H
ealthcare today, especially in the developing
countries, stands at a watershed of service availability and variable
utilization owing to indifferent quality of care – both perceived as
well as actual. With increasing awareness, more and more people are
reaching out to health facilities for accessing needed healthcare but
the quality of services delivered at the health facilities can rapidly
erode their trust and confidence in healthcare system. Quality of care
has presently received attention at the highest level in the World
Health Organization (WHO). The Director General of WHO, in his inaugural
speech, expressed that WHO is fully committed to quality, equity and
dignity in services for every woman and every child
[1]. Regional director of WHO-SEARO highlighted in
her vision that accessible, affordable and quality Universal health
coverage (UHC) is the most important game-changer in public health [2].
Quality of care is an important element in UHC that underlies the
Sustainable development goal-3, towards which all countries are
committed.
It is an essential prerequisite to provide healthcare
services that the health facilities have standard infrastructure,
adequate number of appropriately skilled health workers, evidence-based
guidelines and protocols, and essential equipment and supplies. To
ensure that healthcare services are delivered in conformance with
pre-decide standards of care, healthcare teams have to be mindful of
quality of care being delivered to their clients and to be empowered
with knowledge and skills in continuous quality improvement. However,
presence of all these may not result in compliance to standard treatment
protocols leading to quality gaps. The science of Quality improvement
can bridge these quality gaps by ensuring that compliance to pre-defined
standards of care can be consistently achieved in health facilities and
duly supported by actions at the health system level.
Quality Improvement in Healthcare
Quality improvement (QI) as a principle in healthcare
has been borrowed from the industry, beginning essentially from the
1980s. But even long before that the concept of quality in healthcare
had existed in recordable form since 1910 [3]. In fact, Nightingale’s
specific interventions for improvement have been
reported previously in much details [4].
In the present times, QI has been defined as an
approach to making changes that can result in better outcomes for the
patients as well as result in efficient utilization of the available
resources and optimal functioning of the system [5]. QI also involves
considering the experience of care and ensuring respectful care as an
important aspect of healthcare delivery and not just the patient
outcomes. Present mid-career busy clinicians and those in leadership
positions in the healthcare system might find themselves to be
ill-prepared to lead QI activities since they lack the required
knowledge and skills. Acquiring skills of quality improvement is
essential for all healthcare workers [6,7].
Commonly used QI methods in health facilities include
specific set of skills. QI approach includes building teams of
healthcare workers in the health facilities who learn to use the local
data to identify quality gaps or problems (non-compliance to standard
treatment protocols) at the point of service. The team prioritises the
quality problem they want to address and collectively make an aim
statement that they want to achieve in short term. They use problem
analysis tools like Pareto chart, Five Whys, Fish bone analysis and
patient care flow charts to undertake a root-cause analysis. Based on
this they identify possible solutions or change ideas and decide on one
such idea. They select process and outcome indicators to measure
progress. The team undertakes a rapid and short cycle of using the
change idea to bring in improvement through Plan-do-study-act (PDSA)
cycles. If the change idea succeeds in reaching the aim and improving
the quality of care it is sustained in the system of the health facility
so that it becomes a norm.
However, such knowledge and skills related to QI have
not been included in pre-service education or in-service trainings of
healthcare workers in developing countries, Similar to these QI skills
can also be learnt if appropriate opportunities are provided.
It is commonly observed that when healthcare teams
are provided an orientation or an introductory training in QI they
cannot be expected to practice this without ongoing support. Since these
are relatively new skills they must be supported by facilitators for
clarifications and problem-solving as they begin practicing QI upon
return to their place of work. Hence an initial training of healthcare
teams in QI must be followed by ongoing on-the-job mentoring to enable
them to apply and practice the newly acquired knowledge and skills.
