Leadership and Governance: The Quality Assurance System

1. Leadership and Governance: The Quality Assurance System Unit 5: Reach and Impact

2. Outline • Identifying quality in health system • Locating units, agents, institutions responsible for governing quality • Classify incentives for units and agents positions • Syndromes in governance and quality • Spillovers from quality to service delivery

3. Part 1: Quality in the Health System

4. Where does quality matter

5. How to Define Health System Quality • Donabedian’s Trinity • Structure • Who does what? • What certifications and qualifications? • Process • What gets done? • Did so and so do this or that? • Outcome • What happened to the patient’s health? • Deaths, complications, satisfaction

6. Measurement • The invisibility of quality is the root of countless problems in health systems • Measuring quality and informing agents about quality is the solution • Measurement and information flow: • Costs money • Threatens some important agents

7. Structure Measurement • Document review • What are credentials of staff • What are written policies for operations • Do staff seem to know the policies • Dust, dirt, rodents?

8. Process Measurement • What percent of patients were immunized? • Counseled? • Got timely treatment? • Did staff wash hands? • Do staff take temperatures properly?

9. Outcome measures • Deaths while in treatment • For acute conditions: • Cure rates • Readmission rates • Nosocomial infection rates • For chronic conditions: • Numbers of flare ups, ER visits • Quality of Life Measures

10. Part 2: Agents Units and Institutions

11. Public Goods • Problem because quality is a public good • Pure public goods defined as non-rival and non-excludable • Non-rival goods: consumption by A does not effect consumption by B • Non-excludable goods: goods where one cannot exclude persons who want to enjoy the product

12. Facts about public goods • Public goods are always in shortage • Free riders always assume someone else will provide the public good • Examples: • Throwing litter in the public park • Keeping street lights on at night • Agents not fully incentivized to deliver these goods

13. Principals and Agents • Ultimate principals (the ones who “contract” with agents to receive quality) are the patients • Agents are: • Health providers • Drug vendors and suppliers • Financiers

14. Leading examples of public goods from health • Controlling contagious disease • Controlling environmental health threats • Air, Water, Rats, Mosquitoes • Regulating dangerous consumer products • Safe roads • Ensuring the quality of health services in a country • Protecting vulnerable populations

15. Taxonomy

16. Part 3: Incentives

17. Incentives for Providers • Why would they have low quality? • It takes effort to do the right thing • Extra time to counsel patients • Extra time to look up drug doses and clinical records • Time spent on quality could be used to see more patients in private practice • Quantity and quality are in conflict

18. Institutions and Incentives • There are institutions that affect the trade-off between doing a lot for each patient and seeing more patients • Example 1: The Medical Student • Immediately presenting patient case to their supervisor • Supervisor rates student for thoroughness and quality • Student not paid for seeing extra patients • Example 2: The Drug Seller • 3 drugs on their shelf • no supervisor • income depends on moving product off the shelf • Only potential loss of reputation might reign in profit seeking

19. Typical government health worker • Govt health worker paid a low level salary not tied to number of patients • Some supervision via patient flow log • Inconsistent oversight of the log • Income can be supplemented by referral to income-generating activity • “Come see me in my evening clinic”

20. Private healer paid cash for service • Patients expect to leave with something in the hand: piece of paper, drugs • Potential profit from marking up drugs • Japan: doctors expected to sell and dispense

21. Professionalism and Empathy • Professionalism goes beyond incentives • Admission process tries to select ‘moral’ people into health care professions. • Health workers join the profession because they are concerned for their patients • They are also motivated by knowing how they are they performing relative to peers • Sometimes just telling providers how they are doing is enough to trigger change

22. Part 4: Syndromes in Quality

23. Syndrome 1: Insufficient training • Health workers lacked pre-service training • Lacked in-service training to keep up with new technology • Underlying difficulty is shortage of training resources

24. Cure for lack of training • More Units that training • More institutions that emphasize training • Specialty societies • Specialty boards • Peer credentialling

25. Syndrome 2: Insufficient oversight • Training alone is never enough • Post-training supervision • Underlying difficulty is lack of resources for the supervision • Lack of information flows about health worker quality • Lack of measurement tools

26. Cure for lack of oversight • Units that oversee • Institutions that incentivize oversight • Quality oversight is a public good • Quality oversight can become a “club good” • Example 1) The staff model HMO • Combines financing like vouchers with quality regulation • Example 2) Social franchises • Franchise membership fees paid to quality regulator

27. Syndrome 3: Uninformed Patients • Patients can’t distinguished effective from ineffective technical quality of care • Patients often can’t take action (even if poor quality is recognized)

28. Cure for Uninformed Patients • Need units that inform patients • Need units that help patients act on information about quality • Example 1) A health care services report card by independent rating agency • How financed? How to maintain independent? • How to maintain trust? • Example 2) Malpractice legislation

29. Part 5 Spillover Effects

30. Primary Health Care and Quality • Public vs. Private affects Quality Strategy • Supply led strategies for public sector • Government command and control • Regulation • Demand side strategies for private sector • Tying vouchers to quality providers

31. Supply chain and Quality • Supply is an aspect of healthcare quality that consumers can observe ‘ • They will respond by increases in demand • Empty shelves are an obvious mark of low quality • Full shelves are necessary but not sufficient

32. Financing and Quality • Staff model HMO is one option • So is a Preferred Provider Organization • Many contractual options that can tie finance to quality

33. Summary • Identified 3 aspects of quality in health system • Located units, agents, institutions responsible for governing quality and defined “Public Goods” • Classified incentives for units and agents positions • Syndromes in governance and quality • Spillovers from quality to service delivery