Quality of Hospital Care

in Khyber Pakhtunkhwa
Challenges and Perspectives
  Quality of Hospital Care was a key element of the assessment of
the health sector of the Khyber Pakhtunkhwa (KP) province.
 Special attention was paid to the following:
 Infrastructure and equipment
 Utilization of in-patient and outpatient services
The  Availability and functioning of key referral services (A&E, OT, ICU)
 Availability and functioning of key support services (Imaging,
Assessment Laboratory, CSSD)
 Quality of clinical care (analysis of patient records and discussion
with / interviews of clinical staff)

 The purpose of the assessment was to identify areas of action and

specific measures that would help improving accessibility to
quality hospital care for the population of KP.
  Hospital statistics were analyzed and evaluated of 36 selected
secondary level hospitals selected by the KP DOH out of the 97
secondary level hospitals registered in KP
 A team of three experts experienced in hospital design,
management of hospital services, and quality of care visited 6 of
these Hospitals
Methods and  Qazi Hussain Ahmad Medical Complex, Nowshera
 Moulvi Ameer Shah Qadri Memorial (Women & Children) Hospital
Sample  Naseer Ullah Khan Baber Memorial Hospital, Peshawar
 DHQ Hospitals in Haripur and Swabi
 Type D Hospital Toru Mardan

 Each visit was conducted during one day (4-6 hours per hospital)
following a checklist and semi-standard questionnaire focusing on
the above mentioned elements.
  Hospitals are inadequately
designed and equipped for the
number of patients they receive,
specifically in the outpatient
departments.
 Due to a dysfunctional referral
Findings system, many of the secondary
level hospitals function as huge
outpatient clinics with
OPD services  up to 2,000 patients / working day
 up to 200 patients / MD / work day

 suggesting both a high percentage

of PHC level cases as well as rather
limited quality of care (only 2-3
minutes available to consult,
examine and provide advice to the
patient or the parents of a patient)
  Inpatients only represent a small
fraction of the total workload –
(2-10% of OPD contacts get
admitted) - partially due to
inappropriate infrastructure.
BORs vary between 10 and 60%
 Two of the visited hospitals have
Inpatient been (totally or partially)
accommodated in buildings that
services have never been planned and
constructed for this purpose,
posing serious problems with
regard to patient and staff
safety (hygiene / infection
prevention) and the
organization (efficiency) of work
flows.
  The infrastructure (buildings
and installations) was
inappropriate in almost all
facilities visited:
 outdated in terms of standard
requirements for adequate
spaces / workflows;
Infrastructure  dysfunctional for basic utilities
including power and water
supply, sanitary installations,
sewage and solid waste
management systems;
 lacking both preventive and
curative maintenance.
Sterilization equipment at the
Haripur DHQ
  THQ Hospital
Toru Mardan

Planning

 Lack of equipment and qualified staff

 Two referal hospitals (Teaching and
DHQ Hospital) in about 5 km
 No Masterplan for Hospital Services at
provincial level
  The same is valid for medical
equipment, starting from basic
diagnostic equipment required for
medical consultation moving to more
sophisticated imaging, laboratory,
sterilization, OT/ICU and anesthesia
machines, all is insufficient to
adequately fulfil the referral function
of a secondary level referral hospital.
Equipment
  The most critical point of the assessment:
the team hardly found any quality
management process in place in the
visited hospitals:
 No (written) standard clinical protocols or
pathways for diagnostic and therapeutic
procedures;
 No quality circles or committees
Process established and operational;
management  No monitoring, feed-back or review
mechanism for key performance and
quality indicators

