Dr. Jim Heiby has championed the concept of improving the quality of health care services since 1985, adapting approaches from industrialized countries for use in those with lower and middle-incomes. After working in the Bureau of Epidemiology at the Centers for Disease Control, Dr. Heiby joined the United States Agency for International Development (USAID) in 1978.

“The challenge involves documenting what you learn, sharing that knowledge broadly, and using successes as building blocks to quality”
-Dr. Heiby

The following dialogue was conducted by PSP-One with Dr. Heiby in June 2005. After the interview, Dr. Heiby addressed several issues raised by the PSP-One community members about quality improvement. Questions for Dr. Heiby came from all over the world and the topics ranged from governance to tax liability. Read audience questions and Dr. Heiby's feedback that resulted from this dialogue.

Care that Follows Scientific Guidelines is Good Business Strategy

What have we learned about processes in recent years?

Dr. Heiby’s interest in this field developed during his very first days in the Office of Health when he was asked to take over management of the Primary Health Care Operations Research Project. Of 400 proposals received for improvement of basic health care around the world, he noticed that one important topic was missing: the actual care process, the details of the interaction between the provider and the patient. It later became clear that modern quality assurance was virtually absent from most developing country health programs.

From 1990 onwards, the USAID program in quality improvement evolved along with changes in the US health system. In particular, Dr. Donald Berwick, now President of the Institute for Healthcare Improvement, led a broad initiative to introduce quality improvement approaches used in industry into the US health care system. Ideas developed by American experts such as Edwards Deming and Joseph Juran rapidly became widespread. Similar approaches to quality improvement in developing countries often produced dramatic results. Recent developments in this dynamic field continue to provide new approaches that are being adapted to the needs of developing countries. Modern QI focuses not on resources, but on improving the way health care is organized. In most health systems, it is not difficult to find opportunities to improve the quality and efficiency of care, using available resources.

Importance of quality

Dr. Heiby believes that growing awareness of the importance of quality in health care is potentially a major development. The logical implication of adopting standards for quality is some level of investment in modern quality improvement approaches. There is a critical role for leadership in making such a basic change in health care. Support from the countries themselves, donors and international organizations will all be necessary to make QI activities an intrinsic part of the job of every health worker.

Acceptance of evidence-based standards

The growing acceptance of evidence-based standards in health care may lead to revolutionary changes in international health. Traditionally, it was widely assumed that trained health workers provided good care. Today, quality standards draw attention to what health workers actually do. The organization of care should support meeting these standards, and accomplish this using available resources efficiently. The implication is that it is feasible to study and improve the "design" of health systems. And improved design pays benefits into the future. It would be easier to simply distribute manuals with these standards, but we know that this alone has little benefit.

Anyone can contribute to improving quality

Ordinary health workers, in a wide range of countries, have shown consistently that they are capable of using modern QI methods. They have produced documented improvements in the care that they provide their patients. In fact, these workers are uniquely qualified to understand how the health system really works. The recent expansion of QI in developing countries is based almost entirely on convincing results, not donor funding.

What needs to be accomplished?

Focus on the private sector

Dr. Heiby believes that quality in the commercial private sector has received far less attention than the public sector. There is an important distinction between interpersonal quality and technical quality in the private sector. The real challenge is in technical quality. Market pressures encourage attention to issues like patient satisfaction, but only weakly support following evidence-based technical standards. Few patients notice if they are poorly assessed and treated. A range of strategies could provide motivation for private practitioners to meet technical standards, but most of these are poorly developed. Some strategies appeal to professionalism, the internalized values common among health providers who want to do the right thing.

More informed patients could demand care that is scientifically sound, but such educational programs are rare. As in the US, third parties could represent the interests of patients; these include insurance organizations that pay for services. Government agencies and private regulatory bodies could license, certify, and accredit, but few countries have effective institutions along these lines. Broader civil society institutions could also weigh in more effectively in support of improved quality, such as the press.

Need to improve medical records

For both policy makers and quality improvement teams, better assessment of quality is the critical first step in improvement. For the most part, we can hope to improve only those elements of health care that we can measure. Based on our own health system, we can see that to make quality assessment routine, most developing countries will need to greatly improve their medical record. Otherwise, quality assessment is relatively difficult and costly.

Identifying positive incentives

There is an impressive consensus among quality improvement experts which favors positive incentives over punitive strategies. Certification programs based on demonstrated competency or actual practice can provide such incentives for private practitioners. Educating consumers represents a similar, but long-term, approach.

QI Tools

Dr. Heiby believes the most important tools a practitioner can have today are systematically developed clinical guidelines – memory aides derived from national guidelines which are designed to be used in a hurry. They put key information right at the provider's fingertips. The priority for these "job aids" is to address health issues that are:

1. common,
2. life-threatening, or
3. prone to error.

Job aids are not appropriate for every task, but they can often reduce training requirements. They also do not provide motivation. But in general, job aids are utilized far below their potential for improving performance. Studies also suggest that state-of-the-art methods for developing these tools greatly increases their effectiveness.

Peer review

Even in programs with a formal supervisory system, the peers of a given provider usually are the most effective agents for improvement. Peers are probably less threatening and more knowledgeable about the job. With some support, a peer-based improvement strategy is a good fit with the for-profit private sector. A quality improvement program based on peer review would also require good medical records. There are a number of distinct QI methodologies that such a program could draw on. However, mastery of these techniques appears to be much less important than a real commitment to improving. However, to be effective, peers would need to have a basic understanding of how to develop and test changes.

What changes need to be made to improve quality in private sector health care?

International health donors and priorities of health professionals

International health donors need to play a more active role in supporting quality assurance activities, and countries themselves need to invest in them. Professionals must unite in a real commitment to make improvement activities a part of the job. We have good QI methodologies, and the field continues to produce new ones; the main requirement is the will to use them.

Then, we will need effective ways to make sure that successful changes are spread broadly. The track record of pilot projects is not very encouraging. Fortunately, the field of quality improvement provides a robust new model for spreading best practices. If local QI efforts are widely applied, the quality improvement process itself becomes exponentially more cost-effective. If the results of investments in testing changes in one district in Uganda can be applied in other districts, or in Nigeria, we need mechanisms to share these lessons. We also need to learn how to reward high-quality services in the private sector. And we need insights into how to encourage patients to become more demanding.

We already know a lot about clinical training, and it is often necessary, but its impact on quality or provider performance is surprisingly limited. At the same time, 99% of doctors, nurses, and other providers today are not being trained in quality improvement methods. These are the same programs that do not monitor quality, so quality of care problems are easily overlooked. However, we do have a number of external quality assessment studies that have been sponsored by donors like USAID. The evidence we have points to stagnant or declining performance, with scattered improvements associated with donor funded projects. More external assessments are needed in the short term to track quality issues. But over the long term, developing countries need to assume this role.

In the future, health leaders should be able to routinely describe the quality of care of their programs in numbers, be able to outline a program of concrete activities that improve quality, and to show change. This needs to become the norm for a leader. Real leadership also needs to come from ordinary providers, professors and teachers of health care providers, professional society leaders and even the press--all of these share responsibility for the kind of care now being provided in the commercial sector. We are barely scratching the surface.

Contact Information:
Dr. James R. Heiby, M.D., M.P.H.
Office of Health, Infectious Diseases, and Nutrition, Bureau of Global Health
1300 Pennsylvania Avenue, N.W., Room 3, 7-105
Washington, DC 20523
jheiby@usaid.gov

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