Development of a framework of intervention strategies for point of care quality improvement at different levels of healthcare delivery system in India: initial lessons.

BACKGROUND: Inadequate quality of care has been identified as one of the most significant challenges to achieving universal health coverage in low-income and middle-income countries. To address this WHO-SEARO, the point of care quality improvement (POCQI) method has been developed. This paper describes developing a dynamic framework for the implementation of POCQI across India from 2015 to 2020. METHODS: A total of 10 intervention strategies were designed as per the needs of the local health settings. These strategies were implemented across 10 states of India, using a modification of the 'translating research in practice' framework. Healthcare professionals and administrators were trained in POCQI using a combination of onsite and online training methods followed by coaching and mentoring support. The implementation strategy changed to a fully digital community of practice platform during the active phase of the COVID-19 pandemic. Dashboard process, outcome indicators and crude cost of implementation were collected and analysed across the implementation sites. RESULTS: Three implementation frameworks were evolved over the study period. The combined population benefitting from these interventions was 103 million. A pool of QI teams from 131 facilities successfully undertook 165 QI projects supported by a pool of 240 mentors over the study period. A total of 21 QI resources and 6 publications in peer-reviewed journals were also developed. The average cost of implementing POCQI initiatives for a target population of one million was US$ 3219. A total of 100 online activities were conducted over 6 months by the digital community of practice. The framework has recently extended digitally across the South-East Asian region. CONCLUSION: The development of an implementation framework for POCQI is an essential requirement for the initiative's successful country-wide scale. The implementation plan should be flexible to the healthcare system's needs, target population and the implementing agency's capacity and amenable to multiple iterative changes.

Development of a hub and spoke model for quality improvement in rural and urban healthcare settings in India: a pilot study.

OBJECTIVE: Hub and spoke model has been used across industries to augment peripheral services by centralising key resources. This exercise evaluated the feasibility of whether such a model can be developed and implemented for quality improvement across rural and urban settings in India with support from a network for quality improvement. METHODS: This model was implemented using support from the state and district administration. Medical colleges were designated as hubs and the secondary and primary care facilities as spokes. Training in quality improvement (QI) was done using WHO's point of care quality improvement methodology. Identified personnel from hubs were also trained as mentors. Both network mentors (from QI network) and hub-mentors (from medical colleges) undertook mentoring visits to their allotted facilities. Each of the participating facility completed their QI projects with support from mentors. RESULTS: Two QI training workshops and two experience sharing sessions were conducted for implementing the model. A total of 34 mentoring visits were undertaken by network mentors instead of planned 14 visits and rural hub-mentors could undertake only four visits against planned 18 visits. Ten QI projects were successfully completed by teams, 80% of these projects started during the initial intensive phase of mentoring. The projects ranged from 3 to 10 months with median duration being 5 months. DISCUSSION: Various components of a health system must work in synergy to sustain improvements in quality of care. Quality networks and collaboratives can play a significant role in creating this synergy. Active participation of district and state administration is a critical factor to produce a culture of quality in the health system.