Introducing the WHO quality toolkit: supplemental overview

INTRODUCING THE WHO QUALITY TOOLKIT SUPPLEMENTAL OVERVIEW

INTRODUCING THE WHO QUALITY TOOLKIT SUPPLEMENTAL OVERVIEW Introducing the WHO Quality Toolkit: supplemental overview ISBN 978–92–4-004387–9 (electronic version) ISBN 978–92–4-004388–6 (print version) © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0  IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Design and layout by Inis Communication Contents iii Acknowledgements v Purpose of the document vi The Toolkit at a glance 1 Using the WHO Quality Toolkit What is the WHO Quality Toolkit? 2 How was the Toolkit developed? 3 What is the purpose of the Toolkit? 3 Who is it for? 3 What is contained in the Toolkit? 4 How is the Toolkit organized? 5 Where to start? 5 Considerations for applying the content of the WHO Quality Toolkit How to address quality of health services 7 The COVID-19 context and other public health emergencies 8 Community engagement for quality, people-centred and resilient health services 9 Learning agenda and knowledge management 10 Preparing and adapting tools for implementation 11 Exploring the levels of the health system National 14 Sub-national/district 15 Facility 16 Community 17 iv Exploring key functions to address quality of care in the health system 1. National strategic direction on quality 18 2. Standards supporting quality 19 3. Oversight and regulation 20 4. Management, operational and supervision support 20 5. Improvement interventions 21 6. Measurement and evaluation 22 7. Engagement 24 References 25 vAcknowledgements Acknowledgements The Quality Toolkit was produced under the overall technical supervision of Shams Syed, in the Integrated Health Services Department, within the Universal Health Coverage and Life Course Division at World Health Organization (WHO) headquarters. Overall coordination of document development was provided by Ruben Frescas. The principal writing team consisted of Sepideh Bagheri Nejad, Ruben Frescas, Nana Mensah Abrampah, Matthew Neilson, Julie Storr and Shams Syed. Technical design and review of the document was provided by a dedicated sub-group of the WHO Quality Taskforce, an entity spanning 20 teams at WHO that facilitates collaboration, coordination and knowledge-sharing of technical activities on quality of care. Sub-group participants include Onyema Ajuebor, Wole Ameyan, Melissa Bingham, Neerja Chowdhary, Meredith Fendt-Newlin, Bruce Gordon, Vijay Kannan, Maggie Montgomery, Anayda Gerarda Portela, Teri Reynolds, Paul Rogers and Özge Tuncalp Mingard. WHO gratefully acknowledges technical contributions to the Quality Toolkit from WHO staff spanning a range of technical teams: Moazzam Ali, Benedetta Allegranzi, Wole Ameyan, Shannon Barkley, Marie-Charlotte Bouësseau, Rose Buhain, Bernadette Cappello, Neerja Chowdhary, Michelle Funk, Francine Ganter-Restrepo, Nikhil Gupta, Dirk Horemans, Mai Inada, Ernesto Jaramillo, Vijay Kannan, Rüdiger Krech, Camila Lajolo, Qin Liu, Blerta Maliqi, Lisa Menning, Maggie Montgomery, Clarice Pinto, Anna Ray, Paul Rogers, Julia Samuelson, Erin Shutes, Özge Tunçalp, Anthony Twyman and Evgeny Zheleznyakov. While the Quality Toolkit is intended to serve all programmatic needs, it has been developed to build on the WHO publication Quality Health Services: a planning guide, which supports countries engaged in developing a systematic approach to improving the quality of health services. WHO duly acknowledges the writing team for that publication, which comprised Sepideh Bagheri Nejad, Blerta Maliqi, Nana Mensah Abrampah, Zainab Naimy, Matthew Neilson, Julie Storr and Shams Syed. The Quality Toolkit benefited from a review by a number of WHO regional office advisers on quality health services, including Nino Dal Dayanghirang (WHO Regional Office for Africa), Masahiro Zakoji (WHO Regional Office for South-East Asia), Alaka Singh (WHO Regional Office for South-East Asia), Mondher Letaief (WHO Regional Office for the Eastern Mediterranean), Jonas Gonseth-Garcia (WHO Regional Office for the Americas/Pan American Health Organization [PAHO]), Evgeny Zheleznyakov (WHO Regional Office for Europe) and Mai Inada (WHO Regional Office for the Western Pacific). Valuable inputs in the form of review and suggestions were provided by individuals across multiple countries: Bruce Agins, Emmanuel Aiyenigba, Mwana Ali, Louis Ako-Egbe, Samsiah Awang, Apollo Basenero, Mwemezi Kaino, Ernest Kasiedu, Andrew Likaka, Lydia Okutoyi, Ian Spillman and Sonali Vaid. The Quality Toolkit was supported through several discrete funding streams. It received support from the UHC Partnership, which is funded by the European Union, Luxembourg, France, Ireland, Japan, the United Kingdom of Great Britain and Northern Ireland, Belgium and WHO. In addition, the technical work required to develop the Quality Toolkit was supported through project-specific funding from Canada, Japan and Norway, for which WHO is grateful. vi Introducing the WHO Quality Toolkit: supplemental overview Purpose of the document This document is intended to help you navigate the web-based WHO Quality Toolkit, in order to support its widest possible use. The WHO Quality Toolkit is an online information product providing an interactive and tailored web-based experience for users. It is designed to enable you to find and use the tools most applicable to your work in improving the quality of health services. It supports actions outlined in the Quality health services: a planning guide (1). The Quality Toolkit supports taking action and completing tasks and can be found at qualityhealthservices.who.int/quality- toolkit. The online Toolkit will be periodically updated to ensure new WHO tools and resources are included, to best support your work in improving the quality of health services. This document outlines what you need to know to navigate the online Quality Toolkit, introducing you to the structure and content of that material. It provides an overview of the online Toolkit, its purpose and use. This includes intended audiences, what is contained within the Quality Toolkit, how it is organized and suggests how to start making use of the Toolkit. It also provides additional information on application of the tools contained in the Toolkit. The last two sections of this document provide an orientation to special considerations of how quality of health services can be impacted in any of the four levels in the health system – national, sub-national/district, facility, and community – and the key functions that relate to those respective levels of the health system. By the end of this document, you should be confidently able to access and efficiently use the Quality Toolkit to find the tools you need for your planning for quality and implementation. 1The Toolkit at a glance The Toolkit at a glance The WHO Quality Toolkit: Navigating tools to improve the quality of health services, provides a range of tools to improve the quality of health services. It supports actions outlined in the Quality health services: a planning guide, which provides a structured, systems-approach to addressing quality of health services (1). Whether you work at the facility, sub-national or national level, or in specific communities, you will find content within the Toolkit to help you carry out tasks to improve quality of care. Figure 1 illustrates the overall structure of the web-based WHO Quality Toolkit. FIGURE 1. OVERALL STRUCTURE OF THE WEB-BASED WHO QUALITY TOOLKIT Whether you are looking at the quality of health services through a health system perspective, as a health care worker, advocate, or an expert in the field of quality of care, this Toolkit will guide you through important functions for supporting quality of care and links to the relevant tools to complete tasks and activities. These functions help to organize the types of tools1 at the various levels of the health system that you can reference and access. It also provides an entry point to share information through the various virtual (or online) communities found within the section focusing in on learning. It is a dynamic toolkit that will be periodically updated with new material. The WHO Quality Toolkit is available online at qualityhealthservices.who.int/quality-toolkit as an interactive platform to support you to easily find those tools that will best respond to your specific needs. 1 Tools as referred to in this Toolkit include material that can be implemented/adopted, with necessary modification, possibly, for direct use in carrying out a specific function, task or activity. Users working at different levels of the health system enter the toolkit with varying needs. The Quality Toolkit supports those users to identify and navigate tools that can be used to improve the quality of health services. Users take action with the tools to improve the quality of health services through various entry points for systems-based improvement. Sub-national/ districtNational Facility Community Introduction to WHO Quality Health Servies Toolkit Search ToolkitNew to health system quality thinking? 