Using unannounced standardised patients to obtain data on quality of care in low-income and middle-income countries: key challenges and opportunities (original) (raw)
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Health Policy and Planning, 2019
Standardized patients (SPs), i.e. mystery shoppers for healthcare providers, are increasingly used as a tool to measure quality of clinical care, particularly in low- and middle-income countries where medical record abstraction is unlikely to be feasible. The SP method allows care to be observed without the provider’s knowledge, removing concerns about the Hawthorne effect, and means that providers can be directly compared against each other. However, their undercover nature means that there are methodological and ethical challenges beyond those found in normal fieldwork. We draw on a systematic review and our own experience of implementing such studies to discuss six key steps in designing and executing SP studies in healthcare facilities, which are more complex than those in retail settings. Researchers must carefully choose the symptoms or conditions the SPs will present in order to minimize potential harm to fieldworkers, reduce the risk of detection and ensure that there is a m...
Using unannounced standardised patients as a quality improvement tool to improve primary care
Journal of General Practice, 2017
Background: The Alma Ata declaration states that primary health care should be socially acceptable and universally accessible. Access to primary care has an impact on health outcomes and can contribute to closing the health gap between indigenous and nonindigenous populations. Despite significant government intervention, access to primary care remains a barrier for many of Australia's Indigenous peoples, the Aboriginal and Torres Strait Islander (Aboriginal) peoples. Aim: To improve the quality and appropriateness of targeted care in general practice for Aboriginal patients using unannounced standardised patients (USP). Methods: This research was a mixed-methods multiple-site case study. USPs from the local Aboriginal communities anonymously attended general practices. Data from these visits were combined with data from focus groups, clinical records audit, interviews and surveys with practitioners and staff, and best practice guidelines, and were used to develop a tailor-made intervention to improve the acceptability and appropriateness of care provided to Aboriginal patients in general practice. Findings: Most practices improved their Indigenous-status identification processes and provided more acceptable and appropriately targeted care to their Aboriginal patients. The use of USPs as a quality improvement tool was acceptable to providers and staff and provided the local Aboriginal communities a voice regarding the care they received. Implications/Conclusions: USPs provide direct patient feedback whilst overcoming many of the inherent biases found in other research methods. Using USPs from the local Aboriginal communities ensured relevance with their priorities and was central to the uptake of the intervention. The method can be adapted as a tool for improving access to primary health care to other minority and marginalised populations. Biography Heike Schutze is a lecturer and research fellow at the University of Wollongong. Her research interests include health services research, Aboriginal and Torres Strait Islander health, indigenous health, health inequity, translational research, and the prevention and management of chronic disease.
Health Policy and Planning, 2020
Clinical records in primary healthcare settings in low- and middle-income countries (LMIC) are often lacking or of too poor quality to accurately assess what happens during the patient consultation. We examined the most common methods for assessing healthcare workers’ clinical behaviour: direct observation, standardized patients and patient/healthcare worker exit interview. The comparative feasibility, acceptability, reliability, validity and practicalities of using these methods in this setting are unclear. We systematically review and synthesize the evidence to compare and contrast the advantages and disadvantages of each method. We include studies in LMICs where methods have been directly compared and systematic and narrative reviews of each method. We searched several electronic databases and focused on real-life (not educational) primary healthcare encounters. The most recent update to the search for direct comparison studies was November 2019. We updated the search for systema...
International journal for quality in health care : journal of the International Society for Quality in Health Care, 2018
Present methods to measure standardized, replicable and comparable metrics to measure quality of medical care in low- and middle-income countries. We constructed quality indicators for maternal, neonatal and child care. To minimize reviewer judgment, we transformed criteria from check-lists into data points and decisions into conditional algorithms. Distinct criteria were established for each facility level and type of care. Indicators were linked to discharge diagnoses. We designed electronic abstraction tools using computer-assisted personal interviewing software. We present results for data collected in the poorest areas of Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the state of Chiapas in Mexico (January-October 2014). We collected data from 12 662 medical records. Indicators show variations of quality of care between and within countries. Routine interventions, such as quality antenatal care (ANC), immediate neonatal care and postpartum contrace...
BMJ Quality & Safety, 2019
BackgroundMedical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries.ObjectiveTo provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China.MethodsA sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records.ResultsMedical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incomplete...
Global health, science and practice, 2017
The use of simulated clients or "mystery clients" is a data collection approach in which a study team member presents at a health care facility or outlet pretending to be a real customer, patient, or client. Following the visit, the shopper records her observations. The use of mystery clients can overcome challenges of obtaining accurate measures of health care quality and improve the validity of quality assessments, particularly in low- and middle-income countries. However, mystery client studies should be carefully designed and monitored to avoid problems inherent to this data collection approach. In this article, we discuss our experiences with the mystery client methodology in studies conducted in public- and private-sector health facilities in Kenya and in private-sector facilities in Uganda. We identify both the benefits and the challenges in using this methodology to guide other researchers interested in using this technique. Recruitment of appropriate mystery clien...
The Lancet Global Health, 2018
Background Primary care has the potential to address a large proportion of people's health needs, promote equity, and contain costs, but only if it provides high-quality health services that people want to use. 40 years after the Declaration of Alma-Ata, little is known about the quality of primary care in low-income and middle-income countries. We assessed whether existing facility surveys capture relevant aspects of primary care performance and summarised the quality of primary care in ten low-income and middle-income countries. Methods We used Service Provision Assessment surveys, the most comprehensive nationally representative surveys of health systems, to select indicators corresponding to three of the process quality domains (competent systems, evidence-based care, and user experience) identified by the Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals Era. We calculated composite and domain quality scores for first-level primary care facilities across and within ten countries with available facility assessment data (