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Quality Improvement within Social Franchise Networks

Program Brief
Incorporating the Health Network Quality Improvement System (HNQIS)

The Role of Quality

Poor quality of care not only leads to poor patient outcomes but also compromises the safety of health care providers. For PSI it is important that the quality of care provided in the franchised clinics is consistent with national and global standards and practices. This ensures the best possible outcome for patients seeking services in the franchise.

The Challenge
Growing scale and scope of the network

One of the key challenges faced by PSI in regards to network quality is how to cope with the increasing scale and scope of the network.
The number of health facilities and franchised health areas (e.g. family planning, cervical cancer screening, etc.) within the network continues to grow, making day-to-day quality assurance complex
and resource intensive.

Typically, social franchise network quality assurance visits are provided across the networks in the form of routine monthly assessments conducted by Quality Assurance Officers (QAOs) and follow-up visits that are based on a pre-determined routine schedule. However, the level of support needed among providers varies depending on client loads and current levels of quality.
Utilizing this method is unresponsive to the level of support needed across the different providers and produces a low return on investment.

Limited quality assessment tools

n the past, the quality assessment tools utilized by supervisors have focused solely on the skills of clinical providers, as opposed to the rationale for why the skills are necessary. Furthermore, various
networks have modified the tools to better meet their individual assessment needs, leading to a lack of continuity in the scoring and benchmarks across networks. This has created a challenge when comparing facilities and in ensuring external validity.

Poor quality feedback and coaching

The provision of feedback and coaching of providers following quality assessments has been inconsistent and subjective, given that it is left to the QAO to determine (i) what areas to focus on and (ii) how to structure the feedback provided. QAOs rely on clinical service delivery protocols for the provision of feedback, yet these principally focus on how to undertake procedures rather than why
it is important to do so which is vital for provider behavior change that will improve service quality.

Poor use of monitoring data

QAOs do not fully utilize routinely collected data on service quality. This is due to (i) poor access to the data as data is often paper based and centrally located at the head office and (ii) poor presentation of data (lack of decision-driven dashboards). QA managers therefore do not have network performance trends at their fingertips, which is vital to understanding how the network is responding to support from QAOs and also important for identifying common areas of weakness across the network that may require additional attention and strategic decision making from the project management team.

The Response

In order to address these challenges, PSI has established the Health Network Quality Improvement System (HNQIS), designed to support quality improvement delivered by network providers. The electronic tablet-based system is principally focused on enabling QAOs to:

  • Effectively plan their support visits prioritizing where support is required, and where it will have most impact
  • Undertake assessments with comparable scoring and benchmarking mechanisms
  • Consistently and effectively provide feedback and coaching following assessments
  • Monitor performance of providers over time in order to understand the return on their support efforts and conduct mid-course corrections (such as refresher trainings)

HNQIS is fully functional without Internet connectivity and operates off an Android application linked with the information management system Demographic Health Information Software 2 (DHIS2), an open source technology adopted by many ministries of health across the world. The system consists of four modules designed to
support the focus areas above and is applicable to a range of health provider networks, in addition to social franchises.

Plan module

This module automatically schedules future assessments based on where support is needed most (quality score), and where it will have most impact (client load). Furthermore, the planning module
prioritizes planning of support visits by segmenting all outlets into (i) those that have never been assessed, (ii) those with overdue assessments, (iii) those scheduled to be assessed in the current month, (iv) those scheduled to be assessed in future months. Each health area has independent planning variables (quality score/client load), but the planning report is integrated across all areas the QAO is responsible for supporting.

Assess module

This module enables QAOs to assess clinical procedures in each health area catered for by network providers through case observation or simulation. The assessment checklist is aligned with national supervision checklists. An assessment score is automatically generated on-site, and performance is subsequently benchmarked (e.g. Good/ Satisfactory/Poor). The module contains a consistent approach to scoring and benchmarking all health areas to allow comparability within and across network providers Informaiton collected from this module is used in the three other modules.

Improve module

This module ensures that provider feedback following a quality assessment is undertaken in a robust and
consistent manner, rather than based on the subjectivity of the QAO. The module (i) highlights the key
areas of weakness identified during the assessment, (ii) displays tailored feedback scripts that take into account both how the procedure should be undertaken (as per protocols), as well as why it is important to do so. This places all the relevant information required to improve the performance of the provider in one place. The module facilitates a consistent approach to provision of feedback, eliminating subjectivity regarding the areas of focus or the actual feedback provided.

Monitor module

This module consists of a performance monitoring dashboard tailored to meet the needs of the QAO. The
dashboard contains a range of charts, graphs, maps and tables highlighting trends and overall performance of all the providers the QAO is responsible for supporting. Dashboards can also be used to visualize data collected through other channels that is relevant to quality improvement, such as availability and sales of health commodities. The main purpose of this module is to facilitate the use of data in decision-making at the QAO level. It offers the QAO an opportunity to track the return on their support visit efforts over time, so as to give them insight on where they need to apply a different approach. The system also allows to develop tailored interfaces to meet the need in terms of data of different users of HNQIS (i.e. project managers, medical detailers, etc.), and therefore enable mid-course correction(e.g. conducting a refresher course in a particular, low performing health area).

Implementation and Expected Outcomes

Implementation of the HNQIS is split into two phases. Phase one involves undertaking a baseline assessment of all network providers using the assessment module in order to determine performance benchmarks. Phase two involves full roll-out of the four module system. HNQIS quality assurance data will be triangulated with outcome data and client exit surveys to provide a more accurate picture of quality. The use of DHIS2 facilitates the system’s integration within the public sector HMIS and supports increased oversight of private health providers by the public sector, by enabling them to easily track private outlets’ performance over time on relevant national health indicators.
Ultimately, the intent is that the HNQIS tool will enable services to become more cost effective, safe and efficient, thus achieving more health impact at scale. This initiative ensures improved planning
and resource allocation, strengthened onsite capacity building efforts, and tracking the return on investment over time, which will feed into the overall franchise objective of delivering quality
services to the clients. Thus, HNQIS will form the backbone to quality improvement initiatives in integrated service delivery being carried out across a range of private provider networks (including
pharmacies and drug shops) and is also applicable to performance improvement in the public sector. An evaluation of HNQIS is expected which will measure whether the system improves provider practices, the speed at which the improvements are made, and whether it does so in a more cost-effective way compared to typical private sector quality improvement efforts.