2 Introducing the WHO Quality Toolkit: supplemental overview Using the WHO Quality Toolkit What is the WHO Quality Toolkit? The WHO Quality Toolkit is an organized set of practical tools and resources to support improvement in the quality of health services and is a companion to the WHO quality health services: a planning guide (1). The quality health services: a planning guide outlines actions required at the national, district and facility levels to enhance the planning and actions necessary to address the quality of health services. The Toolkit supplements that guidance and helps you to select and navigate practical tools that can support completing the tasks outlined in the planning guide. The toolkit offers a structured, systems-based approach – how tasks, interventions and actions impact the health system – for you to find the material that is most applicable to you given your specific query and needs. The Quality Toolkit is dynamic and will grow from its initial version that captures currently available WHO tools, recognizing that gaps may exist as certain tools may not yet be readily available for all needs. This may help support future work based on user feedback. The Toolkit includes key WHO tools related to the quality of health services. Indeed, it focuses exclusively on materials published by WHO, so does not include third party publications and tools which may also be of value to you. The Toolkit will be updated periodically to reflect new and emerging WHO information relevant to improving quality of health services, for example quality- related tools and emerging resources from various WHO technical products currently under development. WHO works extensively on many specific technical areas which are not all reflected in this Quality Toolkit. For a comprehensive index of all WHO published material, visit apps.who.int/ iris/ and for WHO technical guidelines, visit who.int/publications/who-guidelines. The Quality Toolkit and the Operational Framework for Primary Health Care In 2020, WHO and UNICEF launched the Operational Framework for Primary Health Care: Transforming Vision into Action (2). This document outlines a series of strategic and operational levers requiring attention by countries as they plan and implement primary health care reforms within their health systems. Primary health care is a cornerstone of the broader effort towards achieving universal health coverage and the Sustainable Development Goals, as repeatedly affirmed by all countries of the world. One of the levers within the Operational Framework for PHC, is on Systems to improve the quality of care, which highlights the need for a “multimodal suite of interventions tailored to the local context, while simultaneously working to improve the broader health systems’ environment and culture that support the delivery of quality care.” In fact, there are strong linkages to quality of care across all fourteen levers within the Operational Framework for PHC. Stakeholders involved in primary health care reforms are a key audience for the Quality Toolkit, which responds to the need for practical tools that these stakeholders can employ to implement the PHC Operational Framework, and thus firmly embed quality of care within health systems strengthening. 3Using the WHO Quality Toolkit How was the Toolkit developed? The Quality Toolkit was developed through a series of collaborative exercises reaching across technical teams, WHO regions, and country offices, to collate all the tools found within the Toolkit. Basic criteria were applied to assess inclusion, which also looked at various factors and characteristics of the tools in order to support search functions. An internal team at WHO led the review process and organization of the Quality Toolkit. The Toolkit then underwent a number of rounds of external consultation with end-user groups, to provide input into its evolving design. The final product included input from various stakeholders and was supported by graphic design experts to enhance an end-user focus working closely with web development expertise. What is the purpose of the Toolkit? This Toolkit provides you with tools to facilitate specific actions to enhance the quality of health services in your country. In addition, this toolkit supports and hopefully enhances your understanding of the key interlinkages across the health system when implementing any tool. This may mean that conditions are required at the national level to support local level efforts to be successfully deployed, or for instance, that engaging the community helps gain perspective and trust at any level within the health system and thus facilitates change. The ultimate goal of the Quality Toolkit is to IMPROVE the quality of health services. I IDENTIFY tools and resources relevant to quality of care M MAP those tools against improvement needs or identify gaps P PLAN implementation of activities for improving quality of care R RECOGNIZE interlinkages between technical areas and the process of change O OPTIMIZE multi-level action V VISUALIZE journeys for improving quality of care E ENGAGE stakeholders across the health system Who is it for? The Quality Toolkit is designed to support stakeholders using the WHO Quality Health Services: a planning guide, to plan and implement interventions to improve the quality of health services. The Toolkit is relevant to key health stakeholders from the national, sub-national, and local levels, including communities. Users may more specifically include, but are not limited to, authorities (at national, sub-national and local levels), regulators, managers, health care workers, and patients/ communities. In addition to those listed, the Toolkit will also be of use to others who are focused on advancing quality health service delivery across the continuum of planning, assurance/control and improvement, for example development partners and advocates, among others, such as health training institutions. 4 Introducing the WHO Quality Toolkit: supplemental overview What is contained in the Toolkit? The Toolkit provides a broad range of tools that will help support your work, regardless of the health system level you work in, to execute tasks and actions that strive to improve the quality of health services. Three cross-cutting functions are present at all levels: 1) measurement and evaluation; 2) improvement interventions; and 3) engagement. These three functions acknowledge the key role of measuring and evaluating efforts throughout the health system to inform the application of improvement interventions and the need for continuous improvement and impact, and the engagement of key relevant stakeholders, including the community. Drawing on WHO publications, the Toolkit also presents a brief narrative around how different parts of the health system work together to support the delivery of quality of health services and how relevant tools can be selected and used to support such efforts. The types of tools contained in this Toolkit include: Key functions for supporting quality of care2 Types of tools in Toolkit Levels the tools are directly applicable at National Sub-national /district Facility Community National strategic direction on quality Tools that support the development, refinement and implementation of national quality policy and strategy Standards supporting quality Tools that support the use of standards based on guidelines and evidence from across WHO technical programmes that support and reinforce efforts to improve quality of care Oversight and regulation Tools that aid responsible entities to oversee and assure quality of health services to strengthen accountability Measurement and evaluation Tools that aid in measuring, monitoring and evaluating the quality of health services Management, operational, and supervision support (MOSS) Tools that support district and facility managers: 1) to conduct managerial and administrative tasks; 2) to support operational tasks, for example, utilities, facilities, logistics; and 3) to support formal supervision processes – all aimed at improving quality of health services Improvement interventions Tools focused on specific interventions for improving quality of care Engagement Tools that support building, strengthening, or maintaining partnerships and the engagement of communities, peers and multidisciplinary collaborators. 2 These are the subsections in which the tools are organized within the Toolkit, following each level of the health system (i.e. national, subnational, facility, and community). 5Using the WHO Quality Toolkit How is the Toolkit organized? The Toolkit is primarily organized in line with the different levels of the health system, to help you find the tools applicable to your specific work setting. Users may seek input and work from various levels of the health system depending on the roles and tasks at hand. However, irrespective of the level that you are working in, being familiar with the various levels is advised to best appreciate how different factors may influence the success of applying a specific tool you may seek. This multi-level orientation allows the user to understand the interlinkages with other levels of the health system. Within each level of the health system, key functions help organize the various tools – to enable you to select the specific tool you could use. This approach may also expose you to new topics and areas beyond your initial query which could help broaden your thinking and considerations in your effort to improve the quality of health services in your respective work setting. Where to start? FIGURE 2. TWO PATHS FOR ACCESSING THE TOOLS OF THE QUALITY TOOLKIT The Toolkit not only provides users from various disciplines with the opportunity to find tools that they may specifically seek, but also offers a structure to see the implications and various linkages that quality initiatives have within the health system. For the platform to be versatile to this degree, various ways are suggested for you to engage with the Toolkit. There are two general approaches that can help you best start to use the Quality Toolkit. If you are new to working on quality of care, you may choose to read through each level to understand the various factors that influence quality within the health system as a whole. It is important to first have a read of the WHO Quality Health Services: a planning guide, to understand where to start across the health system levels. If you know what you are looking for (i.e. a specific type of tool or resource), your primary objective is to find the specific tool(s) that will help respond to your specific need. You may choose to look more broadly at the level of the health system, or the type of function you need help with. You may also simply use the search feature to type key words or filter for the tools most applicable to your specific needs. Policies Cyber security Ethics Permissions and licensing Terms of use Regions Africa Americas Eastern Mediterranean Europe South-East