Real-time perceived quality monitoring at primary healthcare

Improving primary care begins with better measurements of primary healthcare performance, and to ensure that the data is both accessible and used to drive decisions that improve health outcomes.  Strong primary health care requires quality, easy-to-understand data to pinpoint strengths and weaknesses, and measure and monitor improvements. This ensures that decision makers have the data they need to strengthen primary care systems on the way to achieving health for all.

The Primary Healthcare Performance Initiative (PHCPI) Conceptual Framework was developed by WHO, Unicef, Worldbank & Bill & Melinda Gates Foundation, and guides what should be measured to inform and drive efforts to improve PHC. A focus on service delivery processes sets the PHCPI Conceptual Framework apart from previous frameworks.

Within this framework, the problem we address is how to measure the quality of service delivery, as perceived by the patients, and to use this to influence behavior of both healthcare providers and patients. Our focus is on low resource healthcare settings in Africa.

Many challenges in primary healthcare, such as especially reluctance to seek care, are related to unpleasant interactions between patients and health care providers. For example maternal care studies across Africa have demonstrated that health-seeking behavior is negatively affected by (1) negative attitude of providers, (2) lack of communication, (3) inadequate health education, and (4) shortage of medicine.

Recognizing that improvement of patient experience and satisfaction can improve behaviors of healthcare providers and patients, patient satisfaction surveys have gained traction as an important tool for health service improvement in high income countries. However, the  traditional approach to this has limited applicability in low-resource settings; typically patient satisfaction surveys rely on online, paper-based, or interview-based data collection, and for low resource settings this is too resource intensive both in terms of human and financial resources.

In addition to this, traditional survey methods tend to focus on past performance and cannot provide real-time data. Therefore, patient-satisfaction surveys have mostly been used largely as an evaluation tool for perceived satisfaction, but not as a monitoring tool.

We propose an innovative approach to overcome the limitations of traditional patient-satisfaction surveys, while also enabling real-time monitoring and feedback for healthcare staff, to help them improve quality of service delivery.

Our solution is a low-tech instrument that patients/care takers can use to report whether they were satisfied with a specific service or their visit of the day through three smiley faces (happyJ, neutralK, unhappyL) or other icons sensitive to local culture. The instruments can be placed at predefined points (for example registration office, doctor’s office, laboratory, pharmacy) so that we can track specific service related satisfaction (by asking customers to rate a specific service), in addition to general satisfaction (by asking to rate general satisfaction). In this way, we evaluate whether the client perceived the care as complete and client-centric (two indicators in the PHCPI framework). Since every feedback is time-stamped, it may be possible to infer the root-cause of the problem (long waiting times, stock-outs, communication, etc.).  

By generating an automated report-card and sharing this with the care-providers and facility-in-charge, our aim is to improve quality of service delivery by changing behavior of both providers and patients.

This method of monitoring satisfaction is proven effective in other segments (such as monitoring satisfaction with cleaning services, or hospitality services), and this will be the first time it is tested in low resource healthcare settings in Africa.

Our target segment are low resource healthcare settings in Africa. It would improve access to quality healthcare for the most vulnerable populations.

 Our hypothesis is that our simplified measurement of patient satisfaction (general and service-specific) is a useful measure of whether the client perceived the care as complete and client-centric (two indicators in the PHCPI framework).

In addition, we hypothesize that sharing of the results with the healthcare staff will measurably improve behavior of health workers and also improve health seeking behavior of the population. Care providers will become aware that their behaviors are assessed by patients and monitored by their managers on daily basis. At the same time, patient will feel more empowered, because they will have a risk-free means to easily report their level of satisfaction on the service they received.

We hypothesize that our simplified system has no inferior effect on care quality improvement in comparison to the traditional more detailed data collection and analysis on the patient satisfaction.  

The International Center of Frugal Innovation (ICFI) has many years of experience around innovation in low resource settings, around the themes healthcare, water and agriculture. The center is a collaboration between Leiden University, Delft University and Erasmus University, and in this way brings together expertise around technical, business and social elements that are all important for inclusive innovation.

