre
n’s
right
s to
he
alth
and
hea
lthca
re. (
n=9)
44%
0%0%
0%0%
0%0%
0%0%
Sta
tem
ent
5.3
All
child
ren
and
the
ir ca
rers
are
tre
ated
w
ith r
esp
ect
and
dig
nity
, and
the
ir rig
ht t
o p
rivac
y an
d
confi
den
tialit
y is
res
pec
ted
. (n=
7)
57%
14%
43%
43%
0%14
%14
%0%
57%
Sta
tem
ent
5.4
All
child
ren
are
pro
tect
ed fr
om a
ny
viol
atio
n of
the
ir hu
man
rig
hts,
phy
sica
l or
men
tal
viol
ence
, inj
ury,
ab
use,
neg
lect
or
any
othe
r fo
rm o
f m
altr
eatm
ent.
(n=
9)
11%
0%0%
0%22
%0%
0%0%
0%
Sta
tem
ent
5.5
All
child
ren
have
acc
ess
to s
afe,
ad
equa
te
nutr
ition
tha
t is
ap
pro
pria
te fo
r b
oth
thei
r ag
e an
d t
heir
heal
th c
ond
ition
dur
ing
thei
r ca
re in
a fa
cilit
y. (n
=10
)
40%
30%
20%
10%
0%10
%10
%0%
0%
Sta
ndar
d 6
: All
child
ren
and
the
ir f
amili
es a
re p
rovi
ded
wit
h ed
ucat
iona
l, em
oti
ona
l and
psy
cho
soci
al s
upp
ort
tha
t is
sen
siti
ve t
o t
heir
nee
ds
and
str
eng
then
s th
eir
cap
abili
ty
Sta
tem
ent
6.1
All
child
ren
are
allo
wed
to
be
with
the
ir ca
rers
, and
the
rol
e of
car
ers
is r
ecog
nise
d a
nd s
upp
orte
d
at a
ll tim
es d
urin
g ca
re, i
nclu
din
g ro
omin
g- in
dur
ing
the
child
’s h
osp
italis
atio
n. (n
=9)
78%
22%
0%0%
0%0%
0%0%
11%
Sta
tem
ent
6.2
All
child
ren
and
the
ir fa
mili
es a
re g
iven
em
otio
nal s
upp
ort
that
is s
ensi
tive
to t
heir
need
s, w
ith
opp
ortu
nitie
s fo
r p
lay
and
lear
ning
tha
t st
imul
ate
and
st
reng
then
the
ir ca
pab
ility
. (n=
10)
60%
10%
0%0%
0%0%
0%0%
20%
Sta
tem
ent
6.3
Eve
ry c
hild
is a
sses
sed
rou
tinel
y fo
r p
ain
or s
ymp
tom
s of
dis
tres
s an
d r
ecei
ves
app
rop
riate
m
anag
emen
t ac
cord
ing
to W
HO
gui
del
ines
.(n
=13
)
62%
0%8%
0%0%
0%0%
0%23
%
Sta
ndar
d 7
: Fo
r ev
ery
child
, co
mp
eten
t, m
oti
vate
d, e
mp
athi
c st
aff
are
cons
iste
ntly
ava
ilab
le t
o p
rovi
de
rout
ine
care
and
man
agem
ent
of
com
mo
n ch
ildho
od
ill
ness
es
Sta
tem
ent
7.1
All
child
ren
and
the
ir fa
mili
es h
ave
acce
ss
at a
ll tim
es t
o su
ffici
ent
heal
th p
rofe
ssio
nals
and
sup
por
t st
aff f
or r
outin
e ca
re a
nd m
anag
emen
t of
chi
ldho
od
illne
sses
. (n=
15)
67%
27%
40%
53%
0%13
%0%
13%
7%
Sta
tem
ent
7.2
Hea
lth p
rofe
ssio
nals
and
sup
por
t st
aff h
ave
the
app
rop
riate
ski
lls t
o fu
lfil t
he h
ealth
, p
sych
olog
ical
, dev
elop
men
tal,
com
mun
icat
ion
and
cu
ltura
l nee
ds
of c
hild
ren.