Asia Western Pacific Privacy Legal Notice © 2021 WHO About us Careers Library Procurement Publications Frequently asked questions Contact us Subscribe to our newsletters Give feedback on Toolkit Choose appropriate filters/selection criteria below to narrow down your search for tools. Find tools Search Toolkit Learn more New to health system quality thinking? Find out more How to use WHO Quality Health Services Toolkit Keyword(s)/technical area(s) (type relevant keywords) Key functions for supporting quality National Strategic Direction on Quality Standards Supporting Quality Management, Operational, Supervision Support (MOSS) Measurement & Evaluation Oversight & Regulation Browse all tools Engagement Improvement Interventions Health system levels National Facility CommunitySub-national/District Search filters HelpSearch Toolkit About Toolkit Quality services New to health system quality? /maybe need a refresher National Sub-national/ District Facility Community By key word/With filters National Strategic Direction on Quality Standards supporting Quality Oversight & Regulation Measurement & Evaluation Management, Operational, Supervision Support Improvement Interventions Engagement YES NO LEVEL OF HEALTH SYSTEM SEARCH FUNCTION FUNCTION OF TOOL LIST OF RELEVANT TOOLS 6 Introducing the WHO Quality Toolkit: supplemental overview Considerations for applying the content of the WHO Quality Toolkit It is important for users to have a basic understanding of quality through a health systems approach – how tasks, interventions and actions impact the health system – when using the tools contained in the Toolkit. The WHO health systems building blocks are an often-cited approach to understanding health systems (3). The more recent Primary health care operational framework provides a clear entry point for action to improve the quality of health services through a primary health care approach (2). These broad frameworks can help to understand and appreciate how health systems may respond to applying any given tool focused on quality of care. Additionally, engagement mechanisms are critical at all levels of the system to ensure adequate representation and can support a joint vision on quality of care. FIGURE 3. CONCEPTUAL MODEL FOR IMPROVING QUALITY HEALTH SERVICES The tools presented in this Toolkit will require adaptation and contextualization to meet local needs. You should carefully consider modifications required before using tools to execute any specific action. The Toolkit recognizes five fundamental requirements mentioned in Improving the quality of care for maternal, newborn and child health – Implementation guide for facility, district and national levels, which are relevant across the health system and culminate in a health system-wide approach (4). First, onsite support is required to ensure health workers receive the necessary coaching, mentoring and clinical skills support to improve quality of care. Second, measurement mechanisms are required to track the delivery of quality health services and promote accountability. Third, sharing and learning is required to enable the exchange of experiences in improving Levels of Health System Foundational Requirements Sub-national/ District Facility Community National E N G A G E M E N T Health systems building blocks Implementing quality interventions Culture of quality On-site support Sharing and learning Stakeholder and community engagement Measurement Management Sustained improvement in quality of health services 7Considerations for applying the content of the WHO Quality Toolkit quality of care between and across the different health system levels. Fourth, stakeholder and community engagement is required to ensure regular, active and meaningful engagement of the community in efforts aiming at improving quality of care. Finally, good management is needed to ensure activities to improve quality of care are carried out within a functional support architecture. How to address quality of health services The Toolkit addresses quality of care with a health systems approach as noted earlier along with the five foundational requirements. This acknowledges the multidisciplinary and interdependent nature of health systems. Some basic concepts are helpful to know when considering how to address quality of health services. Quality health services across the world should be: ƒ effective, providing evidence-based health care services to those who need them; ƒ safe, avoiding harm to people for whom the care is intended; ƒ people-centred, providing care that responds to individual preferences, needs and values; ƒ timely, reducing waiting times and sometimes harmful delays for both those who receive and those who give care; ƒ equitable, providing care that does not vary in quality, on account of age, sex, gender, race, ethnicity, geographic location, religion, socio-economic status, linguistic or political affiliation; ƒ integrated, providing care that is coordinated across levels and providers and makes available the full range of health services throughout the life course; and ƒ efficient, maximizing the benefit of available resources and avoiding waste. A local definition for quality of care can be drawn from these domains to help guide and focus direction and resources broadly. These interlinked domains contribute to the quality of health services within the wider system. Indeed, “quality” is often considered to be an attribute of the health system and/or its specific services/components, but can be understood more broadly as how well the system is functioning. This can be described as a type of journey, which requires continuous adaptation and rate-adjustment. The Quality Trilogy, based on the work of Juran, is frequently used as a reference and widely applied in the field of quality of care. The Quality Trilogy consists of three inter-related processes that are required for managing quality in health care : ƒ planning for quality – the structured inputs and processes within the design and coordination of health services aimed at ensuring the needs of users and populations are met; ƒ assuring quality – internal and external assessment processes and mechanisms to ensure that services are fulfilling stated requirements for quality (internal assessment processes may be referred to as quality control, and external reviews as quality assurance); and ƒ improving quality3 – the action taken by every person working to implement iterative, measurable changes, to make health services more effective, safe and people-centred. Lastly, it is helpful to organize your approach by understanding the various components of implementing a tool which enhances quality health services. The Donabedian Model provides 3 Improving quality refers to any systematic action across the different levels of the health system to address gaps and challenges related to making health services more effective, safe and people-centred. Meanwhile, quality improvement is used to describe an iterative process to improve performance by identifying improvement needs, making changes, and monitoring the effects over time. Quality improvement plays a key role in the systematic examination of the processes and systems that affect how health care is delivered by health workers and received by patients. 8 Introducing the WHO Quality Toolkit: supplemental overview a structure to help organize and understand these components that will lead to the intended outcome. The three parameters used to evaluate quality of health services include: ƒ structure – the setting within which care is delivered, including facility, human resources and assets/financial resources; ƒ process – the provision of care itself, including aspects of interaction between receivers and providers of care and interactions across the different levels of the health system; and ƒ outcome – the measurable effect on health status, which may be influenced by a range of additional factors. The COVID-19 context and other public health emergencies The 2019 novel coronavirus (COVID-19) pandemic has altered the health systems environment across the entire world.4 This is, therefore, the context within which this Toolkit will be used. Given the protracted nature of the COVID-19 pandemic, the initial application of this Toolkit in many settings seems likely to take place during response5 and recovery.6 This requires careful consideration of two key points: 1) how efforts to address quality of health services are affected by the COVID-19 situation, and 2) how application of the tools and approaches within this Toolkit can best support response and recovery of health services. Quality of health services is a key consideration for case management of COVID-19 and maintenance of essential health services. WHO has developed a training module course on Clinical Management of Patients with COVID-19,7 taking users through basic principles of improving quality as they relate to COVID-19. On the maintenance of essential health services, there is an ongoing need to understand the secondary effects of the COVID-19 pandemic on the wider health system and its ability to respond. This is discussed in more detail in WHO’s Operational guidance for maintaining essential health services in the COVID-19 context (5). Maintenance of essential health services helps to ensure care meets the needs of people, while also being mindful of the protections necessary for health care staff. Intentional efforts should be made to ensure that work related to the maintenance of essential health services in the COVID-19 context help to improve quality of care by being additive and complementary to broader approaches on COVID-19 response and recovery. This will require close monitoring, liaising with those involved in response and recovery planning, and the adaptation of tools and approaches to meet emerging needs. Further, COVID-19 has demonstrated the need for quality health services to be the foundation of resilient health systems. This will certainly not be the last major global pandemic, and besides, many countries are frequently dealing with a range of other serious public health emergencies. Experience from a range of these emergencies has shown the value of building services that are of sufficient quality to effectively perform their roles in prevention, detection and response, and that are trusted and utilized by communities. System-focused action on quality of care is therefore critical to health security. In practical terms, those taking action on quality of care at different levels 4 Note: For further information and resources specific to COVID-19, please see https://www.who.int/emergencies/diseases/ novel-coronavirus-2019 5 As defined in the WHO Glossary of Health Emergency and Disaster Risk Management Terminology: 1. The provision of emergency services and public assistance during or immediately after a disaster, in order to save lives, reduce health impacts, ensure public safety and meet the basic subsistence needs of the people affected. 