 This project will be implemented through the Kenya Hub of the ICFI, which is led by Elsie Osongo. She has relevant previous experience in evaluating innovation in primary healthcare in Kenya, including an evaluation of the Philips Community Health Centers, which is an all-encompasing solution to primary healthcare.

The team further includes prof. André Leliveld (development economist, Associate Director of ICFI), Dr. JC Diehl (J.C. Diehl is Associate Professor at the Faculty of Industrial Design Engineering), and Dr. Maarten van Herpen (previous head of the Philips Africa Innovation Hub, and now independent social innovator), who all have tremendous experience in inclusive innovation in primary healthcare. 

ElWe would like to create proof-of-principle for our idea. To do that we need a budget to develop the instrument and test the feasibility.

To develop the instrument we need to identify culturally-sensitive icons through anthropological analyses and focus groups with patients and care providers, do patient-flow analyses to identify best location for placement and how to avoid unwanted interference from healthcare providers, develop a set of prototype instruments, and develop supportive interventions that can provide the feedback to the healthcare staff.

To test the feasibility, we plan to focus on maternal care, and do a user test of the instrument prototypes by mothers and caretakers. We also want to do user tests of a prototype a report cart to provide feedback to healthcare staff. 

Compared to traditional patient satisfaction surveys, our solution provides real-time monitoring, and is much simpler and requires substantially less human and financial resources. This makes it better suited for monitoring in low-resource settings. In addition, our solution is focused on creating impact by sharing the data with the healthcare staff, so that they can improve the quality of service delivery. 

If our proof-of-principle is successful, the next step is a study to create scientific evidence of the impact that our solution has on the quality of care. With such evidence, the solution can transition-to-scale through partnerships with NGOs and local governments, implementing the solution at scale. Because the solution is very low-cost, it can be financed through existing programs and budgets.

The future impact study would use an intervention group and a reference group to evaluate the significance of implementing a self-administered real-time client-satisfaction tool on service utilization and quality of care-delivery. Such a study might also evaluate the possibility of integrating quality-based reimbursements to the facilities based on client satisfaction. 

We intend to use the primary healthcare performance initiative framework to measure the impact.

 Also, the main impact of our solution can be measured through improvements in perceived quality of care. Thus, our solution is monitoring the impact indicator that it is also aiming to improve.

If our solution is effective, we should therefore see an improvement in perceived quality of care, as time progresses. 

Problem: poor quality of service delivery, lack of data about perceived quality of service delivery.

Activity/input: (1) measuring perceived quality of care through low-tech instruments placed at dedicated locations at the primary healthcare facility. (2) providing feedback to healthcare staff of the measured perceived quality of service delivery.

Output: Continuous monitoring and feedback on perceived quality of service delivery. Healthcare staff improves behavior to improve quality of service delivery. Patients feel more empowered to share their feedback on perceived quality, and more pleasant interactions between patients and care providers.

Outcome: Improved healthcare outcomes, and improved health seeking behavior.

The instrument that we will develop will be low-tech, comprising buttons with culturally adapted symbols to provided feedback, and a means for storing or transmitting data to a database. Data processing will generate a report-card that can be shared with the care providers. 

Patients/clients. Their incentive is an anonymous way to provide feedback.

We will work through our local hub in Kenya, and will use focus group discussions to get deep insights in the needs and aspirations of people. We will focus on maternal care in our proof-of-principle, to ensure that women are sufficiently involved in the design of the solution.

Our solution is focused on the most vulnerable populations, and therefore helps creating inclusivity in access to quality healthcare.

To be determined after proof-of-principle. We envision scaling through either a social enterprise approach, or otherwise through a foundation that creates global access to our solution.

To be determined after proof-of-principle. The solution is very low-cost, so we expect it can be financed through existing programs in partnership with NGOs and local governments.

Not applicable.