(n=
17)
76%
47%
65%
71%
6%35
%18
%24
%6%
Tab
le 4
C
ontin
ued
Con
tinue
d
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Per
cent
age
of
Qua
lity
Mea
sure
s as
sess
able
in e
ach
Qua
lity
Sta
tem
ent
WH
O- E
uro
pe
WH
O- S
E A
sia
SPA
HR
BF
HeR
AM
Sr-
HFA
SA
RA
HFS
- IM
CI
HC
AH
PS
- Chi
ld
Sta
tem
ent
7.3
Eve
ry h
ealth
faci
lity
has
man
ager
ial
lead
ersh
ip t
hat
colle
ctiv
ely
dev
elop
s, im
ple
men
ts a
nd
mon
itors
ap
pro
pria
te p
olic
ies
and
lega
l ent
itlem
ents
th
at fo
ster
an
envi
ronm
ent
for
cont
inuo
us q
ualit
y im
pro
vem
ent.
(n=
12)
67%
25%
50%
50%
0%17
%0%
8%8%
Sta
ndar
d 8
: The
hea
lth
faci
lity
has
an a
pp
rop
riat
e, c
hild
fri
end
ly p
hysi
cal e
nvir
onm
ent,
wit
h ad
equa
te w
ater
, san
itat
ion,
was
te m
anag
emen
t, e
nerg
y su
pp
ly,
med
icin
es, m
edic
al s
upp
lies
and
eq
uip
men
t fo
r ro
utin
e ca
re a
nd m
anag
emen
t o
f co
mm
on
child
hoo
d il
lnes
ses.
Sta
tem
ent
8.1
Chi
ldre
n ar
e ca
red
for
in a
wel
l-
mai
ntai
ned
, saf
e, s
ecur
e p
hysi
cal e
nviro
nmen
t w
ith
an a
deq
uate
ene
rgy
sup
ply
and
whi
ch is
ap
pro
pria
tely
d
esig
ned
, fur
nish
ed a
nd d
ecor
ated
to
mee
t th
eir
need
s,
pre
fere
nces
and
dev
elop
men
tal a
ge. (
n=15
)
40%
47%
40%
33%
20%
13%
33%
0%20
%
Sta
tem
ent
8.2
Chi
ld- f
riend
ly w
ater
, san
itatio
n, h
and
hy
gien
e an
d w
aste
dis
pos
al fa
cilit
ies
are
easi
ly
acce
ssib
le, f
unct
iona
l, re
liab
le, s
afe
and
suf
ficie
nt t
o m
eet
the
need
s of
chi
ldre
n, t
heir
care
rs a
nd s
taff.
(n=
22)
68%
59%
41%
45%
41%
18%
18%
0%0%
Sta
tem
ent
8.3
Chi
ld- f
riend
ly, a
ge- a
pp
rop
riate
eq
uip
men
t d
esig
ned
to
mee
t ch
ildre
n’s
need
s in
med
ical
car
e,
lear
ning
, rec
reat
ion
and
pla
y ar
e av
aila
ble
at
all t
imes
. (n
=15
)
40%
27%
27%
27%
33%
7%33
%0%
13%
Sta
tem
ent
8.4
Ad
equa
te s
tock
s of
chi
ld- f
riend
ly
med
icin
es a
nd m
edic
al s
upp
lies
are
avai
lab
le fo
r th
e ro
utin
e ca
re a
nd m
anag
emen
t of
acu
te a
nd c
hron
ic
child
hood
illn
esse
s an
d c
ond
ition
s. (n
=14
)
71%
64%
57%
50%
43%
43%
50%
14%
0%
Red
box
es in
dic
ate
that
the
ass
essm
ent
tool
did
not
ass
ess
any;
ora
nge
box
es in
dic
ate
less
tha
n ha
lf; y
ello
w b
oxes
ind
icat
e eq
ual t
o or
mor
e th
an h
alf a
nd g
reen
box
es in
dic
ate
all o
f the
q
ualit
y m
easu
res
wer
e as
sess
able
in t
he a
ssoc
iate
d q
ualit
y st
atem
ent.
