Quality of Care

Director: Girgio Tamburlini
Tech advisor: Tamburlini

About the Program Area

Social determinants of health play a major role in influencing exposure and susceptibility to disease, and together with inequalities in access to care are the main causes of the striking differences in child mortality across countries.  But quality of care, at both primary care and hospital level, also play an important role in influencing child health outcomes. However, despite evidence that there is substantial scope for quality improvement even without major investments, and that inequities in quality may be as important as inequities in access, the quality of care issue has been neglected in international as well as in national programmes aimed at decreasing child mortality. Based on current guidelines it has been estimated that about 10-20% of sick children presenting for primary care, i.e. the most severely ill, may require referral to a first referral or district hospital.  The quality of care provided in these hospitals is likely therefore to have a major impact.  There is good evidence that hospital care is often deficient in many countries, including a study of 21 hospitals across 7 countries in Asia and Africa (Nolan, 2001). This study showed that more than half of the children were under-treated, or inappropriately treated, with antibiotics, fluids, feeding or oxygen.  Lack of triage and inadequate assessment, late treatment, poor knowledge of treatment guidelines and insufficient monitoring of sick children were key adverse factors observed.5,6  Hospital assessment exercises supported by WHO over the past few years have found similar deficiencies in countries including Cambodia, Indonesia, Kazakhstan, Russia, Solomon Islands and Timor Leste.  Similar observations were made in studies in Kenya, with clear indications that most practitioners were neither aware of nor followed international guidance on best practice, and by assessments carried out in Brazil and Angola, where severe malnutrition and triage and emergency care were identified as priority areas to be addressed to decrease hospital mortality.

Technical Advisor: Giorgio Tamburlini
Program Committee: To be determined

Why is it important for IPA to have this area as a program area?

Director: Girgio Tamburlini
Tech advisor: Tamburlini

There is now substantial global experience of strategies and interventions that improve the quality of care for children, particularly in hospitals of countries with limited resources.  WHO has developed a toolkit containing adaptable instruments, including tools for quality assessment, a framework for quality improvement, evidence-based clinical guidelines in the form of the Pocketbook of Hospital Care for Children, teaching material, and mortality audit tools. These tools have been field-tested by doctors, nurses and other child health workers in many developing countries.  In most countries paediatricians may not be available at primary care but they are responsible for child care at hospital level.  The challenges for them is to bring these and other strategies to scale, and to support research into their use, impact and sustainability in different environments.  Hospital care represents in most countries the very heart of paediatricians role and therefore IPA must see in this area a priority area for collaborations with national societies.  National Paediatric Societies should play an important role in improving QoC across the health system by promoting and disseminating existing clinical standards (such as I(N)MCI guidelines and the Pocket book for hospital care, the latter endorsed by IPA) as well as promoting training and CME on quality of care assessment, tools and quality improvement strategies. Pre-service and in-service training in evidence based paediatric medicine - including in academic centres - is an essential component to promote and maintain good quality of care for children, and to provide paediatricians with the knowledge and skills for developing and updating clinical practice guidelines and protocols.  

Start of the program in IPA’s history IPA and what has been done so far

The Quality of care issue was first addressed by a plenary lecture given by Giorgio Tamburlini at the IPC held in Cancun in 2004. The plenary lecture was accompanied by an introductory symposium.  Then the issue was again addressed in Athens with a symposium which reported several experiences of quality assessment carried out at country level.  The issue of evidence based paediatric practice (sources, debate on EBM, current experiences and available tools) was addressed by a plenary lecture at the Athens meeting.  IPA has been thereafter active in several meetings on this subject including a meeting organised by WHO in Bali in 2008 and several Regional meetings. The results of the Bali meeting have been disseminated widely and reported in a paper published in Pediatrics (see references).

IPA has established a working group on QoC and EB pediatrics. The technical advisor is Giorgio Tamburlini, former SC member, who is also assisting WHO in several programmes aimed at improving quality of care and disseminating existing guidelines at country level . Currently Quality of care is among the priorities of the collaboration between IPA and WHO- Child Health and Development.   

