The road to institutionalizing quality assurance in Ecuador in an ...

International Journal for Quality in Health Care 1999; Volume 11, Number 5: pp. 447–450

Country Report

The road to institutionalizing quality assurance in Ecuador in an environment of health sector reform JORGE HERMIDA The Quality Assurance Project, Center for Human Services/University Research Co., LLC, Bethesda, Maryland, USA

Ecuador’s healthcare system Ecuador has around 12 500 000 inhabitants, an infant mortality rate of 20.4 per thousand live births and a maternal mortality rate of 159 per 100 000 live births. The proportion of the population without access to potable water is 42.9%; without an indoor drainage system, 60.4%; and without electricity, 21.2%. The principal causes of infant mortality are perinatal respiratory conditions, prematurity, pneumonia and acute diarrhea [1,2]. The delivery of health care in Ecuador is fragmented into five different institutions: the Ministry of Health (MOH), the Social Security Institute (SSI), non-profit non-governmental organizations, private health care clinics and hospitals, and military facilities. Each of them provides care to a different portion of the population. According to recent national estimates, the MOH, with 122 hospitals, 6694 beds and 1535 ambulatory facilities, reaches 30% of the population, mainly the poorest. The SSI follows, covering 20%, and the private sector, 15%. More than 25% of the population lack access to any form of health care services; only 26% have some form of insurance [3]. The percentage of the government budget allocated to health care for 1995 was 4.4% of the overall budget. Total public expenditures on health care were equal to 0.75% of the gross domestic product (GDP) [4].

The evolution of quality assurance activities in the MOH in Ecuador Quality Assurance (QA) activities began with a focus on a specific priority program. In 1994, the MOH of Ecuador requested technical assistance from the Quality Assurance Project (QAP)1 of University Research Corporation in

Bethesda, USA, to initiate activities aimed at improving clinical case management of cholera and acute diarrhea in two small rural areas of the Pacific coast. Until 1995, QAP worked with physicians and nurses of rural health centers and one hospital in those areas applying focused quality assurance tools. Using direct observation, checklists, clinical records review, and provider and patient interviews, QA teams identified gaps between ideal clinical performance according to the MOH’s national standards and the actual clinical practice in health centers and the hospital. Numerous problems were identified, for example, the overuse of intravenous solutions and insufficient use of oral rehydration salts. QA teams applied fishbone diagrams for cause analysis and designed and implemented intervention plans to address main causes. Although it was not feasible to implement a structured monitoring system, pre- and post-intervention measurements were taken, permitting documentation of significant improvements in compliance with clinical norms and cost reductions attributable to a more rational use of drugs [5,6].

The MOH upgrades QA to a national program These initial results drew the attention of national MOH authorities who had been struggling for years with the issue of how to improve performance with very limited possibilities of budget increases. After a period of planning and discussion, in early 1996 the Minister of Health issued an official decree creating the National Program for Quality Improvement of Health Services (NPQI). Led by a coordination committee composed of the directors of the main MOH divisions, the NPQI trained a cadre of 15 facilitators, who embarked on promoting and providing technical assistance to QA teams in hospitals and health districts selected by the MOH. Between

Address correspondence to J. Hermida, Avenida Colon #720, Diego Almagro, Edificio El Cisne 5 piso, Oficina CD, Quito, Ecuador. Tel: +593 2 222 119. Fax: +593 2 222 120. E-mail:[email protected] 1 The Quality Assurance Project, implemented by University Research Co., LLC/Center for Human Services, is financed by the United States Agency for International Development (USAID), through contract # HRN-C-00–96–90013.

