Health Reform in Kyrgyzstan

1
The Field of Improvement An Approach to Removing
Barriers to Quality Bruno Bouchet, MD,
MPH Regional Quality of Care Director ZdravPlus
Project
2
Outline

• Fundamental Improvement Concept
• 3 targets for changes
• 3 types of barriers
• Modern Management of Improvements
• Conclusion

3
Fundamental improvement concept

• Every System is perfectly designed to achieve
  the results it achieves
• (Donald Berwick, IHI)
• Health outcomes and performance is a
  characteristic of the system
• the way it is designed
• the organization of healthcare services
• the care delivered

4
Fundamental improvement concept

• No improvement in quality will happen without
  changes in the healthcare system
• Results
  Changes
• The field of improvement is about the management
  of changes

5
Three Targets for Changes

• Healthcare Providers (change practices, so that
  the care is based on scientific evidence)
• Patients Population (change lifestyle, use of
  services and demand for care)
• Health System (change structure, decision making,
  organization of services, financing)

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Main Barriers with Providers

• Knowledge
• Medicine
• Epidemiology, statistics, research
• Knowledge management
• Skills
• Clinical skills
• Critical thinking
• Attitude
• Skepticism
• Authoritative
• Fear
• Personal characteristics
• Age
• Motivation

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Main Barriers with Patients

• Information
• On clinical care
• On healthy lifestyle and risk factors
• On rights and responsibilities
• Beliefs
• On diseases
• On treatments
• Demand
• For drugs
• For use of services, referral
• Preferences
• Family Medicine vs. Specialist
• Ambulatory vs. in-patient care

8
Main Barriers with Systems

• Structure/Resources
• Overall design not adapted to needs
• Facility resources inconsistent with guidelines
• Centralized allocation of resources limits field
  adaptability
• Organization of Services
• Duplication of vertical structures
• Fragmented care
• Centralized decision-making
• Financing
• Insufficient budget
• Inefficient use of money
• Care not reimbursed
• Regulations
• Contradictions in regulations
• Unrealistic expectations
• Not evidence-based
• Unclear processes

9
System Changes for the IMCI Standard
We need to reorganize our work assignments and
flow of patients
We need to teach IMCI in pre-service and post
graduate institutes
We need to train the supervisors in IMCI and
change the health information system
We need to buy a timer
IMCI Standard
We need to update our essential drug policy
We need to change children medical records and
develop a specific job-aid
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Techniques and Tools
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Conclusion

• The field of improvement can help identify and
  remove barriers to quality, but
• It requires a change in management