Cuban Medical Research

A Methodology For Assessing Quality Of Primary
Healthcare Attention

Leonor Jiménez Cangas, MD¹
Rosa María Báez Dueñas, MD²
Benito Pérez Maza, MD³
Iliana Reyes Álvarez, MD⁴

ABSTRACT: The aim of this paper is to propose a methodology for assessing the quality of primary healthcare attention through the use of selected activities and/or health problems that can be considered "tracers" in this process, as well as participatory methods for the selection of criteria, indicators and standards to be included in the evaluation. Health professionals at the facility being assessed participate in the selection of these tracers. The aim of this assessment is to appraise not only the results of medical attention but also structural and procedural aspects in these facilities. The opinion of users of primary healthcare facilities is also taken into consideration. The application of this methodology gives rise to a greater commitment from healthcare providers the results of their work as well as to the adoption of any corrective measures suggested by evaluators. This facilitates the solution of the problems detected during the assessment process. Moreover, we show how thethis methodology was used in a primary healthcare facility to assess the quality of the attention to hypertensive patients, by evaluating two important dimensions of quality: the scientific and technical quality of services and the level user satisfaction. This methodology is also used to assess the quality of attention to mothers and children; and a project is being designed to evaluate the quality of hygiene and epidemiological services in a local health system.

Introduction

Primary health care is essential medical attention based on practical methods and technologies, scientifically based and socially accepted, and made available to all individuals and families in the community with ample popular participation, at a cost that the community and the country can afford in each one of the stages of its development, with a deep sense of responsibility and self-determination.

Primary care is an integral part of the National Healthcare System, of which it is the mainstay and core, as well as of the global social and economical development of the community. It represents the first contact of individuals, families and the community with the National Health Care System, bringing medical care as close as possible to the place where people live and work, and it is the first link in the entire process of medical attention.1

In Cuba, since the 1959 revolution, the state has assumed responsibility for the health care of the population and, in this respect, has carried out economic and medical actions to ensure the protection of people's health, based on the principles of gratuity and total accessibility to health services, among others. This ensures that the country's entire population, regardless of where they live or work, their profession, social status or income, have equal opportunities to receive complete medical attention, even if the most complex forms of medical attention are required, as well as the participation of highly qualified specialists or the use of the most advanced medical technology.2 In Cuba, primary care has gradually evolved and improved with the introduction of neighborhood-based family doctor and nurse teams.3

Improving the quality of primary care has been one of the specific objectives within the overall goal of improving the Cuban population's health between the years 1992 and 2000.4

There is not total agreement concerning the concept of quality applied to medical care. Rather, there are many different conceptions, which relate quality to factors such asscientific and technological advances, accumulated experience,5 effectiveness, efficiency and equity,6 to name a few. It is crucial to the process of assessing quality that staff of medical care units be informed of the process and participate in it. In services, including health care services, the evolution of quality control has undergone various transformations: from the tendency to inspect quality through norms and measures, which prevailed in the time of the Industrial Revolution; to the use of statistical control methods, between 1930 an 1949; the implementation of a system of quality assurance through special programs and systems, from 1950 to 1979, when quality was believed to be an initiative of administrators; and the strategic administration of quality, from the 1980s until today, based on the mobilization of the whole organization toward the assurance of quality and the conviction within organizations that quality can be administered.6 Using the current terms of quality assurance or continual improvement of quality, no definition can be useful unless it is accompanied by specific forms or instruments to measure quality. However, the existence of so many definitions of quality presupposes the existence of a great variety of dimensions, factors, components or attributes that can be measured in an effort to characterize the quality of healthcare services.7

Many attributes or dimensions of quality are described in the literature. However, those that are most useful in our context are those related to:

1. Professional competence and performance.
2. Effectiveness.
3. Efficiency.
4. Accessibility.
5. Satisfaction.
6. Adaptation.
7. Continuity.

It is necessary to tailor these attributes to the context of each healthcare facility.

The purpose of this paper is to develop a methodology to assess the different attributes of quality in primary healthcare facilities, which ensures the active participation by the staff at these facilities in this process of assessment.

Semantic Guidelines

Quality of Healthcare Services: Activities aimed at ensuring accessible and equitable services, with optimal professional performance, taking into consideration the resources available and achieving the support of users and their satisfaction with the attention they receive.

Dimensions of Quality: These are the attributes or components of quality. Those most frequently reported in specialized literature are: efficiency, effectiveness, scientific and technical quality (competency and professional performance), accessibility and user satisfaction or acceptance.

Quality Criteria: Tangible characteristics that make it possible to conceptualize what is considered good practice. These can be implicit (reflecting what should be done by a good professional in a given situation), or explicit (specifying what should be done in a given situation as the result of a process of discussion and consensus among the professionals involved.).

Quality Indicators: An observable parameter that allows for evaluation, which can help identify problems and/or variations in models of professional practice.

Quality Standards: The tolerable margin of deviation from the norm of a given criteria.

Health Problem Tracer: Specific problem that can serve as a model to assess the attention provided by the healthcare system. It is selected taking into account Kessner's criteria:

- Defining functional impact.
- Well defined and easy to diagnose.
- High prevalence rates that allow for the gathering of data on a limited sample
   of a population.
- The evolution should vary with the appropriate intervention of health care
   workers.
- Well-defined techniques.
- Easy-to-identify risks.

Tracer Activity: An activity that, due to its frequency, importance, repercussion on health and/or satisfaction of users, and possibility to be modified in accordance with the quality with which it is performed, can serve as a model for the assessment of the quality of the services provided by a facility.