Such support is difficult to provide through field
visits and face-to-face mentoring in an ongoing manner due to distances
between centers and time-constraints. Moreover, the number of QI
facilitators may not be adequate to provide the ongoing mentoring to
multiple healthcare teams. At the same time, healthcare teams can learn
effectively from similar teams who may be practicing QI in their own
health facilities as well as those in the neighborhood. Such
opportunities promote cross-learning, healthy competition and motivation
in QI. Given this need of bringing together the QI practitioners with
each other and with QI coaches, internet- and web-based learning
platforms present a plausible solution to collaboratively learn, apply
and share their experiences for continuous QI.
This article presents the characteristics and
advantage of online learning platforms and reviews the published
evidence for use of such learning platforms in medical education and
potential use in quality improvement programs.
Online Learning Platforms
Technology now plays an important role in educational
transformation. The online learning platforms provide a reasonable
combination of accessibility of knowledge with learner flexibility and
interactivity. This learner centred approach, also called asynchronous
e-learning [8] can help balance professional development with personal
and work commitments.
Components of Learning Platforms
A Learning platform is a framework of tools that work
seamlessly and unify educational theory, practice, technology and
content [9]. From educational perspective, a Learning platform is an
integrated set of interactive online services that provides the
teachers, learners and others involved in education with information,
tools and resources to support and enhance educational delivery and
management [10,11]. When used properly, it can reduce teacher workload,
minimize expenditure, and enhance teaching and learning. Creating a
learning platform requires some basic pre-requisites (Table I).
Various attempts have been made to develop international standards for
Learning management systems [12-14]. These include choosing a
user-friendly learning management system, creating course content and
curriculum mapping, creating learner engagement tools by judicious use
of interactive and multimedia content, enabling learner assessment in an
objective manner and providing communication tools such as email,
messaging, internet or mobile calls, discussion forums, blogs, etc.
Content management enables coaches to create, store and repurpose
resources and course work.
TABLE I Prerequisites for a Learning Platform
|
Feature |
Implication |
|
User-friendly |
Scope for asynchronous and synchronous communication using
emails, chats, announcement areas and discussion forums
|
|
Creation of course content |
Availability of a variety of learning resources including power
points, case studies, webinars and videos and links to other
internet resources) |
|
Curriculum mapping |
Planning the delivery of content starting from learner
registrations to proposed timelines, managing learner activities
and tracking online office hours. |
|
Learner engagement tools |
Judicious use of interactive and multimedia content. |
|
Learner communication and assessment tools |
Online multiple choice questions, case scenarios, collaborative
projects. |
Advantages of Learning Platforms
Learning platforms are beneficial for group learning
where healthcare teams can not only learn together synchronously in
their own learning and also collaborate with others in different health
facilities for mutual learning in the whole network. Learning platforms
can create a network of QI practitioners (healthcare teams) as well as
mentors (QI coaches) and mentees (healthcare teams) who are all
connected through information and communication technology solutions
while they continue to remain at their own work places without too much
disruption in their routine work.
Such learning platforms are used for enabling
healthcare teams in the whole cycle of learning from initial training to
acquire new skills of improving quality of care followed by ongoing
coaching to effectively apply QI skills in their day to day work,
continuously practice quality improvement by undertaking micro-projects
and sharing their experience with peers and coaches.
Use of Learning Platforms in Medical Education
There is an extensive body of literature on the role
of web-based learning platforms in medical education [15]. In a recent
systemic review, 251 articles on software platforms and interventions in
medical education were analyzed as well as experience from 25 learning
platforms [16]. The authors observed that with regard to the use of
learning platforms in medical education, there was a trend towards using
reusable software platforms with special emphasis analysis of online
activity for an interactive feedback and more student centered models.
Learning platforms have been utilized in a variety of
ways. Apart from being a standalone method for delivery of a concept or
a skill, these have been integrated with traditional teaching
methodologies in a symbiotic manner for the benefit of the learner. Use
of learning platforms has shown to improve the persistence and
completion rates of the intended program [17]. Stewart, et al.
[18] found that the group of medical students who
received blended learning which had an online component, in addition to
the conventional teaching, achieved a significantly higher mean score in
a module for teaching newborn physical examination skills than the
control group.
