Indian Pediatrics 2002; 39:523-528  

Improving the Quality of Care for Children

What is the Problem?

Every year more than 10 million children in low- and middle-income countries die before they reach their fifth birthday(1). Among the major determinants of mortality and unnecessary morbidity is the quality of health care provided to children. Every day, millions of parents seek health care for their sick children, taking them to hospitals, health centers, pharmacists, doctors, and traditional healers. Very often, these children do not receive good quality care, both at the level of ambulatory and institutional care. Surveys reveal that many sick children are not properly assessed and treated by these healthcare providers, and that their parents are poorly advised (2). For more severely ill children who require care in hospital, inadequate triage and assessment, poor inpatient treatment and insufficient monitoring adversely affect the outcome of a significant proportion of hospitalised children, and result in unnecessary suffering or avoidable death for many children each year (3).

Until recently little attention was paid to the problems of care at first-level referral hospitals. One reason for this may be that many more children in developing countries die before reaching hospital for want of even more basic interventions, such as measles vaccine or oral rehydration solution, and the legitimate concern that in promoting hospitals we may detract from the vital importance of primary level or community-based care. Another is that there is a lack of systematic evidence that quality could be improved without very major investment in staffing and equipment. However, good quality pediatric care in both outpatient and inpatient services of health facilities of first referral is essential for a credible and efficient primary health care (PHC) system. The clinical guidelines for Integrated Management of Childhood Illness (IMCI) take an evidence-based, syndromic approach to the case management of children at first-level outpatient facilities. Training health workers in the use of these guidelines is not enough: the system needs to support the health worker to apply their knowledge and skills. Health workers require the necessary drugs and supplies, a system of supportive supervision to reinforce the use of the guidelines and to help overcome clinical and management problems. Implementation of the IMCI guidelines implies referral of around 20% of patients in most settings. These children are the most severely ill and those at highest risk of death. The prompt and appropriate referral of these patients, and the way they are managed has a great influence on the short and long-term impact of the PHC system in general and IMCI in particular.

There is now evidence of the potential for significant improvement in outcomes without major investment, through support for health workers, structured clinical care, and better use of existing resources. Several names have been used for a variety of essentially similar pro-cesses such as Quality Improvement, Quality Assurance, Total Quality Management, Performance Improvement and others. In this article, we refer to all those as "Quality Improvement". WHO recognises quality improvement as a process of continuous positive change designed to define and attain standards of quality health care(4,5). The process promoted is a cyclical, participatory one where all stakeholders are identified and involved as early as possible and throughout the process. The typical steps include: (i) Defining performance goals or standards; (ii) Collecting data (preferably locally) on the structure, performance and outcomes of health services, and identifying where there are gaps between these processes and accepted standards of care; (iii) Identifying problems (the sources of gaps between actual performance or outcomes and accepted standards of care); (iv) Defining feasible solutions or interventions to deal with these problems, and implementing these; (v) As interventions are implemented the cycle continues with collecting and reviewing data, so that the appropriateness and effect of interventions can be measured.

As each intervention is only a hypothetical solution to the identified problem, the hypothesis that the critical problems and solutions have been correctly identified is tested by ongoing data collection. It is only after data show that outcomes have improved and been sustained that the hypothesis can be accepted. If outcomes have not improved, further problems or solutions must be sought.

Defining what constitutes quality care, or acceptable standards of care is important. Campbell and colleagues(6) suggest there are two key elements to quality: access and effectiveness. In short, do patients get the care they need, and is the care effective when they get it? They further define two components of effectiveness: effectiveness of clinical care and effectiveness of inter-personal care. While quality of care can be evaluated most easily for the individual patient, it also must be put in context of the need to provide health care to entire populations. Therefore the notions of equity and efficiency also become important. As such, quality improvement should be integrated into a variety of clinical, public health and management initiatives, including all PHC strategies. In hospitals the overall approach should not be limited to pediatric medical care, as there is evidence of a need for improvement in the quality of perinatal care(7-8), pre- and post-surgical care and anesthesia management(9-11), and general hospital practices(11), to further lower case fatality rates in less developed countries. For issues of quality of care to be part of the health culture, teaching on this will need to be integrated into under-graduate and post-graduate training, and principles that are introduced in small hospitals will need to be incorporated into regional hospitals providing second-level care and tertiary teaching hospitals, where they are equally needed. These larger hospitals are where medical students, interns and nurses get their value systems about good medical practice, and set patterns for a lifetime of work. It is also vital that quality of care be incorporated into training for child health nurses, clinical assistants, health extension officers and other health workers, as these are often the clinicians who work in the least supported and poorly resourced environments.

Essential components of a quality improvement strategy are standards, assessment tools and driving forces. Standards of care must be specific to the level of the health facility and the country, must reflect an appropriate balance between resources used for curative and public health, and emphasize low cost simple technology options and drugs. WHO has developed clinical guidelines for the outpatient care of sick children (IMCI)(12) that have been adapted to specific countries needs, and guidelines for clinical management of children with severe illnesses at district hospitals(13). Some countries have their own comprehensive treatment protocols that act as standards of care(14), or that can be modified to incorporate approaches, developed by WHO and others, that have been proved to work in other similar countries.