2. Any public health action triggered by the detection of a public health risk (e.g. monitoring of the event, information of the public, triggering field investigation and/or implementation of any control or mitigation measures). 6 As defined in the WHO Glossary of Health Emergency and Disaster Risk Management Terminology: The restoring or improving of livelihoods and health, as well as economic, physical, social, cultural and environmental assets, systems and activities, of a disaster-affected community or society, aligning with the principles of sustainable development and ‘build back better’, to avoid or reduce future disaster risk (UNGA 2016). 7 Module 5: maintaining quality care during COVID-19 is available at Apple store; Google Play and OpenWHO. 9Considerations for applying the content of the WHO Quality Toolkit of the health system should consider how to link up with local structures and planning processes for preparedness and health security, how to include quality of care as a key component of local preparedness activities, and how to plan for the adaptation of quality activities in times of crisis. The WHO technical package on quality of care in fragile, conflict-affected and vulnerable settings is a key resource alongside this Toolkit to guide efforts to improve quality of care in situations of crisis. Community engagement for quality, people-centred and resilient health services Community engagement (CE), in the context of health systems, is a process of developing and maintaining relationships that enable the different stakeholders to work together to address health-related issues and promote well-being to achieve positive and sustainable health impact and outcomes. Community engagement has often been used interchangeably with community empowerment, mobilization or sensitization, which has caused some confusion and ambiguity as different stakeholders form different kinds of communities. Some important definitions and principles are discussed in this section to provide some conceptual clarity and a well-defined scope and purpose for the role of community engagement to address the human dimensions of high-quality health services – further information is provided in the Community level. Community engagement is relationship-building between stakeholders who integrate their interests among interdependent communities, from service users, government programmes, health service providers, policy-makers, researchers and donors/insurers, to achieve shared health goals that are meaningful to both local populations and health systems. Community engagement is also concerned with how power and authority is addressed to support mechanisms and processes through which shared goals can be negotiated among stakeholders. At its worst, community engagement has the potential to burden some communities with the unintended consequences of consultation fatigue, stress, financial and time loss, and disappointment when health services fail to respond or address their needs. At its best, community engagement has the potential to strengthen transparency and accountability between all key stakeholders, but this requires discarding linear cause-and-effect approaches and embracing how to work in complex adaptive systems. Work on quality of care always requires us to remember that health systems, services, and programmes are made up of people and are inherently interlinked. There have, traditionally, been two perspectives when assessing the quality of the health system: 1) measures related to disease-specific health processes and outcomes, and 2) measures that account for patient, family and community experience or satisfaction with the respective health service(s). Consequently, health programmes and services have developed engagement interventions and tools that are tailored for the uptake of their health interventions and respective population profiles. However, further work is required in developing these tools and approaches to best meet the needs of communities and health workers. Beyond assessment of quality of care, the engagement of patients, families, and communities is also increasingly recognized as a key component in the planning and delivery of quality health services, necessitating attention by stakeholders across the system to build capacity and support for effective engagement. WHO is currently collaborating with pathfinder countries8 to fill an evidence gap at the health service and systems levels and is drawing upon systems thinking in order to fill that gap. The foundational premise is that in a system, existing or naturally developed (i.e. organic), relationships already function in which one another’s every interaction is an active intervention and communication. Consequently, the focus for understanding community engagement needs to shift from 8 WHO is supporting pathfinder countries to generate empirical data, advance research methods, and prototype relational community engagement models and tools. 10 Introducing the WHO Quality Toolkit: supplemental overview understanding “community” as a geographical or static group, to understanding the notion of “community” as the connections between and within people who function, interact, and create a sense of “community”. This approaches community engagement as a process of relationship- building that underpins health care planning and delivery. This means that the patterns of interaction and the nature of linkages within a health system are of equal importance as direct engagement with health service users, their families and health care stakeholders. Trust continually emerges from these relational connections between people and needs to be monitored and attended to across all levels in the health system and over time. Learning agenda and knowledge management Capturing learning – both success and failure – is critical to all efforts to enhance health service quality. The focus is to understand why actions or changes applied within a system/context led to improved outcomes and influenced impact, or conversely what has not brought about the intended outcome. A proactive move is required away from blame, since this generally impedes improvement by hiding issues or facts and not taking the opportunity to appreciate those as important learning moments. Vast amounts of new knowledge are produced during efforts to improve quality of care. How this new knowledge is transformed into effective decision-making across different levels of the health system requires deliberate action with a focus on how that change occurs – the stories behind improvement. Key issues surrounding why, when, for whom and how, are fundamental questions to be addressed when learning about improvement. Being able to document and communicate these lessons is important to help accelerate successful actions and ensure the planning of quality health services is informed by local actions. The process of sharing the learning from improving the quality of health service merits careful attention during the design, implementation and review of efforts to improve quality of care. Learning should be shared at the most proximal level of the health system – within the original site where the improvement occurred, with teams at the relevant level, whether that be at the sub-national/district level, national level, and even between countries. This approach ensures that successful actions are scaled up to drive overall impact on the quality of health services. How these lessons are institutionalized and used will likely bring in multiple disciplines, which include stakeholders within and beyond the health sector, in order to bring about broad buy-in and understanding. These may include formal education sectors, as well as professional bodies and research institutions, and sometimes also the private sector. Reducing barriers to shared learning and applying a critical lens to lessons allow for better use being made of tried-and-tested novel approaches for improving health service quality. WHO is committed to advancing learning related to quality of health services. Key learning mechanisms that exist within WHO to advance the learning agenda are outlined below. Learning mechanisms with guidance (tools, resources, case studies and peer-to-peer learning exchange) on improving health service quality: ƒ The Global Learning Laboratory for Quality Universal Health Coverage: a dedicated community of multidisciplinary stakeholders with the ability to connect with professionals globally on issues related to quality of health services. ƒ Integrated People-Centred Health Services: a global knowledge exchange platform dedicated to supporting people-centred health service delivery reforms for universal health coverage. ƒ Global Community of Practice for Quality of Care: a community of health practitioners from around the world sharing their know-how, ideas and challenges on quality improvement for maternal, newborn and child health. 