These are some of the advantages that make online
teaching platforms attractive for teaching quality improvement science
to the healthcare professionals. Most of the professionals (doctors,
nurses, paramedics, administrators/managers) trying to learn and
practice QI methodology can be pressed for time due to heavy workloads
they already may have. Online platforms are good solutions for diverse
teams of professionals because they can learn as teams and also get
tailored content for their discipline. Others have reported on use of
e-learning platforms for patient safety [19,20] and factors affecting
successful utilization [21].
The various virtual training tools in QI can
similarly train health professionals in understanding the concepts of QI
by presenting simulated settings which can be later replicated or
extrapolated in the real-life scenarios. Another role of web-based
learning platforms has been explored in fields like occupational
medicine [22] where rarity of clinical situations makes traditional
bedside teaching quite limited. The essential learning from this online
platform (NetWoRM Europe) is the knowledge sharing among multiple groups
that has been inculcated to overcome the serious limitations of rarity
of disease findings. Taking cue from this experience, learning achieved
in QI projects at one health facility can be used for learning for teams
at other health facilities through a common learning platform.
TABLE II Benefits of a Learning Management System as Relevant to Coaching in Quality Improvement Methodologies
|
Benefits of Learning management system |
Relevance to QI coaching |
|
Organizes eLearning content in one location |
Ready availability of coaching modules for a step-by-step
approach |
|
Provides unlimited access to e-Learning materials |
Options of completing courses at convenience rather than a fixed
time |
|
Easily tracks learner progress and performance |
Gives the QI coaches an opportunity to track the progress of the
mentee and give a feedback |
|
Reduces Learning and Development costs and time |
Step by step webinars and virtual platforms can provide training
opportunities to QI enthusiasts in remote places or different
countries also where direct training may not be feasible.
|
|
Quickly and conveniently expands eLearning courses |
Any course material can be updated at a nominal cost and made
available to all learners |
|
Integrates social learning experiences |
Provides an important link to other social and professional
platforms for connecting with QI enthusiasts from different
parts of the world. |
Currently Available QI learning Platforms
We briefly describe selected learning platforms
available for quality improvement.
Institute of Health Improvement (IHI)
[23]: Institute of Health improvement has an online learning
platform for providing education in the improvement science. The
educational programs and trainings offer webinars, presentations and
audio- visual aids for understanding the essential principles and tools
of QI. Besides providing an understanding of improvement science, the
platform provides opportunities for in-person and virtual training in
professional development programs as Improvement advisors or in
Leadership programs. IHI Open School is a unique concept that provides a
wealth of knowledge to the QI enthusiast. There are certified online
courses and a section called Practicum which certifies a practical care
improvement process in the learner’s own settings.
International Society for Quality in Health Care
[24] (ISQUA): Another prominent QI learning platform
is the International Society of Quality Improvement in Health care. It
provides web-based educational opportunities through structured
fellowship programs broadly divided into seven modules namely;
leadership and health policy, patient centered care, patient safety,
education and research, health information and technology, external
evaluation systems and quality and safety in developing countries. There
is also opportunity to learn as mentees from experts on board or become
virtual mentors for various QI teams in various geographical regions
across the world.
Point of Care QI (POCQI)
South-East Asia Regional office of WHO (WHO-SEARO) is
working with countries in the region to develop capacity in preparing
national plans and roadmaps for improving quality of care for maternal,
newborn and child health and provide knowledge and skills to healthcare
teams to improve quality of care in their own health facilities. For
this, POCQI model has been developed by WHO-SEARO, WHO Collaborating
Center for Newborn (WHOCC AIIMS) and ASSIST (United States Agency for
International Development Applying Science to Strengthen and Improve
Systems) and is supported by UNICEF, UNFPA and USAID as a collaborative
QI model in the South-East Asia Region. The POCQI package
[25] provides a simplified model for initial
training of healthcare teams in a four step process by using local data
to identify quality gaps, analyze underlying causes and improve health
care practices in their own specific context without much additional
resources. The four step approach includes identification of a problem,
forming a team, making an aim statement (Step 1), using analytical tools
for identifying the root cause of a problem (step 2), planning an
intervention using Plan-Do-Study-Act cycle (Step 3) and plans for
sustaining the change (step 4). This simple common sense approach to
problem solving encourages frontline workers to begin by changing the
circumstances within their sphere of influence and slowly work their way
up to a systems change to ensure sustenance. In addition to POCQI
training manuals, a coaching guide for ongoing on-the-job coaching and
an implementation guide for institutionalizing QI in district systems
have also been developed.