HC
AH
PS
, Hos
pita
l Con
sum
er A
sses
smen
t of
Hea
lthca
re P
rovi
der
s an
d S
yste
ms;
HeR
AM
S, H
ealth
Res
ourc
es A
vaila
bili
ty M
app
ing
Sys
tem
; HFS
- IM
CI,
Hea
lth F
acili
ty S
urve
y—us
ing
Inte
grat
ed
Man
agem
ent
of C
hild
hood
Illn
ess
clin
ical
gui
del
ines
; HR
BF,
Hea
lth R
esul
ts B
ased
Fin
anci
ng im
pac
t ev
alua
tion
tool
kit;
n, n
umb
er o
f Qua
lity
Mea
sure
s w
ithin
the
ass
ocia
ted
Qua
lity
Sta
tem
ent;
r-
HFA
, rap
id H
ealth
Fac
ility
Ass
essm
ent;
SA
RA
, Ser
vice
Ava
ilab
ility
and
Rea
din
ess
Ass
essm
ent;
SPA
, Ser
vice
Pro
visi
on A
sses
smen
t.;
Tab
le 4
C
ontin
ued
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The purpose and context of the assessment tools needs to be considered when examining how comprehensive they are in comparison to the WHO Standards. The WHO Hospital Care assessment tools were found to be more comprehensive in their ability to capture the WHO Stan-dards. These tools were first developed in 2001 to provide government and stakeholders guidance in performing evaluation of quality of healthcare practices in order to identify key areas to improve on.17 They have since been revised multiple times and adapted to multiple settings with the most recent European version including indica-tors for child rights, communication and alignment with evidence- based practice as outlined in the WHO Pocket Book of Hospital Care for Children.18 The WHO Stan-dards for improving QoC have been modelled on similar frameworks, which may explain the overlap of indicators between the WHO Hospital Care assessment tools and the WHO Standards.
Of the three broad arms of QoC in the WHO Stan-dards: provision of care (QSd 1–3) and available human and physical resources (QSd 7–8), were more widely covered by the tools than experience of care (QSd 4–6). This may be because provision of care and system inputs have more definitive QM, which make them amenable to be assessed through checklist style questionnaires. The SPA and Service Availability and Readiness Assessment were developed to provide nationwide data on the capac-ities of health facilities to provide quality services and have been used in over 30 countries.10 19 These surveys are designed to be repeated at periodic intervals, every 1–5 years, to monitor progress and inform development of national health policies and programmes. It is there-fore not surprising that their strengths lie in assessing availability of concrete measures such as physical infra-structure and human resources, with less emphasis on subjective components such as communication and emotional support. The HeRAMS similarly was developed to collect information on availability of health resources and services. Designed to be implemented in humani-tarian and emergency response settings, rapid reporting is essential to its purpose in order to obtain supplies and resources required for basic healthcare needs.
The child- specific assessment tools such as the WHO hospital tools, HFS- IMCI and Child- HCAHPS, had relative strengths in assessing experience of care when compared with the remaining tools. This may be in recognition that communicating with parents/carers is a large component of paediatric healthcare. The Child- HCAHPS survey was developed for the sole purpose of obtaining parent/guardian feedback on their experience of care of their child in hospital. Health service delivery has traditionally revolved around disease diagnosis and treatment. However, there has been a gradual global shift towards integrated people- centred health services, where people and communities are seen as active participants as well as beneficiaries of their responsive health systems. In 2016, the WHO adopted the ‘Framework on integrated people- centred health services’ to help drive change in
national policies on health services delivery to include cross- sectoral collaboration and community involve-ment and empowerment in decision- making processes.20 Involving people in their own care, especially marginal-ised subpopulations, is considered essential to achieving equitable access and QoC towards UHC. So, although tools such as the Child- HCAHPS may not be a suitable tool to assess all aspects of QoC for children, it can be a useful adjunctive tool to assess communication skills and patient experiences of care, which may otherwise be lacking in existing quality assessment frameworks.
Feasibility was not formally assessed as part of this review. The more comprehensive WHO Hospital Care Assessment tools are extensive and labour intensive and yet only cover about half the QM in the WHO Standards. Our search only identified two original peer- reviewed publications that used the WHO Hospital Care Assess-ment Tools.21 22 It is possible that the tools are used for auditing and quality improvement practices with infor-mation only being disseminated within country. However, there is little anecdotal evidence of this occurring. Without clear quality frameworks in place and limited resources, health facilities would likely find it challenging to implement these assessment tools effectively. In order for LMICs to effectively implement quality improvement practices and to sustainably assess and monitor them, key indicators need to be clear and manageable. We recom-mend that the QM in the WHO Standards be simplified and that key indicators to monitor in each QSd be high-lighted. Key indicators should obtain global consensus and adhere to a measurement framework to ensure that they are relevant, acceptable, achievable and robust. Existing core assessment tools could then be combined and simplified, to incorporate the key indicators, with flexibility for other QM to be included as prioritised by individual health facilities. This will be more achiev-able and constructive at the local level, while assisting in reporting of national progress of uniform child health indicators in LMICs.