11Considerations for applying the content of the WHO Quality Toolkit ƒ WHO Global Infection Prevention and Control (IPC) Portal: a resource that supports situational analysis, tracking progress and making improvements to IPC programmes and/or activities at the national and facility levels, in accordance with WHO standards and associated implementation materials. ƒ Global Patient Safety Network (GPSN): an online platform for key stakeholders to share and discuss ideas, approaches, tools, and best practices from around the world, with the aim of improving patient safety. ƒ COVID-19 Health Services Learning Hub (HLH): A knowledge platform that supports cross- country learning in maintaining essential health services during the COVID-19 pandemic, including the post-pandemic recovery phase. The HLH supports implementation of WHO’s operational guidance on maintaining essential health services. WHO’s lifelong learning development platform, the WHO Academy, is a state-of-the-art training institution that aims to bridge the gap between learning and doing by optimizing adult learning through online and classroom-based courses. The Academy expands access to critical knowledge, informed by a wide range of WHO normative guidance, to millions of health workers, managers, public health officials and policy-makers, enabling and implementing evidence-based, high quality and safe health care. Preparing and adapting tools for implementation The tools included within this Toolkit vary widely in scope and structure and may not be immediately ready for practical application in all settings. Most tools will require some form of preparation or adaptation before they can be effectively applied in a given context. The approach required for preparation and adaptation will vary according to the type of tool, the user, and the context in which it is being applied. Considerations around adaptation may be outlined within the tool itself, and there are a number of adaptation frameworks and guides for different types of material in the published literature. Below we summarize some key points and questions that may be useful for users to consider when planning to use any tool to improve quality of care. Please note, that tool application is an iterative process and will likely require levels of refinement and improvement in practice. This will require a level of monitoring and review to assess the tool’s effect and impact which can inform any necessary adjustments in practice. Adapting to context The adaptation of tools to local context will require the consideration of many factors, such as the acceptability of the methods and approach in the context of local customs and culture; the language in which the tool must be made available; alignment with structures, systems and terminology in use; accountability mechanisms; issues related to funding/cost; and the feasible scope and scale of its use in the face of competing local needs. The health system faces constant and new challenges, whether triggered by new diseases/infections, environmental disasters, socio-political strife, or other challenges which can strain the quality of health services. It is important to consider the utility of a specific tool in this new/challenging environment which may require changes in the scope of the tool, engagement of stakeholders, and even processes for implementing the tool. Tools chosen for implementation may require some modification or adaptation for the specific improvement needs you may encounter, including modification of the scope or technical content to reflect proximal/local QI processes, the disease burden or existing guidelines. 12 Introducing the WHO Quality Toolkit: supplemental overview General questions and answers: … Is the tool available in your local language, or does it require translation? – Consider translation of material to meet local need – may require re-messaging to be acceptable to the local context. … Does the setting you plan to implement the tool in match the intention of the tool? – Keep in mind that tools may have shown promise and success in one setting, however their success in differing settings may vary. It is important to assess and document adaptations necessary to meet the specific needs in your specific context. … Is there local support available from leadership and partners to implement the tool? – This may require engagement of key leaders at the specific level where the tool is to be implemented. Gaining buy-in will generally facilitate engagement, can unblock resources, and result in the overall success of implementation. … Will applying the tool be acceptable to beneficiaries of the intervention? – Using a tool should be responsive to those who benefit from its implementation and use – this could be the health care workers; patients, families and communities; as well as regulating agencies, policy-makers and others in the health sector. … Does the technical content of the tool need to be modified to align with other guidelines or quality improvement tools? – This may require detailed review of guidelines already in use or liaison with local QI teams to understand where the tool will fit within broader improvement processes. … Is the technical focus of the tool relevant to the locally identified improvement needs? – Tools developed for a specific technical or disease area may still be of use in related areas with adaptation, if no other more specific tools are available. For example, a tool supporting situational analysis for one disease area might provide a useful starting-point for certain questions to then be refined to gather more relevant information on a related clinical topic. Preparing for implementation Ahead of implementation, there will also be a need to consider both the practical requirements for successful use of the tool (e.g. human, financial or other resources; training of tool users) as well as extrinsic factors that may influence its implementation. These include stakeholder engagement, political will, social advocacy, which often helps set the environment which will either catalyse or impede improvement efforts when implementing a specific approach, method, or tool. General questions and answers: … Who should be involved/engaged? – Consider relevant stakeholders influenced by the tool, including potential beneficiaries of the intended action/intervention. … When should involvement/engagement occur? – It is important to consider proper timing of engaging various stakeholders. Not everyone may need to be engaged at the same time, and the manner of engagement may be different for various stakeholders. … Does capacity exist among those involved to complete the action or task? – Those involved should be knowledgeable about the elements needed to apply the tool or intervention, or you may need to arrange training (capacity-building). 13Considerations for applying the content of the WHO Quality Toolkit … Are those needed to implement the tool/intervention available to do this? – If you have staff who have the knowledge and competency to implement the tool/ intervention, consider if they have the time and ability to actually do it. … Is it necessary to out-source or seek additional support? – It may be necessary to bring external experts in to help support implementation of a given tool or initiative, maintaining full connectivity with the internal team. … What resources exist to complete the action or task? – It is important to understand what would be required to implement the tool, which will include personnel and capacity, necessary facility/equipment, supplies, medicines, etc., and the means to support any additional costs or adjusting workloads, as necessary. … What resources need to be requested or sourced? – Analyse what is needed, what you have to meet that need, and what additional resources you require to cover that need. … Does the tool provide sufficient guidance to apply it or does it require additional context? – It may be helpful to read and familiarize yourself with some of the background documents for some of the tools. 14 Introducing the WHO Quality Toolkit: supplemental overview Exploring the levels of the health system These functions within the national level usually fall to the ministry of health or other parallel governing bodies that provide support. Whether it be guidelines, accreditation, monitoring or licensing, the various responsibilities are reflected among nationally recognized entities which help support these functions and influence the quality of health services provided at facilities and at the point of care. The tools under each function include those that provide guidance for supporting policy development, as well as technical guidance to support improving quality of specific services and care settings, and tools to help implement improvement interventions or ways of measuring and evaluating improvement and quality of health services nationally. These tools can also help to address and execute key actions, as described in Quality health services: a planning guide, namely: 1. to establish a national commitment to improve quality of care; 2. to develop a national quality policy and strategy; 3. to select and prioritize a set of quality interventions; 4. to develop a pragmatic quality measurement framework; 5. to develop an operational and resourcing plan with key stakeholders. It is important to remember that although there are different levels within the health system, actions taken at any one level will impact and affect the other levels of the health system. Activities targeted nationally have direct or indirect impacts at both the sub-national and local levels, but should also be responsive and inclusive of the needs at the community level. National The national level of the health system provides broad support and guidance across the country, with the bulk of responsibility lying with national government (and the ministry of health in particular). However, it is important to acknowledge other entities, including private sector stakeholders, that also provide services, care and support on a national scale, as well as other national bodies that may play key roles in assuring quality of care and governance. Many ministries of health recognize the importance of defining core values that address the needs of their populations in terms of health care. This is fundamental to the purpose and goals of the health care system and aligns decision-making and how the system works with planning and delivery structures, governance mechanisms, and operational and administrative functions. This section of the Quality Toolkit contains tools that support the following functions at this level:
