Strategies for Optimal Implementation of Simulated Clients for Measuring Quality of Care in Low- and Middle-Income Countries (original) (raw)
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Social Science & Medicine, 1997
The simulated client method (SCM) has been used for over 20 years to study health care provider behavior in a first-hand way while minimizing observation bias. In developing countries, it has proven useful in the study of physicians, drug retailers, and family planning services. In SCM, research assistants with fictitious case scenarios (or with stable conditions or a genuine interest in the services) visit providers and request their assistance. Providers are not aware that these clients are involved in research. Simulated clients later report on the events of their visit and these data are analyzed. This paper reviews 23 developing country studies of physician, drug retail, and family planning services in order to draw conclusions about (1) the advantages and limitations of the method: (2) considerations for design and implementation of a simulated client study; (3) validity and reliability: and (4) ethical concerns. Examples are also drawn from industrialized countries, related methodologies, and non-health fields to illustrate the issues surrounding SCM. Based on this review, we conclude that the information gathered through the use of simulated clients is unique and valuable for managers, intervention planners and evaluators, social scientist, regulators, and others. Areas that need to be explored in future work with this method include: ways to ensure data validity and reliability: research on additional types of providers and health care needs; and adaptation of the technique for routine t.se. ~ 1997 Else-
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...
Bypassing Health Centres in Tanzania: Revealed Preferences for Quality
Journal of African Economics, 2002
When patients bypass one health facility to seek health care at another, strong preferences are revealed. This paper advances the view that the patterns of bypassing observed in Iringa Rural district in Tanzania show evidence of patients' understanding of various measures of quality at the facilities that they visit and bypass. Importantly some of these measures are 'unobservable,' meaning that we do not expect patients to be able to evaluate whether or not these types of quality are present just from visiting a center. We use two data sets on various features of health facilities including consultation quality and prescription quality as evaluated by a team of clinicians. This is matched with data collected from health center registers that included the symptoms of patients and the village they traveled from. The register data is transformed into a patient-based sample and we use a multinomial/conditional logit regression on patient choice of provider to show the relationship between patient behavior and objective measure of technical quality in the health facilities. Patients seek facilities that provide high quality consultations, are staffed by more knowledgeable physicians, observe prescription practices, and are polite. They avoid facilities that use injections too liberally or over-prescribe medication.
ABSTRACTEvery year an estimated 5 to 8 million people die in low- and middle-income countries (LMICs) due to poor-quality care. Although quality improvements in healthcare facilities in LMICs are well-possible with tailored implementation plans, costs are often mentioned as a prohibiting factor. However, if quality improvements increase trust among patients, this might translate into increased visits and higher revenues for providers and enable them to further invest in quality. This paper assesses the potential business case of quality improvements in Sub-Saharan Africa (SSA). It focuses on both the public and private sector since the latter provides at least half of all health services in SSA. The analysis is based on a dataset including multiple assessments of quality and business performance indicators for almost 500 health facilities in Tanzania, Kenya, Ghana, Nigeria, and other SSA-countries. We studied the association between changes in quality assessment scores and subsequen...
Evaluating health worker performance in Benin using the simulated client method with real children
Implementation Science, 2012
Background: The simulated client (SC) method for evaluating health worker performance utilizes surveyors who pose as patients to make surreptitious observations during consultations. Compared to conspicuous observation (CO) by surveyors, which is commonly done in developing countries, SC data better reflect usual health worker practices. This information is important because CO can cause performance to be better than usual. Despite this advantage of SCs, the method's full potential has not been realized for evaluating performance for pediatric illnesses because real children have not been utilized as SCs. Previous SC studies used scenarios of ill children that were not actually brought to health workers. During a trial that evaluated a quality improvement intervention in Benin (the Integrated Management of Childhood Illness [IMCI] strategy), we conducted an SC survey with adult caretakers as surveyors and real children to evaluate the feasibility of this approach and used the results to assess the validity of CO. Methods: We conducted an SC survey and a CO survey (one right after the other) of health workers in the same 55 health facilities. A detailed description of the SC survey process was produced. Results of the two surveys were compared for 27 performance indicators using logistic regression modeling. Results: SC and CO surveyors observed 54 and 185 consultations, respectively. No serious problems occurred during the SC survey. Performance levels measured by CO were moderately higher than those measured by SCs (median CO-SC difference = 16.4 percentage-points). Survey differences were sometimes much greater for IMCI-trained health workers (median difference = 29.7 percentage-points) than for workers without IMCI training (median difference = 3.1 percentage-points). Conclusion: SC surveys can be done safely with real children if appropriate precautions are taken. CO can introduce moderately large positive biases, and these biases might be greater for health workers exposed to quality improvement interventions.
