|
Patient safety and healthcare quality are high is defined as
being safe, effective, patient centered, timely, efficient and
equitable [1]. Thus patient safety and health care quality are
inter-related. There is a gap between “what we do” and “what
we can do” and successful outcome depends mostly on a range of
factors, not just the competence of an individual healthcare
provider [2]. If we wish to improve our patient health care,
improvement methods must focus on understanding the steps
(process) and improving the structure of systems where we
work. It is thus imperative that we clinicians and staff must
be competent in quality improvement (QI) skills. QI is the
science of improvement using system based approach.
QI - Science of Improvement
QI
is an intentional, structured approach to problem-solving in
clinical practice. The goal is to make changes that lead to
improvement. There are several frameworks to achieve this
goal. A point of care quality improvement (POCQI) module [3]
developed in India simplifies it using four steps – (i)
Identifying the problem; (ii) Analyzing the cause of the
problem and collecting data to measure the performance; (iii)
Identifying, testing and analyzing ideas for change using
Plan-Do-Study-Act (PDSA) cycle; and (iv) Sustaining the
change.
Quality improvement is about changing
behaviors, approaches and systems within the given
infrastructure without any additional resources. Every unit
has unique answers to similar problems because every system is
unique in the challenges that it faces using the same QI
tools. We need to move from individual-led care to team- based
care which fosters openness, collaboration, communication,
feedback and learning from mistakes from all care providers.
Motivation, teamwork, data and leadership are keys to success
in QI projects. To the pediatrician, involvement in successful
and sustained QI project can be a very rewarding experience.
Unlike clinical research which seeks to discover new knowledge
in a prescribed population, QI science seeks to use and apply
knowledge in real life scenarios. In short, QI is a common
sense approach of planning your work and working your plan to
find better ways of doing things in a consistent manner. It is
all about closing the gap between actual practice and best
known practice, be it clinical or operational [4].
QI and Pediatric Care
QI science has
the potential to improve coverage of evidence-based practices
across the spectrum in pediatric care viz acute and chronic
conditions (eg. asthma, epilepsy, diabetes, ADHD,
gastroenteritis, sepsis, medication errors etc.), inpatient
and outpatients, intensive care services (eg. effective
central line care, decrease in nosocomial sepsis, improved
hand hygiene, reducing use of antibiotics etc.), daily patient
care (eg. triaging of OPD patients, reducing admission delays,
reducing oxygen use, improving breast feeding rates, improve
follow up rates etc.) across all sizes of hospitals [5-9].
This can led to strengthening of processes - adherence to
guidelines, delivery of services in a consistent manner,
reducing variations, decreasing delays, eliminating
inefficient processes and improved outcomes - reduced patient
costs, decreased hospital stay, improved survival and
increased patient satisfaction. The standards for improving
quality of maternal, newborn and adolescent care have been
laid down by WHO [10,11]. There is need to have India specific
indicators to monitor, compare and improve performance of
practices across diverse settings which are of importance to
patients, providers, payers and policy makers.
Role of IAP: The Way Forward
Indian Academy of
Pediatrics (IAP) is committed to develop nationwide standards
for pediatric training and services. IAP advocates, supports
and promotes the QI movement. The vision and mission is to
identify a core set of pediatric quality indicators from five
categories: prevention, acute care, chronic care, practice
management and patient safety in primary care. The
benchmarking of structures, processes and outcomes, could
reveal opportunities for improving newborn, child and
adolescent care across India. By embracing QI, IAP with
collaboration with professional bodies (NNF, FOGSI, IMA etc)
and organizations (WHO, UNICEF etc) plans to build a cadre of
QI Coaches, Champions and Mentors who in turn shall educate,
stimulate and motivate QI uptake. A combination of web based
module, workshop learning and project implementation will
engage the learner and help facilitate practice the art and
science of QI. IAP realizes the value of QI in pre-service
education and would strive to create a framework and essential
competencies for quality, safety and systems level thinking to
guide and support our future pediatricians. We are aware that
QI work is not easy and can be particularly challenging given
some of the barriers that exist within the existing system. We
have a responsibility to our children and families to ensure
universal right to high quality care. Let us join hands and
apply the science of improvement to our clinical care and have
zero tolerance to risks, errors and harm.
Acknowledgement: Dr Ashok Deorari, QI Guru, for his
exemplary leadership in Quality care.
REFERENCES
1. Institute of Medicine (US)
Committee on Quality of Health Care in America. Crossing the
quality chasm: A new health system for the 21st century.
Washington, DC: National Academies Press (US); 2001. Available
from: http://www.ncbi.nlm.nih.gov/books/NBK222274/. Accessed
February 10, 2020.
2. Institute of Medicine (US)
Committee on Data Standards for Patient Safety. Patient
Safety: Achieving a New Standard for Care. (Aspden P, Corrigan
JM, Wolcott J, Erickson SM, eds.). Washington (DC): National
Academies Press (US); 2004. Available from:
http://www.ncbi.nlm.nih. gov/books/NBK216086/. Accessed
February 10, 2020.
3. Point of Care Continuous Quality
Improvement. Developed by WHO-SEARO, WHO Collaborating Center
for Newborns (AIIMS) and ASSIST, supported by UNICEF, UNFPA,
USAID and WHO CC SEA. Available from: https://www.pocqi.org/.
Accessed February 10, 2020.
4. Shojania KG, Ranji SR,
Shaw LK, Charo LN, Lai JC, Rushakoff RJ, et al. Closing the
Quality Gap: A Critical Analysis of Quality Improvement
Strategies (Vol. 2: Diabetes Care). Rockville (MD): Agency for
Healthcare Research and Quality; 2004.
5. Zaka N,
Alexander EC, Manikam L, Norman ICF, Akhbari M, Moxon S, et
al. Quality improvement initiatives for hospitalized small and
sick newborns in low- and middle-income countries: A
systematic review. Implement Sci. 2019;13:20.
6.
Deorari A, Livesley N. Delivering quality healthcare in India:
Beginning of improvement journey. Indian Pediatr.
2018;55:735-7.
7. Sarin E, Livesley N. Quality
improvement approaches associated with quality of childbirth
care practices in six Indian states. Indian Pediatr.
2018;55:789-92.
8. Sivanandan S, Sethi A, Joshi M,
Thukral A, Sankar MJ, Deorari AK, et al. Gains from quality
improvement initiatives – Experience from a tertiary-care
institute in India. Indian Pediatr. 2018:55:809-17.
9.
Schwartz SP, Rehder KJ. Quality improvement in pediatrics:
Past, present, and future. Pediatr Res. 2017:81:156-61.
10. WHO: Standards for Improving Quality of Care for
Maternal and Newborn Care in Health Facilities. Available
from: https://www.who.int/maternal_child_
adolescent/documents/improving-maternal-newborn-care-quality/en/.
Accessed February 10, 2020.
11. WHO: Standards for
improving the quality of care for children and young
adolescents in health facilities. Available from:
https://www.who.int/ maternal_
child_adolescent/documents/quality-standards-child-adolescent/en/.
Accessed February 10, 2020.
|