 1999 International Society for Quality in Health Care and Oxford University Press

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1996 and 1997, 438 health professionals were trained, and 21 teams carried out small-scale QA projects to improve care provision. These projects addressed areas such as reducing patient waiting times, increasing efficiency in the use of surgical supplies, optimizing the process for procurement of supplies, increasing coverage, improving patient–provider relations, improving acute respiratory infection case management, increasing productivity, and improving scheduling in hospital operating rooms. The NPQI devoted much effort to testing training approaches and developing training materials. Training an adult audience with a wide range of educational levels – from auxiliary nurses to clinical specialists – who had little time available and who usually had to be trained without leaving their job sites was quite a challenge. A practical training approach, combining two 4-day seminars and practical work in between and after the seminars, was tested in the field and refined. The first seminar addressed basic QA concepts, tools for problem identification and analysis, data collection methods and teamwork. During the 4 weeks following this seminar, the teams collected data and implemented the steps learned. Right after this, the teams attended the second seminar, learning about data analysis methods and intervention design and planning implementation and pre–post measurements. The NPQI also produced a QA manual in two volumes, with many examples extracted from real life situations. The manual was tested in more than a dozen seminars, which enabled its adaptation to the real needs and understanding of Ecuadorian health workers [7]. One special success of the NPQI relates to the coordination achieved among international agencies providing technical assistance. For almost 2 years, the Pan American Health Organization (PAHO) and the QAP (representing USAID) collaborated closely in supporting the MOH’s QA activities. At different moments, UNICEF and UNFPA also collaborated. The NPQI experiences were disseminated in Ecuador through its newsletter ‘Avances’ and through a National Conference on Quality Assurance in July 1997.

The NPQI moves from problem solving teams to a quality process management approach After 2 years of putting into practice a problem-solving approach, a clear perception of the possibilities but also of the limitations of such an approach began to appear within the NPQI. Many teams felt that when they tried to improve quality by solving a particular problem, innumerable other related problems were discovered right away, making them feel like they were trying to ‘stop water running out of a barrel with a thousand holes’. Others described that, as the majority of hospitals or districts where they worked had not undertaken any strategic planning and had not established overall objectives as an institution, solving a particular problem was like ‘taking steps forward without knowing where

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the road leads’. More and more, the NPQI and QA teams recognized the need for a comprehensive approach that would address the production of health services from a more integral management perspective. In 1998, the NPQI decided to concentrate efforts in only three provinces: Azuay, Bolivar and Cotopaxi, where a more comprehensive approach was put into practice. In this context, QA was defined as a comprehensive approach for process management, which includes process (re)design, control and improvement or problem solving. Four QA principles were widely disseminated: (i) QA should focus on external and internal client needs and requirements; (ii) QA technical work should be based on objective data; (iii) QA work should be based on team work instead of isolated individual abilities; and (iv) QA should apply a systems approach. With the participation of a majority of health care professionals, strategic plans were developed at the provincial level and at the level of the district health management team. Selected districts, in turn, developed strategic plans in accordance with the provincial plans. Out of these strategic plans, priority technical areas were selected for quality improvement. In all three provinces, management teams, working independently, selected maternal health care as the most important area for quality improvement. With support of the Latin American Maternal Mortality Initiative, financed by USAID, in 1998 the MOH decided to implement a special program in Cotopaxi province, utilizing the quality process management approach to address essential obstetric care, as part of a broader effort to decrease maternal mortality. The program has two components: community and institutional. The community component is aimed at increasing demand for modern obstetrical services among peasant Indian mothers, focusing on obstetrical complications. Through information, education and communication and community mobilization activities, it is expected that more mothers will attend hospitals when an obstetrical complication appears. In the institutional component, QAP is supporting quality design teams in hospitals and health centers to modify priority care processes in the direction of the needs of external and internal clients. Additional actions include a monitoring system of selected quality indicators and a self-directed education model on obstetrical guidelines for professionals at hospitals and districts.