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...
BMC Health Services Research
Background: The Kenyan Ministry of Health-Department of Standards and Regulations sought to operationalize the Kenya Quality Assurance Model for Health. To this end an integrated quality management system based on validated indicators derived from the Kenya Quality Model for Health (KQMH) was developed and adapted to the area of Reproductive and Maternal and Neonatal Health, implemented and analysed. Methods: An integrated quality management (QM) approach was developed based on European Practice Assessment (EPA) modified to the Kenyan context. It relies on a multi-perspective, multifaceted and repeated indicator based assessment, covering the 6 World Health Organization (WHO) building blocks. The adaptation process made use of a ten step modified RAND/UCLA appropriateness Method. To measure the 303 structure, process, outcome indicators five data collection tools were developed: surveys for patients and staff, a selfassessment, facilitator assessment, a manager interview guide. The assessment process was supported by a specially developed software (VISOTOOL®) that allows detailed feedback to facility staff, benchmarking and facilitates improvement plans. A longitudinal study design was used with 10 facilities (6 hospitals; 4 Health centers) selected out of 36 applications. Data was summarized using means and standard deviations (SDs). Categorical data was presented as frequency counts and percentages. Results: A baseline assessment (T1) was carried out, a reassessment (T2) after 1.5 years. Results from the first and second assessment after a relatively short period of 1.5 years of improvement activities are striking, in particular in the domain 'Quality and Safety' (20.02%; p < 0.0001) with the dimensions: use of clinical guidelines (34,18%; p < 0.0336); Infection control (23,61%; p < 0.0001). Marked improvements were found in the domains 'Clinical Care' (10.08%; p = 0.0108), 'Management' (13.10%: p < 0.0001), 'Interface In/out-patients' (13.87%; p = 0.0246), and in total (14.64%; p < 0.0001). Exemplarily drilling down the domain 'clinical care' significant improvements were observed in the dimensions 'Antenatal care' (26.84%; p = 0.0059) and 'Survivors of gender-based violence' (11.20%; p = 0.0092). The least marked changes or even a-not significant-decline of some was found in the dimensions 'delivery' and 'postnatal care'. Conclusions: This comprehensive quality improvement approach breathes life into the process of collecting data for indicators and creates ownership among users and providers of health services. It offers a reflection on the relevance of evidence-based quality improvement for health system strengthening and has the potential to lay a solid ground for further certification and accreditation.
The fake patient: A research experiment in a Ghanaian hospital
Social Science & Medicine, 1998
AbstractÐThe authors report on a research experiment involving the admission of one of them as a pseudo-patient in a rural Ghanaian hospital. The experiment was meant to assess the feasibility of carrying out unobtrusive participant observation in a hospital setting. Practical, methodological and ethical implications are discussed. #
Pan African Medical Journal, 2014
Introduction: Patient satisfaction is one indicator of healthcare quality. Few studies have examined the inpatient experiences in resource-scarce environments in sub-Saharan Africa. Methods: To examine patient satisfaction on the public medical wards at a Kenyan referral hospital, we performed a cross-sectional survey focused on patients' satisfaction with medical information and their relationship with staffing and hospital routine. Ratings of communication with providers, efforts to protect privacy, information about costs, food, and hospital environment were also elicited. Results: Overall, the average patient satisfaction rating was 64.7, nearly midway between -average‖ and -good‖ Higher rated satisfaction was associated with higher self-rated general health scores and self-rated health gains during the hospitalization (p=0.023 and p=0.001). Women who shared a hospital bed found privacy to be -below average‖ to -poor‖ Most men (72.7%) felt information about costs was insufficient. Patients rated food and environmental quality favorably while also frequently suggesting these areas could be improved. Conclusion: Overall, patients expressed satisfaction with the care provided. These ratings may reflect modest patients' expectations as well as acceptable circumstances and performance. Women expressed concern about privacy while men expressed a desire for more information on costs. Inconsistencies were noted between patient ratings and free response answers.