Standards, assessment tools and evidence are essential, but not themselves sufficient for the process to succeed. There is a financial cost to bear for running a service that is good enough to prevent avoidable morbidity and deaths. In many settings a lot can be done with very little if one builds on existing human resources; health workers generally embrace initiatives to improve care as long as such initiatives are appropriately supported; this adds value and a sense of fulfilment to their work. In some settings there will be substantial cost shifting from inefficient practices, and a better quality health service may be provided for not much more than current costs. In other settings resources are so limited and manpower so over-extended that problems highlighted by external or internal assessments will only be demoralizing to health workers if appropriate, and often substantial, financial, technical and human resources are not made available to affect change.

Recent work suggests that emergency triage, assessment and treatment (ETAT) guidelines can be used by nurses to identify children requiring high priority treatment (15,16). In a setting in Brazil where there were no previous triage guidelines and where nurses previously did not provide any emergency treatment except on doctor’s orders, after the introduction of the nurse ETAT assessment nurse initiated treatment was appropriate in more than 90% of cases(15). In Malawi nurses using ETAT priority assessments were able to identify 85% of children requiring admission to hospital(16). In-patient management of severe malnutrition(17,18) and neonatal care(19) can also be substantially improved with organization, guidelines and limited additional resources. In Peru a maternal and neonatal quality improvement program has built a wide variety of improvements to clinical practice and education around self-identification of problems by health facility clinical teams. The problems identified relate to drug and equipment supplies, lack of standardized care or training for specific diseases, and issues of client satisfaction. The clinical teams attempt to identify and solve problems by themselves. In only about 20% of cases this is not possible, and they then request help from the local level authorities, referral hospitals or the central ministries of health. In health centers participating in this project there has been an increased demand for care, and a reduction in case-fatality among mothers delivering, compared with non-participating health centers(20).

Assessment tools for hospitals have been developed in several countries; these include assessments of infrastructure, drugs, equipment, human resources, records, and observed quality of clinical care for key common diagnoses. Models that have been attempted in South America, Angola and soon in Eastern Europe involve assessment of health facilities, comparison against standards, identification of shortfall areas, suggestion of remedial measures, implementation of the measures agreed upon, and reassessment(21). Key features of a useful assessment are that it should be simple to conduct, provide rapid feedback for clinicians, be presented in a form which is usable by busy clinical staff, prompt innovative suggestions for change, and have a component of evaluation and reassessment.

In India, there have been a variety of projects to improve the quality of care, including interventions to improve neonatal resuscitation(22), identification of the need for protocols for oxygen administration(23), surveys of patient satisfaction(24), and highlighting problems leading to nosocomial sepsis(25). Most of these have focused on problems and solutions in teaching hospitals. Regular morbidity and mortality audits are done in many major hospitals, and the Indian Academy of Pediatrics has invested in the Continued Medical Education for Pediatri-cians (T. Cherian, personal communication).

Development of simple approaches to mortality audit and critical incident monitoring may be an important initial step when quality improvement is being addressed within a smaller health facility where staff have limited time and resources. However, the traditional ways audits have been conducted are often over-critical of individuals, especially of junior health staff. A problem solving approach to audit is needed, based on comparison of actual management against minimal standards and evidence-based guidelines. Such audits if conducted in a sensitive way can serve the purpose of team building and be a focus of continuing education(26). Models of audit may also be effective at primary health care level: structured performance feedback to health workers in Niger improved compliance with IMCI guidelines, at about quarter of the cost of the initial formal technical IMCI training(27). The success of external assessments and audit processes depend on there being sufficient resources to effect changes, and local staff having control and ownership over the process(28).

The Indian Academy of Pediatrics has an important role to play in improving the quality of care for children in India. Its role, as a respected professional society representing the pediatricians of the country, gives it unique credibility in promoting this issue. The IAP can draw on the expertise and dedication of a large number of highly qualified professionals. The IAP can help to demonstrate how quality improvement for children works in practice in India, at all levels of the health system, from rural clinics to teaching hospitals, and most particularly in resource poor public hospitals. Research will be needed to field-test a range of generic tools (external assessment, internal audit, feasible and informative data sets etc.) and local adaptations of these, and to evaluate overall strategies in provinces or districts where quality improvement processes have been introduced. Whereas it is clear that doing it alone would demand too much from a professional organization, promotion of the issue and a facilitation of such studies and approaches are feasible. There is rising international interest for joint efforts to document useful approaches on these issues. In resource-poor settings there is a need for advocacy on the equitable distribution of health resources, and this too can be a role for the IAP.

These are pivotal roles for pediatricians and the IAP to play, first to demonstrate useful approaches, and then to help with their implementation on a wider scale, to improve the quality of pediatric care at all levels of the health system. The IAP and local pediatricians should collaborate with health authorities in deciding what approaches are appropriate locally, adapting standards of care to local resources and circumstances, training and supervision, showing approaches on how to assess clinical care at health facilities, also those with non-specialist staff, providing feedback and support and evaluating outcomes. If the IAP can play this lead role, it will result in better health care for children in hospitals, clinics and communities throughout the whole country.

Competing interests: None declared.

Funding: None.

Martin W. Weber*

*Corresponding author

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