A learning health systems approach to improving the quality of care for patients in South Asia

Abstract

Poor quality of care is a leading cause of excess morbidity and mortality in low-and middleincome countries (LMICs). Improving the quality of healthcare is complex, and requires an interdisciplinary team equipped with the skills to design, implement and analyse settingrelevant improvement interventions. Such capacity is limited in many LMICs. However, training for healthcare workers in quality improvement (QI) methodology without buy-in from multidisciplinary stakeholders and without identifying setting-specific priorities is unlikely to be successful. The Care Quality Improvement Network (CQIN) was established between Network for Improving Critical care Systems and Training (NICST) and University College London Centre for Perioperative Medicine, with the aim of building capacity for research and QI. A two-day international workshop, in collaboration with the College of Surgeons of Sri Lanka, was conducted to address the above deficits. Innovatively, the CQIN adopts a learning health systems (LHS) approach to improving care by leveraging information captured through the NICST electronic multi-centre acute and critical care surveillance platform. Fifty-two delegates from across the CQIN representing clinical, civic and academic healthcare stakeholders from six countries attended the workshop. Mapping of care processes enabled identification of barriers and drivers to the delivery of care and facilitated the selection of feasible QI methods and matrices. Six projects, reflecting key priorities for improving the delivery of acute care in Asia, were collaboratively developed: improving assessment of postoperative pain; optimising sedation in critical care; refining referral of deteriorating patients; reducing surgical site infection after caesarean section; reducing surgical site infection after elective general surgery; and improving provision of timely electrocardiogram recording for patients presenting with signs of acute myocardial infarction. Future project implementation and evaluation will be supported with resources and expertise from the CQIN partners. This LHS approach to building capacity for QI may be of interest to others seeing to improve care in LMICs.

Aiming for quality: a global compass for national learning systems

“…Poor quality of care is one of the leading causes of mortality in LMIC, and contributed to five million deaths based on data from the 2016 Global Burden of Disease study [ 118 ]. However, additional challenges are noted for LMIC, including limited resources to electronically collect data at the point of care and evaluate the impact of quality improvement initiatives on patient outcomes [ 119 ]. There is also little standardization of patient health records and hospital forms, which makes the use of routine clinical data a challenge [ 90 ].…”

“…Quality improvement initiatives in LMIC tend to be externally led, with limited insight into contextual barriers and/or lacking local evidence. It is important that learning systems include representation from interprofessional teams working at the point of care and that initiatives are adapted to the local context [ 105 , 119 ].…”

Quality evaluation and future priorities for delivering acute myocardial infarction care in Sri Lanka

“…Overcoming the barriers and bottlenecks to efficient organisational delivery of AMI care (both structure and process) is fundamental to improving the quality of care. 29Work already published by the authors as part of a health systems improvement network have highlighted additional bottlenecks in organisational structure, process and patient-centred- in care. 29 Focus groups held with frontline healthcare workers to map the pathways of AMI care revealed that diagnosis of AMI was delayed due to inconsistencies in patients’ timeliness of presentation, accessibility of ECG investigation for patients when presenting with the symptoms of syndromic acute coronary syndrome and delays in reporting of ECG.…”

Establishing a critical care network in Asia to improve care for critically ill patients in low- and middle-income countries

“…To date, in LMICs, QI initiatives have had limited success in achieving sustained change or have proven difficult to scale [5]. Quality improvement methods are generally neither an established part of medical education nor are they a priority investment for healthcare institutions in resource-limited settings [5,9].…”