• 1) To assess performance of QI teams at several levels in the health system: national, health area, and  health facilities
• 2) To document the QI activities teams performed, including documenting best practices and changes, monitoring and analyzing data, and sharing successful experiences between teams in the collaborative
• 3) Provide information on results achieved by QI teams in the indicators reported during 17 consecutive months measured as absolute improvement in indicators, speed of the improvement and maintenance of the improvement over time.

Various quality improvement (QI) models are applied in the health field. All of them aim to improve the quality of health care but have different structures, steps, and terminology. This variation creates an impression of fundamental differences among the models, while in fact a closer look at their core contents reveals common elements. Failure to see the commonalities creates barriers to communication among QI partners, hinders coordination of QI efforts, and misses opportunities to achieve synergies to augment the collective results of QI programs.

This paper attempts to systematically review and compare QI models that have been applied extensively in maternal, newborn, and child health (MNCH) or are potentially effective models for MNCH programs. These models are:  COPE® (Client-Oriented, Provider-Efficient Services) (COPE), Fully Functional Service Delivery Point (FFSDP), HIVQUAL, Improvement Collaborative, Improving Newborn Health, Partnership Defined Quality (PDQ), Private Sector Quality Improvement Package, Quality Design/Redesign, Reaching Every District (RED), and Standards-Based Management and Recognition (SBM-R).  The authors reached a definition of “quality improvement” that encompasses most models: “a cyclical process of measuring a performance gap; understanding the causes of the gap; testing, planning, and implementing interventions to close the gap; studying the effects of the interventions; and planning additional corrective actions in response.”

The paper identifies the models’ essential elements in an attempt to find common ground: a place where those who apply different QI models can discuss them with a common language and understanding. Such common ground can demonstrate the similarity of the various models and hence facilitate dialogue and coordination among partners, donors, and stakeholders who use or support the different models. 

The maternal mortality ratio in Tanzania is estimated to be 578/100,000.¹  A great majority of these deaths are due to obstetric complications, 90% of which can be avoided. Some obstetric complications can be predicted and most are treatable if women receive high quality care when needed.² Care provided by a competent Skilled Birth Attendant (SBA) during labor, delivery and in the immediate postpartum period is a key component of quality obstetric care. The percentage of deliveries assisted by a SBA has become a proxy indicator for reducing maternal mortality.³

This study presents results of a costing and cost-effectiveness analysis conducted retrospectively of the 2006-2008 Niger Essential Obstetric and Newborn Care (EONC) Collaborative, which was implemented in 33 facilities in Niger to improve maternal and newborn care oucomes by increasing compliance with evidence-based care standards. This study used outcomes data from routine program monitoring and costs from a number of sources including Health Care Improvement Project (HCI) accounting records and surveys of clinical managers. It compares the costs of attended vaginal delivery and immediate neonatal care in the six months before the QI collaborative started with the average of the last three months of the intervention. The four measures of effectiveness used were compliance with AMTSL, rates of post-partum hemorrhage, compliance with essential neonatal care and compliance with breastfeeding within the hour following delivery. Calculating the incremental cost-effectiveness using HCI and MOH costs including development and demonstration gave low, positive incremental cost-effectiveness ratios.

The Pediatric Hospital Initiative was launched by Nicargua's Ministrio de Salud (MINSA) in partnership with UNICEF and USAID though the Quality Assurance Project (QAP) and its successor the Health Care Improvement Project (HCI). The initiative worked to improve the quality of care provided in hospital pediatric wards to children with common infectious diseases. The initiative involved 14 hospitals, which were organized into an improvement collaborative, and focused on children affected by diarrhea and pneumonia.

This study used a longitudinal pre/post design using data from medical records of inpatient admissions to examine the cost effectiveness of PHI initiatives, as measured by the impact on days of hospitalization, disability adjusted life years (DALYs), and deaths attributed to diarrhea or pneumonia from seven of the collaborative hospitals, which were selected based on a minimum criteria of two years of surveillance data for the indicators of interest and where QI teams were actively engaged in monitoring and evaluation of the program and implementing improvement cycles. A total of 2,799 records were examined: 647 records from the year prior to the collaborative and 750 after the collaborative for diarrhea and 647 records before and 755 after for pneumonia.Costs were calculated retrospectively. Those paid by HCI and its partners were determined by the project's accounting records. Hospitalization costs were calculated from a mix of available data from the public sector such as published salary rates and price lists of basic medicines, and from equivalent private sector costs for items such as laboratory blood tests and chest radiographs for pneumonia patients because public hospitals do not account for clinical line items such as these.

The study shows that implementation of the quality improvement collaborative decreased patients' length of stay and the number of deaths and did not increase the cost of hospitalization for diarrhea and pneumonia cases, meaning that the QI collaborative improved health outcomes while decreasing costs to the hospital system.

This study has been submitted to a journal for peer review and will be available when published.

An improvement collaborative is a shared learning system that gathers many teams to work together, with the purpose of rapidly achieving significant improvements in quality and efficacy of a specific care area, with the intention of diffusing these methods to other sites. The improvement collaborative improvement approach often consists of an initial demonstration (pilot) phase in which improvement teams share their experiences. A subsequent expansion (spread) phase allows for the best innovations to be synthesized and communicated to a larger number of health facilities and enables rapid uptake of best practices across the system.

The HCI-supported project for Promotion of Essential Obstetric and Neonatal Care (ProCONE for its acronym in Spanish) introduced a health delivery model that integrates maternal and neonatal health care, linking users (e.g., pregnant women and traditional birth attendants) in rural areas with health services delivery units (e.g., health posts and hospitals). The program was first introduced in the Health Area of San Marcos, and has shown significant results in improving the quality of maternal and neonatal care as well as in the management of obstetric and neonatal complications. Following on this success, the ProCONE collaborative was spread from one health area to 7 new health areas and from 22 facilities in San Marcos to more than 300 health services delivery units in 9 out of 29 health areas in the country, following a consolidation of learning and a publication of best practices.

This is the revised version of the Primary Health Care Supervision Manual developed by the National Department of Health and serves as key tool for strengthening the delivery and improving the quality of Primary Health Care services, the cornerstone of the national health care system. It follows on the earlier Clinic Supervisor’s Manual that was originally introduced to the public health sector at a national workshop in October 2000 and adopted in March 2004 for countrywide use.  Since the introduction of the Manual in 2000, the health care system has undergone significant transformational changes as a result of changes in the burden of disease in South Africa. These changes have resulted in the development of new programmes that were not included in the former manual. Materials used in this revised version draw from a number of sources, all of which have been field-tested and have proven to be very useful tools in supervising primary health care programs.

The manual contains guidelines for quality supervision, use of supervision support checklists, conducing in-depth technical program reviews, and tools for working with Primary Health Care Facility Committees.