Mainstreaming quality improvement in family planning and reproductive health services delivery : context & case studies

SEATS adopted a Continuous Quality Improvement (CQI) methodology to build quality teams with members drawn from all ranks of an organization/facility, from the director to the janitor. CQI proved to be a powerful methodology to improve QOC in a variety of settings, ranging from large maternity hospitals to small clinics, community-based distribution (CBD) programs, and midwives" private practices. It also proved sustainable, since many improvements can be made at little or no cost. The key is to keep the tools and measurement systems simple initially, until the quality teams have seen results and become enthusiastic about the process. CQI was most successful where the process was introduced over a period of several months, with new tools and approaches presented as they became relevant. Data collection and use was the most problematical aspect of CQI. Problems at the local level, such as poor logistics or a lack of training or equipment, often need to be addressed at a higher level. While many local providers were enthusiastic about addressing quality problems, they had difficulty identifying deficiencies in the technical quality of services. These weaknesses needed to be drawn to their attention by supervisors or researchers. SEATS often found that front-line managers and service providers, particularly in the public sector, faced such a difficult working environment that they saw little reason to make things better for their clients until their own situation improved. SEATS and its counterparts identified a number of motivating factors to address such obstacles: Give providers a reason to provide quality care in their own self-interest. Expose providers to clients" perspectives on services. Measure QOC periodically and provide prompt feedback. Build a sense of empowerment and job satisfaction. SEATS encouraged each subproject to identify and address its own problems and objectives. The result was a large number of different problems and solutions addressing local needs. Most quality objectives fell into one of three categories: improving the capability or "readiness" of facilities to provide quality services; improving provider knowledge and skills; and increasing client satisfaction. To encourage providers to see the client"s perspective, a fundamental necessity for QOC, SEATS used multiple mechanisms, including client exit interviews during supervisory visits, focus groups or community/client surveys, and having trainees interview clients or conduct small focus group discussions. SEATS found that quality needs to be measured on at least two levels: At the country, municipality, or NGO level, surveys are extremely valuable to measure quality. The Quick Investigation of Quality methodology developed by the MEASURE- Evaluation project and field-tested by SEATS in Zimbabwe gives FP programs a core set of indicators and a practical methodology to use in measuring quality. To be useful at the local level, however, results need to be fed back to stakeholders promptly in a form that makes the service implications clear and provides an opportunity to discuss the findings. At the facility level, simple measurement strategies are needed for identifying QOC problems, determining their causes and, later, assessing whether improvements have occurred. With some training, providers adopted tools such as suggestion boxes, simple exit interviews, focus group discussions, and time studies to measure quality on their own, without outside support. TA was critical for the surveys, but even for simple studies TA was generally needed, at least initially, to collect methodologically sound baseline and endline data.