6 Future plan of action for the program area

The overall objective is to introduce principles methods and available tools for QoC, essentially but not exclusively addressing hospital care, at country level. The Technical Advisor has proposed joint IPA-WHO training workshops on EBP and QoC to be run at national or regional level.  A modular, flexible approach is proposed so that training modules can be adapted to the contexts, resources and needs of national/regional settings. Module 1a and 2a can be combined in a one-day workshop. Module 2a and 2b can be either proposed separately or combined in one 3-day EBP-QoC workshop. Workshops can be organized back to back with regional national meetings to optimize the use of resources. Short workshops can be run with just one external teacher/facilitator. Long workshops need at least two external facilitators. Financial arrangements could work as follows: WHO (HQ, Regional offices or country offices depending on available funds) could cover the cost of the facilitator/s (travel per diem and fees). All the remaining costs could be covered by National societies. “Back to back” timing of the workshops with national/regional meetings and congresses should be considered to reduce costs and optimize use of time and resources. 

Example of workshops contents

• Module 1a. EBP short module (3 1/2 hours)

Introduction(see attached ppt file as an example): definitions & history,  sources of evidence and limitations, use of Pub Med etc.), plenary session

Examples of clinical queries and evidence based answers(chosen from International Child Health Review Collaboration clinical queries archive, see www.ichrc.org), ideally as a working group session (in this latter case 1 PC and internet connection per group is needed). Both IMCI and Pocket book examples are used (mix to be chosen based on national health system context and role of paediatricians in the system)  .

Strategies and plan for implementationin the national context, plenary session

• Module 2a. QoC short module (3 1/2 hours)

Introduction: definitions & history, available evidence and experience 

The quality assessment tooland adaptation to national contexts

Quality Improvement strategies: advantages and disadvantages, ideally as working groups session

Strategies and plan for implementationat national level, plenary session

• Module 1b. EBP standard module (1 1/2 days)

Follows the short module, but time devoted to clinical queries from ICHRC is much longer ( 4 hours) with participants directly involved in Pub Med Search (needs at least 1 PC station and internet connection per group of 4-5 participants). Examples from both IMCI and Pocket book. 

A session is included on contextual factors and patients factors (issues of feasibility, compliance, etc.) that may limit or modify the proposed (gold) standard of care.

A session is included on community and public health issues (Evidence Based Paediatrics and Child Health, list of effective public health interventions, etc.).

The strategic and planning session is longer ( at least 2 hours).    
   

• Module 2b. QoC standard module (1 1/2 days)

Follows short module sequence but time devoted to assessment tool and strategies is much longer with participants involved in discussing and adapting the assessment tool and in identifying the QI strategies that may be more effective in their settings. A session is included on introducing basic elements of QoC in pre-service training.

A session is included on community and public health QoC issues.

The strategic and planning session is longer ( at least 2 hours).  

Note: a worskshop on quality of care was held in Dakha, Bangladesh on June 21-24 with the support of IPA

IPA also recommends the use of the following:

    Summary of relevant RCTs (2004 to 2009) see reference no.4
    List of ICHRC available reviews (see ref. no. 6) (www.ichrc. org)


Essential references

    WHO, Hospital care for children: Guidelines for the management of common illnesses with limited resources. 2005 WHO, Geneva

    Campbell H, Duke T, Weber M, English M, Carai S, Tamburlini G; Global initiatives for improving hospital care for children: state of the art and future prospects. Pediatrics 2008; 121(4):e984-92

    Tamburlini G, Schindler Maggi R, Di Mario S, Vilarim JN, Bernardino L, Neves I, Pivetta S. Assessing quality of paediatric care in developing countries. Asian Journal of Paediatric Practice, 2007, 11(2): 1-11

    Duke T. Randomised trials in child health in developing countries, 6th  Edition July 2007-June 2008.

    Tamburlini G, Weber M. Promotingquality of hospital care: available tools. Asian Journal of Paediatric Practice. 2007;11(1):34-35.

    Duke T, Campbell H,  Ayieko P, English M., Kelly J, Carai S, Tamburlini G, Weber M. Accessing and understanding the evidence. Bulletin of the World Health Organization2006, 84 (12) 922-23.

    Duke T, Keshishiyan E, Kuttumuratova A, Ostergren M, Ryumina I, Stasii E, Weber MW,  Tamburlini G. Quality of hospital care for children in Kazakhstan, Republic of          Moldova, and Russia:  systematic observational assessment. Lancet.   2006;367(9514):919-25.

    Nolan T, Angos P, J.L.A. Cunha, Muhe L, Qazi S, Simoes EF, Tamburlini G. Weber M.  Quality of  Hospital Care for Seriously Ill Children in Developing Countries. Lancet,  2001;  357 (9250): 106-110.