Methodology

The methodology we propose consists of various stages:

Stage I: Preparation Of Evaluation Process

1. Selection of "tracer" activities and/or health problems that can serve to measure quality of attention. Sources to be considered include:

a) Review of documentation

- Analyses of the health situation.
- Minutes of program analysis meetings, management meetings, scientific committee sessions, etc.
- Results of inspections carried out in the facility, service or program.
- Public opinion surveys.

b) Interviews with

- Personnel directing facilities, services or programs.
- Users or their representatives.
- Direct healthcare providers.

2. Definition of the dimensions of quality to be evaluated.

This definition will depend on:

a) Type of facility, service or program.
b) Health activities and/or problems to be assessed.
c) Time in which the assessment is expected to be carried out.
d) Composition and experience of the group of evaluators.

Overall, the number of quality dimensions to be assessed in each process should be limited. This number should depend on the complexity of the selected dimensions, as well as on the priority they represent for the objectives of the evaluation. Including various dimensions in more than one evaluation process allows for a gradual improvement in the quality of the program devised, thus making such improvements more feasible.

3. Selection of occupational categories and personnel in general to be included in the evaluation.

The quality of health care does not solely involve the work of technicians and healthcare professionals, but also of every individual who in the facility, service, or program (or within its context) has a direct an indirect responsibility in healthcare results.

Therefore, this selection should be preceded by a thorough analysis of:

- The health activity and/or problem included in the assessment.
- The dimensions of quality to be assessed.

4. Determination of criteria, indicators and standards to be used in the assessment process.

For this determination, the following points should be taken into account:

a) Consideration of criteria related to structure, process and results.

b) Ensuring active participation of personnel forming part of the evaluation, regardless of their category or origin, and who have sufficient experience in the activities or programs to be assessed.

c) Moderating the establishment of standards. Standards should be based on attainability in the context of acceptable quality of attention.

Setting standards too high can generate feelings of frustration among staff involved in the assessment process and limit their commitment to carrying out the corrective measures proposed.

5. Selection of assessment methods and elaboration of the assessment instruments to be used.

In accordance with the parameters selected, assessment method(s) can be chosen, which could include the following:

- Observation.
- Medical audit of individual, family and epidemiological records.
- Surveys.
- Interviews.

The corresponding assessment instruments should be created for each assessment method: guides, questionnaires and tables, among others.

6. Training participants for the assessment process.

Stage II: Implementation Of The Assessment Process

1. Application of the instruments devised to assess the selected criteria.
2. Determination of existing deviations in relation to pre-established standards.
3. Classification of deviations into:

- Competency and performance problems that can be modified through training
- Organizational problems:

· Use of available resources.
· Establishment and implementation of support mechanisms.
· Adequate functioning of the organizational structure.
· Communication among leaders, workers and the community.
· Recognition and incentive system.

Leadership and authority problems.

4. Determination of corrective measures (program for the continuous improvement of quality).

a) Elaboration of a program for the continuous improvement of quality, with the opinions of persons involved in implementing the program. These individuals will also have a decisive role in establishing follow-up timeframes through the application of qualitative techniques aimed at reaching consensus.

b) Determination of timeframes for monitoring quality improvement, including the indicators that will be the object of this monitoring activity, as well as those for periodic assessments and final results.

Stage III: Follow-Up

In the follow-up stage of the quality assessment process, the same instruments that were designed for the initial assessment will be used. Monitoring and assessment activities will also be conducted as planned. In the case that quality deviations have not been corrected as expected, they should be re-discussed with those implementing the program, who will reevaluate and readjust the program as necessary.

Results Obtained By Applying This Assessment Process

This methodology was applied, up to the stage of implementation of the assessment process, in a primary care facility, in which the scientific and technical quality of health care provided to patients suffering from essential hypertension. Problems were thus detected concerning both competence and performance of medical and nursing staff in relation with this health problem. The most problematic areas included: diagnostic and therapeutic procedures; and promotion, prevention and rehabilitation activities. These activities were assessed using criteria and standards that were determined and approved by the staff that was the subject of this assessment.

This assessment process was also applied in a study carried out for an MPH thesis, in which the proposed methodology was used to assess maternal and child attention. In addition, a thesis project for a master's degree in epidemiology was developed to evaluate the quality of local hygiene and epidemiology services.

Conclusions

The proposed methodology allows for a gradual assessment of the quality of healthcare services, including various health problems and their diverse components, ensuring adequate adherence of users and providers to the designed program for the improvement of quality, since they actively participate in all stages of the process.

References

1. Las condiciones de salud en Las Américas. Washington: OPS,1994:2-7 (Publicación Científica; No. 549).
2. León Soteras LA, Peralta Rojas JA. La calidad de los servicios de salud. La Habana: MINSAP, 1995;1-5.
3. Antelo Pérez J, Avila Pérez M. Calidad de los servicios de salud. La Habana: MINSAP, 1995:1-5.
4. Objetivos, propósitos y directrices para incrementar la salud de la población cubana 1992-2000. La Habana: MINSAP 1992:1-19.
5. Ramos Domínguez BN. Calidad y eficiencia de la atención hospitalaria. La Habana. ISCM-H, 1990:1-7.
6. Saturno PI. Método de evaluación de la calidad en la atención primaria. (Versión española). España:s.e., 1991:13.
7. Vuori HV. El control de la calidad en los servicios sanitarios, conceptos y metodología. Barcelona: Editorial Masson, 1989;37.

This article originally appeared in Spanish in the Revista Cubana de Salud Pública, No. 1, 1996.

1 Second Degree specialist in Health Administration. Coordinator of the MPH Program, National School of Public Health.

2 First Degree specialist in Comprehensive General Medicine. MPH in Primary Care.

3 Second Degree specialist in Health Administration. Department Head, National School of Public Health.

4 First Degree specialist in Comprehensive General Medicine. MPH in Primary Care.