How to do (or not to do) … using the standardized patient method to measure clinical quality of care in LMIC health facilities

Abstract

Standardized patients (SPs), i.e. mystery shoppers for healthcare providers, are increasingly used as a tool to measure quality of clinical care, particularly in low- and middle-income countries where medical record abstraction is unlikely to be feasible. The SP method allows care to be observed without the provider’s knowledge, removing concerns about the Hawthorne effect, and means that providers can be directly compared against each other. However, their undercover nature means that there are methodological and ethical challenges beyond those found in normal fieldwork. We draw on a systematic review and our own experience of implementing such studies to discuss six key steps in designing and executing SP studies in healthcare facilities, which are more complex than those in retail settings. Researchers must carefully choose the symptoms or conditions the SPs will present in order to minimize potential harm to fieldworkers, reduce the risk of detection and ensure that there is a meaningful measure of clinical care. They must carefully define the types of outcomes to be documented, develop the study scripts and questionnaires, and adopt an appropriate sampling strategy. Particular attention is required to ethical considerations and to assessing detection by providers. Such studies require thorough planning, piloting and training, and a dedicated and engaged field team. With sufficient effort, SP studies can provide uniquely rich data, giving insights into how care is provided which is of great value to both researchers and policymakers.

Use of standardised patients for healthcare quality research in low- and middle-income countries

“…We make three further observations. First, these resources complement our recent practical overview of SP implementation in the field 17. Second, this article’s focus is on the econometrics and statistics of the SP method with most examples drawn from our own studies in low-income and middle-income countries (LMICs).…”

Using unannounced standardised patients to obtain data on quality of care in low-income and middle-income countries: key challenges and opportunities

“…their symptoms, gender, age). In most studies, 5% or fewer of SPs are correctly suspected by providers of being ‘fake’ patients 9…”

“…An important challenge with SPs is the scope of conditions that can be investigated. The SP method is only feasible for conditions that do not require physiological symptoms to be evident or invasive examinations to be performed: family planning request, cold, diarrhoea, tuberculosis or angina are examples of cases popular in SP studies in LMICs 9. However, the spread of mhealth technology may allow SPs to show providers ‘faked’ results on a mobile phone, and therefore, allow for an expansion of SP cases 12…”

“…While there are clear limits around the types of conditions that are suitable for SPs, the method has produced accurate measurements of the quality of care across a reasonably broad range of single encounters in LMIC settings 17. That being said, there is a need, to find ways to extend the SP method for multiple, sequential visits to the same provider for chronic conditions 8 9…”

“…In a paper published in BMJ Global Health, Kwan et al discussed the different types of research questions that can be addressed using SPs, and the various methodological and analytical issues to consider 8. In a recent complementary paper, King et al provide a step-by-step ‘how to’ guide for planning and implementing an SP study 9. The two papers, and the detailed field manual provided by Kwan et al in their appendix, combine to make a valuable set of resources for researchers using the SP method.…”