QA is institutionalized within the regular MOH structure In 1998, a new Government took office in Ecuador. Important reforms were incorporated into the nation’s constitution, among them some related to the modernization of public health services. The concept and the right to quality health services was one of the central ideas in the constitution’s chapters that dealt with the health of the Ecuadorian people. The MOH, in turn, developed its fundamental health care policies and streamlined its role as ‘rector’ of the health care

Ecuador country report

system (public and private), guarantor of the population’s access to health services, regulator of the provision of health services, and provider with emphasis on those most in need. The concept of quality of services appeared in the MOH documents as one of its most important overall objectives and as one of the axes to guide its implementation [8–10]. The MOH reviewed the past achievements of the NPQI and looked for ways to institutionalize it within the structure of the MOH. The NPQI had been, thus far, a parallel program with only a horizontal relation to the organizational structure of the MOH. MOH officials decided that QA activities should be built into the routine work of MOH facilities at every level and that a QA program should be placed within the regular organizational structure of the MOH’s central level, instead of as a parallel program. The QAP continues to provide technical assistance and support through its resident team in Ecuador and consultants. In the proposed new structure of the MOH, QA activities appear as a cross-cutting programmatic axis intended to reach hospitals and ambulatory facilities in urban and rural districts. QA activities are now organized and conducted by a technical team under the command of the Director of the Division of Health Services [11]. In turn, at each MOH provincial directorate, a QA unit will be in charge of organizing and providing support for QA activities. So far, 20% of provincial directorates are already actively leading QA activities in hospitals and districts. For 1999, the MOH decided to scale up QA activities to 53 hospitals (29% of the total number of public hospitals in Ecuador). These hospitals are located in ‘priority districts’ where other development agencies will also concentrate their efforts. It is expected that in the near future the MOH will scale up its QA efforts into more ambulatory units at the district level.

QA finds its role in the health sector reform movement The MOH has started a health sector reform effort that emphasizes decentralization, modernization, hospital autonomy, and increased efficiency in the use of scarce resources. One of the most important aspects of this reform is decentralization of the management of health services. It is envisioned that MOH provincial directorates will manage health services within a province, and that hospitals will be managed with a higher degree of autonomy with respect to the central MOH level. New decentralized approaches for the management of human resources (local hiring, performance evaluation, and training) are being developed and put into action by the MOH. New ways of financing facilities are also being explored. In place of fixed annual allocations irrespective of patient demand for services, the MOH is attempting to implement resource allocation mechanisms. Under this system, the amount of public funds given to a hospital or district will be dependent on the level of demand and consequently on the production of services the facility achieves. This in turn will help to foster an environment in

which the quality of services becomes the cornerstone of the system’s dynamics. In this scenario, the MOH has decided to adopt the use of Quality Management as a valid approach for decentralized facilities. At both hospitals and districts, strategic plans are being developed that will guide the use of resources and direct the efforts of the local quality management teams. Once priority service areas are identified by local strategic plans, a process management approach will be put in place by Quality Management Teams (QMT). Client satisfaction will be a fundamental goal of the system, with the understanding that both individuals and the community are the system’s external clients. QMTs will work on priority processes, applying methods and techniques for process redesign, process control (monitoring), and/or process improvement (problem-solving). It is expected that an improved information system will become the most important source of data for monitoring quality at all levels of the health care system.

QA trends in Ecuador for 1999–2000 Operations Research The QAP is providing technical assistance to the MOH to initiate an Operations Research program, developing the concept of a ‘field QA laboratory’. Under this concept, research questions that come out of field QA experiences will be addressed by operations research teams, providing answers that in turn could be implemented in the QA program. Two initial Operations Research projects will be carried out in 1999: the first addresses the issue of how to improve clinical records at hospitals and their use as information sources for QA work; the second deals with the cost of quality design. Support to University programs The QAP will provide technical support to the School of Public Health of the Central University of Ecuador to initiate a Master’s Degree Program in ‘Public Health Care Management’, which will have quality management as one of its central methodological approaches. The program will be directed at mid-level MOH managers who work at decentralized hospitals, districts or provincial management teams, and will have the full support of the MOH. QAP has also received requests to initiate an academic QA program in the School of Professional Midwives of Quito, Ecuador and in the School of Nursing of the University of Guayaquil. Extension to other health sector institutions An important government institution, the National Council for Women, has requested QAP support to initiate QA activities with a special focus on the role of women’s organizations as promoters of accountability for the quality of reproductive health services.