National strategic direction on quality
Standards supporting quality
Oversight and regulation
Improvement interventions
Measurement and evaluation
Engagement. 15Exploring the levels of the health system These functions at the sub-national level may also play a helpful role in addressing and carrying out key activities to implement a plan that specifically looks at the functions of a district,9 or the most proximal responsible administrative post to referral hospitals for a given area. The WHO quality health services: a planning guide provides further detail on the following key activities to consider at the district level, when supporting efforts to improve quality of care. 1. Align district commitment to national quality goals and priorities. 2. Develop district quality structures and an operational plan (where they already exist, update them based on learning from health facilities and national direction). 3. Orient health facilities to district and national-level quality goals and priorities. 4. Respond to facility needs in reaching selected aims and ensure functioning support systems for quality health services. 5. Maintain engagement with the national level on health services. 6. Adapt any quality intervention packages to the district-level context. As with all levels within the health system, actions taken at any one level will impact and affect the other levels of the health system. Interventions at this level will usually, though not always, be informed or influenced by the national level (through strategic national direction, standards and guidelines) and will directly influence and impact facilities and communities. 9 As defined in the Quality health services: a planning guide: a clearly defined administrative area, where there are local government and administrative structures that take over many of the responsibilities from the national government and where there is a general hospital for referral. Sub-national/district The sub-national level should be defined in accordance with local jurisdictions. It usually encompasses geographical areas within the country, such as provinces, regions, districts or counties, which provide some health administrative function for a specific population. The weight of responsibility will also vary from country to country based on the division of roles among the various entities and authorities within the country. For example, in centralized health systems, the central government plays a strong role that is supported by proximal administrative points to facilities. However, in decentralized systems, the central government generally supports the sub-national levels in applying consensus guidance, policy, and regulation from the national level. How this is applied is determined at sub-national levels. There are also autonomous systems which provide their support independently of the central government. In addition to these types of system differences, health system fragmentation may also exist with a division of certain programmes or functions of the health system. All these parameters need to be considered carefully when planning the use of tools for activities at the sub-national level. This section contains tools that support the following functions at this level:
Standards supporting quality
Oversight and regulation
Management, operational and supervision support
Improvement interventions
Measurement and evaluation
Engagement. 16 Introducing the WHO Quality Toolkit: supplemental overview These functions will apply to a range of stakeholders at the facility level, from administrative management/support to middle management in clinical departments, to health workers interacting directly with patients, as well as quality improvement teams. The tools in this level will help you to consider and implement activities that support improving quality of care at the facility level. These tools help in the development of action plans related to identified aims to improve quality of care. The tools are useful to support important activities at the facility-level for improving quality of health services at the point of care that are described in the Quality health services: a planning guide. It describes how facility leaders: 1. commit to district aims and identify clear facility improvement aim(s); 2. establish, organize and support multidisciplinary quality improvement (QI) teams – prepare for action; 3. conduct situational analysis/baseline assessment to identify gaps; 4. adopt standards of care; 5. identify QI activities and develop an action plan; 6. implement the QI action plan; 7. undertake the continuous measurement of outcomes; 8. focus on continuous improvement – sustain improvements and refine action plans. The actions taken at the national and sub- national levels will impact and affect the facility level. Likewise, facility level action and learning should inform the decisions and actions at the national and sub-national levels, respectively. As with other levels of the health system, engagement of communities is of great importance, particularly because of the proximity of communities being served by health facilities. Facility The health facility is where quality health services are provided to populations. This includes a wide range of settings, including small to large hospitals, clinics and primary care centres, among others, covered by public, faith-based, private-for-profit and private not-for- profit sectors in both rural and urban areas. The health facility also covers ambulatory services and is the point of organization for community-based and outreach services. This section contains tools that support the following functions at this level:
Standards supporting quality
Management, operational and supervision support
Improvement interventions
Measurement and evaluation
Engagement. 17Exploring the levels of the health system In reality, communities are usually a combination of the above and it is important to recognize who initiates community-building and why, and what the shared purpose or goal is. Please refer to the Community engagement framework for quality, people-centred and resilient health services (8) for further information on community engagement. Of note, it is also imperative to incorporate engagement approaches into all levels of the health system, as appropriate, particularly at the facility level, through community- based efforts. This section contains tools that support the following functions at this level, namely regarding: ƒ engagement ƒ improvement interventions ƒ measurement and evaluation. Community Within this Toolkit, “community” is defined as “a specific group of people who share a common culture, values and norms, identity, interest, action, place, practice, or circumstance, and are arranged in social connection according to relationships which have developed over a period of time and may be modified in the future”(6,7). As a consequence of COVID-19 restrictions more and more communities are being formed and developed through social media and virtual platforms. Communities can be:
communities of interest: people who share the same interest or experiences;
communities of action: people trying to collaborate and bring about change;
communities of place: people brought together by geographic boundaries ;
communities of practice: people in the same profession or learning together;
communities of circumstance: people brought together by external events/situations. 18 Introducing the WHO Quality Toolkit: supplemental overview Exploring key functions to address quality of care in the health system 1. National strategic direction on quality National level leadership, ownership and action are required to guide, support and sustain improvement, making national efforts to articulate the strategic direction on quality health services important. The WHO handbook on national quality policy and strategy is a key resource that provides support for this (9). This handbook provides an overview of eight interrelated elements that countries can consider when developing national policy and strategy. FIGURE 4. EIGHT ELEMENTS IN DEVELOPING NATIONAL QUALITY POLICY AND STRATEGY The tools in this section of the Quality Toolkit help to action and support tasks related to these eight elements. Each of these interdependent elements help to provide a strong foundation for a coordinated national direction to improve the quality of health services nationally. It is important to integrate other relevant approaches and initiatives from across the health system, notably national strategic initiatives related to quality of health services for specific conditions or populations. Of note within this eight-element approach is the need to select a multi-level set of interventions for improving quality of care. While the selection of a set of interventions will often take place at the national level, their implementation has implications across each level of the health system, so relevant implementation tools for quality interventions are also highlighted in the sub-national (district) and facility sections of the Toolkit. National health priorities Governance and organizational structure Local definition of quality Improvement methods & interventions Stakeholder mapping & engagement Health management information systems & data systems Situational analysis Quality indicators & core measures 19Exploring key functions to address quality of care in the health system The tools in this section help to support stakeholders who work on national policy or strategy development and its associated operational planning and implementation. Tools will be of particular interest to the ministry of health but would also be important for entities supporting this work, such as supporting agencies, partners and a range of stakeholders (including civil society and communities). It is important to note that although these tools are largely targeted at the national level, they may also be applicable at other administrative levels in the health system, particularly in decentralized health systems where sub-national authorities may look to set strategic direction on quality. There is also the need for an adapted approach to setting strategic direction for quality in fragile, conflict-affected, and vulnerable (FCV) settings, where national authorities may not function, as they do in stable settings. Considerations for adapting the NQPS approach to FCV settings are outlined in Quality of care in fragile, conflict-affected and vulnerable settings: taking action and its associated Tools and resources compendium (10,11). 