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One way to look at Quality of Care at MSF

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by

Maya Fehling

on 28 May 2015

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Transcript of One way to look at Quality of Care at MSF

Quality of Care at MSF
Logistics & Technology
Project
Leadership / Management

Information & Data management
Financing
Service
Delivery

Human Resources
Building Blocs of Healthcare System
Leadership / Management
People
Country specific context
HQ specific context
Leadership / Management
Leadership / Management
Leadership / Management
Health Care Practices
Laboratory & Diagnostics
Pharmacy
Maternity /
Neonatology
In-Patient Department
OPD
Mobile Clinics
Therapeutic Feeding Center
Operation Room
Disease-specific programs
Effectiveness
"Delivering health care that is adherent to an evidence base and results in improved health outcomes for individuals and communities, based on need"
Efficiency
"Delivering health care in a manner which maximizes resource use and avoids waste."
Accessibility
"Delivering health care that is timely, geographically reasonable, and provided in a setting where skills and resources are appropriate to medical need."
Acceptability /Patient-centered
"Delivering health care which takes into account the preferences and aspirations of individual service users and the cultures of their communities."
Equity
"Delivering health care which does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status;
Safety
"Delivering health care which minimizes risks and harm to service users."
Quality of Care
Health System View for Quality of Care in MSF projects?

Major impact on local structures including the health systems
Sometimes the only health system
Quality of care depends on multiple factors and barriers
Longer-term projects benefit from a holistic view in terms of cost-effectiveness, sustainability and exit strategies
Systematic approach helps to anticipate issues and reduce the number of variables

Increasing size, financial resources and political power means
increased possible impact on health of vulnerable populations
increased responsibility to constantly improve and provide best possible care
http://www.who.int/management/quality/assurance/QualityCare_B.Def.pdf
Broad goals
Reducing mortality
Reducing morbidity
Reducing health inequalities
Making health care safer
Leadership challenges in MSF projects
Managerial skills ("enabler")
Volunteers / Employees
High turn-over
Heterogeneous team
Cultural background
Language
Gender
Ethnicity
Dependencies (e.g. shared responsibilities in a partially MoH owned hospital with unclear leadership roles)
Institutional structures versus local structures
Key finding: "misalignment between MSF’s strategy to provide integrated care and its current organizational culture [...], which work better in an emergency project response."
Key recommendation: "Empowerment of national staff in key positions through proper training, standard operating procedures, communication and information dissemination."
Laundry
Kitchen
House-keeping
Preparation of expats

Recruitment & Accreditation


Rostering

Payroll system, incentives
WatSan
Quality of Care Assurance Model
"The primary cause of errors is not individual incompetence, but poorly designed systems"
(WHO patient safety guideline 2014)
MSF Guidelines
Challenges to get the "right" guideline
Multitude of Standards
MSF OCA, OCB, OCG, OCBa, OCP
WHO and other institutions
MoH
"HiC standards" may not apply nor be feasible due to context and/or costs
Revision and updates of guidelines is a difficult logistical and managerial process
Decide on (mandatory) minimum standards and indicators for departments and project types
(
HQ
)

Develop assurance methods (algorithms, supervision checklists, protocols for M&M, training etc)
(
HQ
)

Decide on preferred assurance package for each project (which tools to use when by who)
(
HQ&Field
)

Assure adherence
(Field)

Evaluate, improve and share data
(
HQ&Field
)

Transparency and communication across departments, sections, HQ/field level
(
HQ&Field
)
Medical Ethics
Medical Ethics
Medical Ethics
Medical Ethics
Protocols & Algorithms
Standards &
Best Practice
Content of Care
Process of Care
TB/HIV Clinics
Vaccination Programs
A protocol is "a precise and detailed plan for the study of a biomedical problem or for a regimen or therapy".
Supervision
Training
Ideal for 1. common and 2. life threatening emergencies
Outpatient department / Emergency room
Reduces
Variance of treatments
Delays in treatment
Costs
Medicament overuse
Antibiotic resistances
Risk for liability issues
Stress of staff
Increases patients and staff safety
**Standard practice for emergency medical dispatch. Annual Book of ASTM Standards (No. F 1258-90). Philadelphia: American Society for Testing and Materials, 1990.
1. Direct Observation
Continuous, regularly, random
Informal or formal (checklists / questionnaires)
2. Audit
(M&M, incident reports)
3. Feedback session
(Group / Individual)
Continuous / Regular
(Field)
Needs based
(HQ)
Conditional ("accreditation")
(HQ&Field)
Good protocols
must be well designed (user-friendly)
comprehensive
standardized and
ACTIVELY USED BY STAFF
Making it an integrative part of the care procedure
Mandatory for specific cases
Easy accessible
Innovative ideas (e.g. tablet-based IMCI tool at OCG & terre des hommes)
Based on:
Evidence-based standards of High Income Countries (HiC)
Evidence and experience from the humanitarian context and its limitations
Quality of Care Assurance at MSF
New staff - New ideas - New models
Patch Work
Logistics / HR / Medical
Medical departments
OC / Country / Project level
Ad hoc / responsive
Training Content
Medical knowledge and skills
Team work
Data management
Training modalities
Supervision Methods
...are guidelines directly applied to the "process" of care.
No 100% adherence required but OPT OUT rather then OPT IN
Ideas / Suggestions
Free health care is a core principal guarantees treatment for all
Often working in regions without health care financing models
...if not what is our impact on
Insurance schemes
Local provider's livelihoods
Health provision and financing after exit
Decisions based on data
Challenges
Reliability (e.g. data entry issues)
Validity (e.g. post-op infection)
Interpretation (e.g. # of OPs)
Unused data (e.g. incident reports)
Good excuse
Start a project
Need for more supply, training, staff
Extent or exit projects
1.
3.
6.
1.
5.
4.
2.
Human Resources & Quality of Care
Supply Chain
Site Setup
Technical & Coms
...
Security
Health Care Financing at MSF
Hospital Management Study
"Recommendations on how to improve the hospital management", EMTS, Roth 2014
Supervision versus hands-on

Lack of skilled staff, different knowledge and skills, "bring them up to speed"
Double occupied hospital

Tensions through different payment systems
Process of Care
Process of Care
Finding the right balance of Quality of Care
Before MSF arrival
Best EB health practices
Essential standards
Basic standards
Higher standards
High standards
Highest
standards
Decision to
start a project
Beginning of a project
After first project phase
Full transcript