An alternative to using explicit QoC assessment tools to evaluate and monitor quality improvement prac-tices, would be to have key indicators embedded in other routine data collection systems. In the USA, there are existing monitoring systems of QMs embedded in HIS. Data are collated from multiple databases by such agencies as the Agency for Healthcare Research and Quality to produce annual National Healthcare Quality and Disparities Reports which include indica-tors overlapping with many of the WHO Standards.23 In LMICs, paper- based surveys and medical records have traditionally been the main way to collect health data. Routine HIS which could potentially monitor key indicators for QoC can be variable in levels of data recording and quality, and are seldom used to evaluate programme interventions and policy changes often due to lack of capacity.24 25 The introduction of elec-tronic health records and platforms are emerging as more reliable sources of data management and analyses
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in LMICs.26 27 However, a range of challenges has meant that electronic- HIS have not yet replaced paper- based records or survey tools in most LMIC settings.28–31 Until routine HIS become more robust and reliable, using existing, comprehensive, low- cost tools to assess QoC, will continue to more feasible.
Our review focused on assessing QoC for children and young adolescents. However, it is important to recog-nise that quality healthcare is required throughout the continuum of the life course, including the antenatal and perinatal periods, to ensure improved outcomes for all children. The WHO Standards for children and adolescents are an extension of the WHO Standards for maternal and newborn care in health facilities, with both developed using the same framework. A previous review comparing existing assessment tools with the WHO Stan-dards for maternal and newborn care drew similar conclu-sions to our assessment—that current tools had gaps in assessing experience of care and that there should be global consensus on core data to be collected.6 Although each life stage has its own unique healthcare needs (eg, obstetric care for women; immunisations for children), comparable themes for quality healthcare practices are applicable across the life course. Having similar frame-works to assess and monitor quality of healthcare across the life course would make quality improvement prac-tices and assessment tools easier to develop. It would also foster collaboration between health sectors in the development of common goals towards achieving better health outcomes for all.
Our systematic review had several limitations. In the matching process, clinical judgement deter-mined whether questions/items from assessment tools matched the QM in the WHO Standards. This subjective process could have led to bias in some indicators. Our selection criteria were aimed at identifying stand- alone assessment tools. This may have inadvertently excluded quality assessment tools integrated within other health data collection activities. We also only included English publications, which may have excluded other existing tools used in non- English speaking countries. Our review only evaluated the survey instruments and did not assess feasibility of implementation, which would include preplanning, training, supervision, evaluation and feedback of data. These pragmatic factors would affect the capacity of a tool to reliably assess the WHO Standards and would need to be considered in future activities assessing QoC.
CONCLUSIONThis review found that although the WHO Standards are comprehensive, no single tool can adequately assess all the QM in its current format. Furthermore, operational use of extensive assessment tools is seldom seen due to lack of resources and organisational frame-works. Existing tools tend to emphasise input measures and few tools adequately assess experience of care.
Consensus and harmonisation of select key indicators from the WHO Standards, integrated into simplified assessment tools would make them more achievable in LMICs. Comparable data on key indicators for moni-toring within and between countries will also assist in national and global reporting on progress of child health outcomes. Further research into the feasibility of modified tools with key indicators to assess QoC and the impact on health outcomes, is, therefore, an impor-tant next step in establishing equitable access to quality healthcare.
Author affiliations1Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia2Asia Pacific Health Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia3The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia4Health System Strengthening Unit, World Health Organisation Country Office for Indonesia, Jakarta, Indonesia5International Child Health Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia6Maternal, Newborn, Child and Adolescent Health and Ageing Department, World Health Organization, Geneva, Switzerland
Twitter Alicia Quach @QuachAlicia
Contributors AQ conceived the study, wrote the first draft and is the guarantor of the manuscript. ST and HN were second reviewers for screening and data analysis. FMR and SMG provided feedback on the first draft of the manuscript. All authors including TD, WMW and MM provided feedback on subsequent versions of the manuscript and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors.
Competing interests We declare no competing interests. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
Patient consent for publication Not applicable.
Ethics approval Patient consent and ethics approval for publication not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer- reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
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