Leadership and Governance: The Quality Assurance System

Unit 5: Reach and Impact

Outline

1. Identifying quality in health system

2. Locating units, agents, institutions responsible for governing quality

3. Classify incentives for units and agents positions

4. Syndromes in governance and quality

5. Spillovers from quality to service delivery

Part 1: Quality in the Health System

Where does quality matter

Aspects of Quality

Primary health services

Workforce

Supply chain

Finance

Information systems

Household

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

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

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?

Process Measurement

• What percent of patients were immunized?– Counseled?– Got timely treatment?

• Did staff wash hands?

• Do staff take temperatures properly?

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

Part 2: Agents Units and Institutions

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

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

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

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

Taxonomy

Excludable Non-Excludable

Rival Private GoodsCheeseburgersMerit goods (maybe?)

Haircuts

Personal trainers

Common Pool ResourcesTrout streams

Non-Rival

Club GoodsCable TV

HMO quality

Pure Public GoodsNational Defense

Quality of all the clinical services in a country

Part 3: Incentives

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

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

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”

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

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

Part 4: Syndromes in Quality

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

Cure for lack of training

• More Units that training

• More institutions that emphasize training– Specialty societies– Specialty boards– Peer credentialling

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

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

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)

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

Part 5 Spillover Effects

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

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

Financing and Quality

• Staff model HMO is one option

• So is a Preferred Provider Organization

• Many contractual options that can tie finance to quality

Summary

1. Identified 3 aspects of quality in health system

2. Located units, agents, institutions responsible for governing quality and defined “Public Goods”

3. Classified incentives for units and agents positions

4. Syndromes in governance and quality5. Spillovers from quality to service delivery