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Accreditation The MOH envisions the need to develop accreditation schemes in Ecuador, in accordance with the implementation of new funding mechanisms that relate the amount of public funds allocated to hospitals and districts to client demand, service production and quality levels. The QAP, together with other cooperation agencies such as PAHO, has started preliminary activities in this important technical area.

Ten lessons learned • The long-term success of a QA program is strongly related to its ability to link quality of care issues to the broader agenda of health sector reform. Quality improvement really makes sense and is boosted when it is closely related to changes in the financial logic of how services are paid for and by whom, when decentralization provides facilities with greater autonomy, and when communities are in a better position to exercise social control over health care. • For a country where QA has not yet entered strongly into the public health care scenario, starting ‘bottomup’ from focused problem-solving and scaling up towards quality management, can be a valid strategy for building a meaningful QA program. • It is important to assure political support. The more leaders at all levels of the health system understand the importance and the feasibility of QA, the easier it will be to put QA into practice at the operational level. • Never forget to measure as much as possible and to show results. • A great deal of effort needs to be invested in adapting QA methods and tools produced in developed countries to the particular conditions of public health care systems which do not charge for services, whose financing is completely unrelated to the volume or quality of services produced, and which are quite centralized. Importing such methods and trying to implement them mechanically makes no sense. • Early development of local technical capability to coach QA experiences is vital. • QA methods are effective. It is possible to improve quality of care to a given extent, even in an environment of insufficient resources. The magnitude of the lack

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of basic resources will set the limit for quality improvement. • It is possible to adapt QA methods to be used by health workers at all levels. Teamwork is one of the keys to initiating a different culture of ‘doing things right’. • Most of the obstacles to quality improvement do not lie in problems of lack of equipment, but in lack of management oriented to quality results. • Physicians are the most difficult category of providers to actively engage in QA work. Nurses and professional midwives are the quality pillars in facilities.

References 1. CEPAR, Principal provincial indicators (in Spanish). CEPAR: Quito, Ecuador, 1996. 2. National Institute for Statistics and Census (INEC). Annual of Vital Statistics (in Spanish). INEC: Quito, Ecuador, 1996. 3. National Institute for Statistics and Census (INEC). Annual of Hospital Statistics (in Spanish). INEC: Quito, Ecuador, 1996. 4. Technical Secretariat of the Social Front. National Social Development Plan (in Spanish). Quito, Ecuador, 1996–2005. 5. Hermida J, Laspina C, Idrovo F. QA Methods Improve Quality of Cholera/Acute Diarrhea Care in Local Health Districts in Ecuador. In QA Brief, vol. 3, no. 3. Bethesda, Maryland: Center for Human Services, 1994. 6. International Society for Quality in Health Care. Twelfth ISQua World Congress. St. John’s, Newfoundland, Canada, June 1995. 7. Ministry of Public Health. National Program for Quality Improvement. Module 1: Basic Concepts for Quality Improvement of Health Services. Module 2: Methods and Tools for Solving Service Quality Problems (in Spanish). Quito, Ecuador, 1997. 8. Ministry of Public Health of Ecuador. Modernization of Health Services, a Shared Social Responsibility (in Spanish). Quito, Ecuador, 1998. 9. Ministry of Public Health. Role of the State, National Health Policies and Constitutional Reform (in Spanish). Quito, Ecuador, 1998. 10. Ministry of Public Health. Government Health Plan 1998–2002 (in Spanish). Quito, Ecuador. 11. Ministry of Public Health. Operational Structure of the National Directorate of Services Development (in Spanish) (Proposal). Quito, Ecuador, 1999.

Accepted for publication 14 June 1999