2. Standards supporting quality Setting clinical standards is an important task in supporting quality of health services in line with national strategic direction. These standards are applied to influence practices and services provided at the facility level. The tools included support the development and use of standards based on guidelines from across WHO technical programmes. Although all applicable standards and associated guidelines produced by WHO are relevant, this Toolkit focuses more on those materials that directly contribute to the specific attributes of quality of care. Use of these tools within any country will require a review/assessment of the current clinical standards in place and the modifications needed to update these. Updating standards periodically should be based on the latest evidence and assessment of health system performance through measurement and evaluation. The Toolkit includes a selection of materials to aid in clinical care and improvement processes, adaptation and development of those standards, as well as the planning necessary to effectively roll out these clinical standards. These tools will be applicable to national, sub-national and facility levels, as well as to other parallel bodies, which set clinical standards based on evidence-based guidelines. Agencies that provide this technical support domestically and internationally would also find these tools helpful. Although these entities would most directly conduct this work, input from across the health system would help to better ground adapted standards to the context within the country. Although standards help to establish benchmarks, they may need to be supplemented with relevant guidelines to help achieve those standards. For a collation of recent guidelines WHO has created a database of all publications which can be referenced online at https://www.who.int/publications/who-guidelines. WHO has worked to gather and review the evidence to help develop these guidelines across a number of technical areas in order to provide a basis for quality service provision, medication and medical device use, diagnostic and laboratory practices, as well as engaging people and communities to improve the interaction between populations and their health system. 20 Introducing the WHO Quality Toolkit: supplemental overview 3. Oversight and regulation Both oversight and regulation provide important functions to help assure quality performance and maintain public trust, through transparency and assurance. This may be accomplished at the central level through various means, via the ministry of health, parallel governing bodies and/or sub-national/district-level authorities/offices. These activities can help to focus attention and efforts on the improvements felt to be needed, but also work to maintain any gains made in the quality of health services. These tools aim to provide support for agencies responsible for oversight activities and those which define regulations and monitor their compliance. In line with the purpose of this Toolkit, you will find tools that focus on aspects of oversight and regulation that specifically relate to quality of care. However, the application of other oversight and regulatory functions may be transferrable to this work as well. In order to implement these tools, a thorough understanding of the standards supporting quality of care should be considered in their application. This will also require the input and participation of local level stakeholders in facilities, as well as the communities, families and people who receive and rely on the care provided by the health system. These functions will also require and benefit from data and information generated through measurement and evaluation of the quality of health services. 4. Management, operational and supervision support This section contains tools relevant to three important managerial functions at both the sub-national/district level as well as the facility level which relate to management, operation, and supervision support (MOSS). This helps managers to organize their work in such a way as to strengthen and support the quality of health services. The optimal management of resources (including human, financial and other assets) is key to developing and maintaining the quality of health services. Without this administrative management, hindrances may be felt at the point of care by either lack of supplies or equipment, staffing or facilities. It is important to acknowledge that there are skills and knowledge that are required among managers working to support this key activity in the health system. Operational support refers to functions that assist the daily work of providing care, which can include facilities operation, utilities, logistics, as well as service delivery processes. These two functions (management and operation) are usually carried out hand-in-hand and have the critical role of ensuring that the structures necessary to support health services are available and functional to provide quality health services. In addition, supervision support can help individuals charged with supervisory roles who help lead teams, such as QI teams, within the health facility. A supervisor is seen as a mentor, leader, team member and person who cooperates with a multidisciplinary team to drive positive change and improvement within the facility or institution. Individuals in these positions will have their own skills and knowledge built upon experience, while continuously staying updated on the latest evidence and information through available education and training opportunities. Familiarity with national and sub-national level guidance and direction is important for supervisors to be aligned with wider initiatives and priorities across the country. The tools in this section aim to support the execution of management functions, support personnel in implementing initiatives required to improve and maintain the quality of health services with respect to day-to-day work, and aid supervisors in 21Exploring key functions to address quality of care in the health system their supervisory roles and engagement with patients, families, and communities – all relating to supporting quality of health services. MOSS at the sub-national level is targeted at administrative offices that support health facilities within its jurisdiction, while its application at the facility level is more proximal to its direct support of the provision of care. This may include ensuring access and proper use of basic utilities, supplies, equipment, pharmaceuticals and staffing, as well as how these factors work together in a way that support quality of health services across different facilities. This will require knowledge of operational support activities, improvement interventions that may be implemented, requirements set forth under oversight and regulation, and the data that can inform strategic decision-making through measurement and evaluation of the work in delivering care and services. Managers will likely be working with collaborators at the facility as well as national levels. Being aware of resources and direction from the national level has clear implications on the work to be supported at the facility level. 5. Improvement interventions Improvement interventions are actions taken at different health system levels to improve quality of health services. The WHO Handbook for national quality policy and strategy and the report Delivering quality health services produced jointly by WHO, OECD and the World Bank outline the need for action across four broad intervention areas (12), namely: ƒ shaping the system environment ƒ reducing harm ƒ improving clinical care ƒ engaging and empowering patients, families and communities. The WHO technical package for quality of care in FCV settings outlines an additional set of interventions recommended to ensure access and basic infrastructure for quality of care, which may be particularly applicable in challenging settings. Emphasis is placed on selecting pragmatic interventions that address local quality challenges, are feasible and cost-effective within each given context, and that come together in a coherent manner across different health system levels, to support planning for quality, assurance and improvement. While the national level will have a key role in selecting a set of interventions and implementing many of them, implementation will often touch each level of the health system. Interventions are also likely to span complex, multi-stakeholder actions right through to the application of discrete tools at the point of care. More detail on interventions is available in the WHO handbook for national quality policy and strategy and its accompanying Tools and resources compendium. Tools may support broad approaches, such as the plan-do-study-act (PDSA) model or root-cause analysis that help to define systems weaknesses in order to understand quality variations. There are also very specific improvement interventions that aim to improve some