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PROQUALI 

Collaborating Partners: Secretariats of Health in Bahia and Ceará, JHPIEGO, Johns Hopkins University/Center for Communication Programs, Management Sciences for Health/Family Planning Management Development

In northeastern Brazil, the PROQUALI (Performance and Quality Improvement) project, which is funded by USAID and implemented by the state Secretariats of Health and three Cooperating Agencies, has used a multi-agency collaborative performance improvement approach to increase access to and improve the quality of reproductive health (RH) services at primary healthcare clinics. Since 1996, this project has followed the 5-step performance improvement process.

1. Performance Analysis

Desired performance was defined through the establishment of achievable quality criteria in each of the following areas:

• Reproductive Healthcare

• Infection Prevention

• Counseling Resources and Practices

• Physical Resources and Supplies

• Management System

At the start of the project, performance at the clinics was analyzed to determine how close each was to meeting the established criteria. The overall percentage of criteria met at baseline ranged from 5% in the lowest performing clinic to 30% in the highest performing site, reflecting a significant performance gap.

2. Root Cause Analysis

PROQUALI identified one or more of the following causes for performance gaps in each clinic:

• Lack of basic equipment and medical supplies

• Lack of client-centered approach

• Ineffective management practices

• Low employee motivation and morale

• Limited capability of nonphysician providers (the primary RH care providers in many locations)

• Lack of provider clinical knowledge and skills

3. Intervention Selection

The PROQUALI project has selected multiple interventions which include:

• Clarification of job expectations: Establishment and dissemination of minimum standards for quality performance

 

• Training and technical assistance: Increasing provider and clinic capacity to perform at a minimum quality standard

 

• Facility improvements: Development of logistics systems, management and facilities changes

 

• Rewards and recognition: Institutionalization of an accreditation system to motivate, support and reinforce continuous learning and sustained performance and quality improvement

4. Implementation

Self-assessment, external assessments, monthly progress review meetings and client feedback are components of PROQUALI’s ongoing monitoring process. These activities allow for performance and quality improvement interventions to be continuously selected, designed (or adapted) and implemented to address the remaining gaps. In addition, results from accreditation assessments along with the reproductive health service guidelines, are used to guide and monitor performance and quality improvement efforts in participating health clinics. Supervisors, acting as quality improvement teams, also support change using stakeholder analysis and management techniques and resource mobilization.

5. Monitoring and Evaluation of Performance

At the end of an 18-month demonstration project, four of the five participating clinics received accreditation meeting 95% to 98% of the performance criteria. A dramatic increase in service quality was observed within all five participating health clinics. Performance improvements were most substantial in clinics that were performing at a moderate to high level at baseline, where the internal champion for the project was someone in a formal position of power, and where the least amount of staff resistance or conflict occurred. Financial support from state and local governments for commodities and staff increased as a direct result of these interventions. Positive changes in client satisfaction, service delivery and utilization statistics were also observed. A second phase of the project will focus on developing cost-effective strategies for reaching the desired goal of expanding quality statewide.

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