To scale up the capacity building in quality
improvement in countries of the Region WHO-SEARO has supported WHO
Collaborating Center at AIIMS, New Delhi to develop Regional POCQI
Learning Platform. It includes four ways in which countries and facility
teams are being supported in their QI efforts:
(i) In-person training: Trainings,
workshops and coaching visits for QI capacity-building.
(ii) Remote coaching support: QI
coaches have been assigned to support POCQI trained hospital teams
in the countries to provide ongoing mentoring through modern
communication technology.
(iii) Dedicated website [26]:
The Point of Care Quality Improvement website (www.pocqi.org)
has been developed. This website has a wealth of resources and
information viz.,Training materials, including the POCQI
Learner’s Manual and the POCQI Facilitator’s Manual; Video lectures
on quality improvement; POCQI Virtual Workbook: This is a case-based
e-learning tool in the POCQI model; QI experiences from hospital
teams: QI project posters and QI project videos; It also has space
for each country to share their progress with the network; and
Technical resources like recent publications will be posted on the
website for everyone to use.
(iv) Webinars: A
series of webinars have been launched in May 2018. Two types of
webinars are planned: teaching webinars on QI topics to upgrade the
QI knowledge and skills; and experience sharing webinars, for QI
teams from various countries to share their work on QI so that teams
in the Region could learn from each other.
A virtual learning platform has been created by
linking the QI experts (mentors) to the healthcare teams (mentees)
located in different places. These healthcare teams were initially
trained by the same QI experts in New Delhi in an inter-country
workshop. In the follow-up the mentors and mentees were paired and they
used emails, phone calls and video calls to communicate with each other.
The mentors remained in touch with the mentees and provided
clarifications, problem solving and technical support in an ongoing
manner. This support was effective in keeping the motivation of newly
trained healthcare teams high and they continued to implement QI
projects in their hospitals and acquired confidence to sustain the
practice.
The platform provides a common ground for QI
enthusiasts from the SEA region to come together and learn from each
other’s experience with QI projects. The website also provides an
educational tool for the POCQI methodology.
Conclusion
Learning platforms provide the opportunity to share a
wide range of teaching and learning resources and experiences among
learners and teachers. This is also an effective way to
collaborate on projects with co-learners and teachers. These can both
motivate and support independent learners.
Online learning platforms provide an attractive
modality for teaching and learning in medical education and QI
methodology to the healthcare professionals, bringing them together for
a knowledge sharing and collaborative learning experience.
Disclaimer: Rajesh Mehta is staff member of the
World Health Organization. The author alone is responsible for the views
expressed in this paper and they do not necessarily represent the
decisions, policy or views of the World Health Organization.
Contributors: Both authors contributed to
literature search, literature review and mancuscript writing.
Funding: None; Competing interest: None
stated.
References
1. Director-General Dr Tedros takes the helm of
WHO: address to WHO staff (2017,July 3). Available from: http://www.who.int/dg/speeches/2017/taking-helm-who/en.
Accessed
May 1, 2018.
2. Healthier WHO South-East Asia Region;
Responsive Regional Office. Available from: www.searo.who.int/mediacentre/features/2014/rd-singh-vision/en//.
Accessed May 1, 2018.
3. Let’s make our health system healthier. (n.d)
Quality Improvement. Available from: http://www.hqontario.ca/quality-improvement. Accessed May 1,
2018.