specific service provision, practice, or approach in care delivery. In both cases, people who both develop and implement improvement interventions would benefit from the tools in this section. The tools in this section aim to support you to identify quality issues and act in a systemic manner to address and bring about improvement to the issues, documenting the process and means to evaluate the result for subsequent action. The application of these tools can guide improvement efforts, as well as support innovative improvement 22 Introducing the WHO Quality Toolkit: supplemental overview approaches that have shown promise in practice. Capturing the lessons of the application and implementation of these interventions is important through an active focus on learning. Measurement and evaluation efforts can help inform whether an intervention was successful with the potential to lead to positive impact or provide important lessons for future application. Improvement interventions at the national level are likely to directly affect the sub- national level aimed to help support administrative and operational functions that impact facilities under their jurisdiction. Working in a decentralized or autonomous region sub-nationally still requires review of the improvement interventions from the national level. Improvement interventions at the sub-national level are aimed to help support administrative and operational functions that impact their respective facilities under their jurisdiction. At the facility level, these tools may support you to strengthen the capacity of staff and apply improvement interventions. Having close coordination between facilities in developing and implementing improvement interventions and the engagement of communities, is also important to build and strengthen trust and accountability with those being served by those respective facilities. This key function allows there to be a mechanism for accountability and identifying gaps from standards and adherence to relevant guidelines. Improvement interventions also help engage the community as empowered agents to contribute to improving health services across the health system. This can also inform and empower people to understand the quality of health services provided and how to advocate for improvements where necessary, to strengthen the health system. Improvement interventions at the community level are aimed to help support and feed priorities back from the community to improve and offer recommendations which may be applicable at the national, sub-national, and/ or facility levels. 6. Measurement and evaluation Measurement and evaluation provide the means to assess the quality of health services and generate the information necessary to inform subsequent plans and actions, either to maintain or improve aspects of quality health services. At the national and sub- national levels, this information helps to feed and drive informed decision-making, policy, and transparency, thereby strengthening trust of communities broadly. At the facility level, this information supports informed decision-making at the point of care. At the community level, this information helps to feed and drive people-centred considerations in improving health services – ensuring that these perspectives are also considered among other metrics for assessing health service quality. Purposefully engaging the community will help to strengthen accountability and trust in the quality of health services provided and allow systems to respond to the needs and expectations of those communities. Most countries will already have some form of monitoring and evaluation, or information system, built into their health system. Quality measurement efforts should align, where possible, with these broader system-wide efforts. Of note is WHO’s Primary health care monitoring and evaluation framework, which proposes a core set of indicators for all countries to integrate in their health system measurement approaches, as well as a series of additional indicators that can support more detailed efforts on health systems monitoring and improvement, in different technical areas (13). While the measurement tools within this Toolkit draw on a large existing body of work from WHO, the PHC monitoring and evaluation framework is seen as a foundational resource from which countries should work, representing a consolidated list of global indicators that can inform efforts to improve the quality of health services. 23Exploring key functions to address quality of care in the health system FIGURE 5. APPROACH TO MEASUREMENT OF QUALITY OF CARE TO SUPPORT NATIONAL STRATEGIC DIRECTION *Global lists such as the WHO PHC M&E Framework Being able to critically review and contextualize measurement frameworks, to balance the need for data with the burden of data collection, is important. Beyond the selection of indicators, a critical consideration for measurement efforts at all levels is how the information gathered can then be used to inform improvement processes. Regarding the measurement and evaluation of the quality of health services, it is important to be able to answer some key questions. 1. What is being measured/evaluated? 2. Why is it being measured/evaluated? a. Is this useful and practical? If so, for whom and why? b. How will the information generated through the measurement/evaluation be used to drive improvement? 3. How is it being measured/evaluated? 4. When, or how often, is it being measured/evaluated? The tools in this section will help those who develop these measurement frameworks to apply them in practice and use them to inform decision-makers. Those involved in creating these systems or using them would benefit from the use of these tools. A systematic approach can help to better organize your measurement approach to be lean, efficient and effective, thereby informing the key actions that need to be taken, without being a burden to health care workers. Figure 5 illustrates one such approach that helps frame the tools within this section. The three steps consider the national strategic direction on quality, which can inform the quality measurement approach and subsequent use of the data. The approach can help guide the organization, selection and visualization of indicators and data to inform strategic decision-making for taking action on quality. This should be considered across the entire health system and will be applicable to each level, from national, through to the facility and community. Nationally, this information can inform the national strategic direction on quality, update/modify or develop standards supporting quality of care and guidelines for quality of care, as well as inform oversight and regulatory authorities. Sub-nationally and locally in facilities, this information can inform management, operational and supervision support, hold improvement interventions accountable and build trust in engagement with communities. Consider National Strategic Direction on Quality1 Quality Measurement Approach2 Use the Data3 … Align national priorities … Define quality … Engage all key stakeholders … Refer to Situational Analysis … Defined governance structure and processes … Align improvement methods and Interventions … Align health management information system and data systems Define a Framework for Quality Measurement Map Quality Indicators and Sources Selecting Quality Indicators Implement and Refine Analyze and Visualize the Data ƒ What do we need to measure? ƒ How can indicators be organized? ƒ What is a priority? ƒ Is the data used by all stakeholders? ƒ Does the data contribute to informed decision making to improve care? ƒ Are lessons captured and learned for continuous quality improvement? ƒ What is currently collected? ƒ Is it of sufficient quality? ƒ Do indicators meet criteria? ƒ Can the framework be filled with existing indicators and those from global lists* ƒ How will data be used for improvement? ƒ Where should implementation start? ƒ Is the data user friendly? ƒ Does it tell a story? ƒ Does it answer important questions to improve quality of care? 24 Introducing the WHO Quality Toolkit: supplemental overview 7. Engagement Engagement occurs at all levels and in various processes focused on improving the quality of health services. This may include engaging various departments within the ministry of health, but also the possibility of engaging other ministries and private sector stakeholders at the national level. At the sub-national level this may include engaging various departments or agencies within respective sub-national/district structure, while at the facility level this may require engaging with various departments in that facility. Engagement across the levels is important also, as well as external engagement among other partners, facility leads and private sector stakeholders. Special attention should also be given to engaging with communities. These relationships work together through a process that is founded in empowerment, health promotion, health equity, gender equality, human rights and in the widest possible sense, planetary health. The process of working together is navigated through various interrelated aspects, at all levels of the system, with a focus on human interaction. These include having: ƒ compatible values, vision and purpose; ƒ interactions that are based on compassion, respect, and dignity; ƒ widespread, active and inclusive participation; ƒ equitable, conjoined decision-making; and ƒ an equitable and dynamic flow of power, control and resources. Engagement is thus seen as a set of competencies and skills to support the emergence of collaborative action and partnership-building. WHO continues to work in this area and anticipates having further tools and resources as research and evidence continues to emerge in this arena. This function allows for effective collaboration from multiple stakeholders to accomplish a shared vision. 25References References 1. Quality health services: a planning guide. 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