 despite the fact that many of the staff

interviewed confirmed the necessity of
having such tools and instruments of
process management in place to
guarantee minimum quality levels of care.
  Currently guidance is being provided
by heads of departments / senior
specialists on a case by case basis
 Modern, interdisciplinary and inter-
professional, team oriented care
requires predefined standards
following international best practice
and considering scientific evidence.
Clinical
Pathways
Clinical
Pathway
Best Practice Example
  The analysis of medical records
unveiled significant weaknesses:
 Clinical and social anamnesis poorly
documented;
 Diagnostic measures and treatment
registered but without using tables
and graphs prepared for this
purpose.
Clinical
Records
  No analysis of data and
indicators has been undertaken
in any of the visited hospitals to
evaluate the outcomes of
clinical care:
 inpatient morbidity and
mortality directly or indirectly
Performance related to the medical
intervention (e.g. hospital
and outcome acquired infection – though
related data collection forms
monitoring are available on the DOH
website);
 no mortality audit / “verbal
autopsy” has taken place (in the
hospitals visited) in cases of
maternal mortality – despite Data analysis and evaluation?
the fact that maternal mortality Surgical interventions at the Haripur
ratio is still high in KP.
DHQ
  Lack of financial resources to significantly improve the quality of
the infrastructure available to secondary level health care
facilities;
 Low performance, and lack of trust of the population in the quality
and effectiveness of PHC level services leading to overrun of
secondary level hospitals with PHC level patients and pathologies;
 Lack of autonomy of hospital managers (general management,
Root Causes clinical department management) to (formally and officially)
generate resources and to steer and control the utilization of
resources available to them (e.g. through patient fees, insurance
payments, other sources like donations).
 Hospitals are complex (service) enterprises requiring flexible and
efficient use of resources and strong and effective leadership to
develop and maintain outstanding levels of quality – this is
obviously impossible under the given circumstances
  Existing standards documents
 Secondary Health Care Standards for
Quality Health Services, developed in the
framework of a GIZ TA Project in 2007
 Minimum Health Services Delivery
Package for Secondary Care Hospitals
(MHSDP-SC), published November 2016,
 are focusing on
 structural elements of care: buildings,
Reference equipment, drugs, consumables and
human resources;
Documents  processes required to operate hospitals
(clinical and support services);
 however, they do not contain clinical (i.e.
disease or syndrome / symptom specific)
guidelines, protocols, or pathways
(algorithms), describing diagnostic and
therapeutic measures to be undertaken in
a patient who is being admitted with any
of these symptoms, syndromes, or specific
diseases / health problems.
  Having structural
standards for buildings,
equipment and general
processes for service
organization and
management is already
an important step
Reference towards improved
Documents quality.
 However, it will be
necessary to harmonize
and disseminate these
standards (nobody at
facility level was aware
of their existence!) and
to enforce compliance.
  Clinical guidelines and protocols for
the most frequent diseases /
medical conditions requiring
admission to secondary level
inpatient care.
 A comprehensive framework for
Continuous Quality Improvement
(CQI) not only at service / facility
What is level but at the level of the
(provincial) health care system:
required  Internal Quality Management
(clinical protocols / pathways are
part of such internal QM system)
 External Quality Management
(benchmarking with hospitals of
the same level)
 Both systems are based on a
continuous monitoring and
evaluation of performance and
quality indicators.
  Timely and reliable
collection of related data
and analysis of these
indicators will depend on
the availability of a
functional Hospital
Information System
Preconditions including Electronic
Patient / Medical Records
(EPR / EMR).
 Continuous Medical
Education (CME) will be
needed to implement a
systemic Quality
Management approach
  Quality has not yet become an overall guiding principle for the
management of hospital care in both private and public hospitals in the
Khyber Pakhtunkhwa Province.
 Main quality problems are related to
 infrastructure and equipment, the lack of qualified staff, and
 the lack of processes and tools to improve quality of care.

 A QM System needs to be established composed of

Key messages  Internal QM procedures like
 clinical pathways
 quality circles (morbidity / mortality, hygiene, risk management)
 continuous M&E of performance and quality indicators
 annual quality reports
 External QM procedures like
 benchmarking on key quality indicators
 annual reports on the status of quality in provincial health care facilities
  Workshop
 Awareness: Which problem do we have with quality in health care?
 Definition: What is Quality in Health Care? Basic principles, and
objectives, framework conditions.
Next Steps  How to improve Quality in Health Care? Concepts, methods, and
models for Quality Management in Hospitals.
 Strategy for better quality to be implemented in KP.
 Outline of draft administrative order to introduce a QM system
  To err is human (IOM 2000)
 Retrospective studies on more than 5 million cases of in-hospital
treatment in New York (1984) and Utah / Colorado (1992)
 Complications were observed in 3,7 and 2,9% - mortality in 0,5%
and 0,2% respectively
Quality  Almost 30% of all complications were caused by medical error
 Rates of erroneous behaviour varied from 0.2% to 7.9%, depending
Problems on the hospital, higher rates were observed for patients >64 years
 48% of all complications were observed after surgical procedures
(wound infection), 19% caused by side effects of drugs and 14%
related to invasive diagnostic procedures
 In the USA, 40.000 - 90.000 deaths / year are caused by
(preventable) medical error
  Components of Quality Care (WHO)
 Effectiveness
 Efficiency
Components  Adequacy
 Scientific-technical quality
Categories and  Categories of Quality (Donabedian)
Methods to  Structure
 Processes
analyse and  Outcomes
evaluate  Methods
 Standardisation of the care process through guidelines / protocols /
Quality clinical pathways
 Monitoring and evaluation of compliance and impact through
selected indicators
 Tracer Diagnoses and peer review
  Clinical Pathways are structured, multidisciplinary plans of best
clinical practice for specified groups of patients with a particular
Clinical diagnosis that support the coordination and delivery of high
quality care. They are both a tool and a concept which embed
Pathways guidelines, protocols, and locally agreed, evidence-based patient
centered best practice into everyday sue for the individual patient.
 The European Foundation for Quality Management

People People
9% Results
9%

Key
Leadership Policy & Procedures Client performance
Models Strategy
8%
Results results 15%
10% 14% 20%

Partners & Society

Resources Results
9% 6%

Enablers Results
50% 50%