4. Sheingold BH, Joyce AH. The history of
healthcare quality: The first 100 years 1860-1960. Int J Africa Nur
Sci. 2014;1:18-22.
5. Sheingold BH, Joyce AH. The history of
healthcare quality: The first 100 years 1860-1960. Int J Africa Nurs
Sci. 2014;1:18-22.
6. Luce JM, Bindman A, Lee PR. A brief history of
health care quality assessment and improvement in the United States.
West J Med. 1994;160:263-8.
7. Spreading Quality Improvement, cited 2017,
March 28. Available from:https://www.rwjf.org/en/library/research/2011/12/spreading-quality-improvement-.html.
Accessed May 2, 2018.
8. Dobrow MJ, Neeson J, Sullivan T. Canadian
chief executives’ prescription for higher quality: more clinical
engagement, shared accountability and capacity development. Healthc
Q. 2011;14:18-21.
9. Sinclair P, Kable A, Levett-Jones T. The
effectiveness of internet-based e-learning on clinician behavior and
patient outcomes: a systematic review protocol. JBI Database of
Systematic Reviews and Implementation Reports. 2015;13:52-64.
10. Plourde M. What is a learning Platform?
Available from:
http://mfeldstein.com/what-is-a-learning-platform/. Accessed
May 2, 2018.
11. Timeless Learning Technologies. Available
from: www.timelesslearntech.com/learning-platform.php. Accessed May 2, 2018.
12. SCORM. (2015, October 23). Available from www.adlnet. gov/scorm. Accessed May 02, 2018.
13. IMS Global Learning Consortium. Available
from: www. imsproject.org. Accessed May 02, 2018.
14. Open Knowledge Initiative. Available from: web.mit.edu/oki/.
Accessed May 02, 2018.
15. Dhir SK, Verma D, Batta M, Mishra D.
E-learning in medical education in India. Indian Pediatr.
2017;54:871-7.
16. Taveira-Gomes T, Ferreira P, Taveira-Gomes I,
Severo M, Ferreira MA. What are we looking for in computer-based
learning interventions in medical education? A systematic review. J
Med Int Res. 2016;18:e204.
17. McLaren, C. HA comparison of student
persistence and performance in online and classroom business
statistics experiences. Decision Sciences J Innovative Education.
2004;2:1-9.
18. Stewart A, Garry I, Jardine L, Pieter K ,
Davies, William M. A randomised controlled trial of blended learning
to improve the newborn examination skills of medical students. Arch
Dis Child-Fetal Neonatal Ed. 2013;98:F141-4.
19. McHugh SM, Corrigan M, Dimitrov B, Cowman S,
Tierney S, Humphreys H, et al. A targeted e-learning program
for surgical trainees to enhance patient safety in preventing
surgical infection. J Conti Edu Health Profess. 2010;30: 257-9.
20. Marshall NL, Spooner FM, Galvin PL, Ti JP,
Gerald McElvaney FN, Lee MJ. Evaluation of an e-learning platform
for teaching medical students competency in ordering radiologic
examinations. Radiographics. 2011; 31:1463-74.
21. Woods CR, Kemper KJ. Curriculum resource use
and relationships with educational outcomes in an online curriculum.
Acad Med. 2009;84:1250-8.
22. Kolb S, Reichert J, Hege I, Praml G, Bellido
MC, Martinez-Jaretta B, et al. The NetWoRM group. Int Arch
Occup Environ Health. 2007;80:553-7.
23. Institute for Healthcare Improvement. Available from:
www.ihi.org/education/Pages/default.aspx.
Accessed May 2, 2018.
24. ISQua Fellowship Programme. Available from: www.isqua.org/education/the-isqua-fellowship.
Accessed May 2,
2018.
25. World Health Organisation, Improving the
Quality of care for Mothers and Newborns in Health Facilities (2018,
January 09). Available from: www.searo.who.int/entity/child_adolescent/topics/child_health/facilitators-manual/en/.
Accessed May 02, 2018.
26. Point of care Quality Improvement. Available from: www.
pocqi.org. Accessed May 2, 2018.
