Validation of a New Method for Testing Provider Clinical Quality in Rural Settings in Low- and Middle-Income Countries: The Observed Simulated Patient

Abstract

BackgroundAssessing the quality of care provided by individual health practitioners is critical to identifying possible risks to the health of the public. However, existing assessment methods can be inaccurate, expensive, or infeasible in many developing country settings, particularly in rural areas and especially for children. Following an assessment of the strengths and weaknesses of the existing methods for provider assessment, we developed a synthesis method combining components of direct observation, clinical vignettes, and medical mannequins which we have termed “Observed Simulated Patient” or OSP. An OSP assessment involves a trained actor playing the role of a ‘mother’, a life-size doll representing a 5-year old boy, and a trained observer. The provider being assessed was informed in advance of the role-playing, and told to conduct the diagnosis and treatment as he normally would while verbally describing the examinations.Methodology/Principal FindingsWe tested the validity of OSP by conducting parallel scoring of medical providers in Myanmar, assessing the quality of their diagnosis and treatment of pediatric malaria, first by direct observation of true patients and second by OSP. Data were collected from 20 private independent medical practitioners in Mon and Kayin States, Myanmar between December 26, 2010 and January 12, 2011. All areas of assessment showed agreement between OSP and direct observation above 90% except for history taking related to past experience with malaria medicines. In this area, providers did not ask questions of the OSP to the same degree that they questioned real patients (agreement 82.8%).Conclusions/SignificanceThe OSP methodology may provide a valuable option for quality assessment of providers in places, or for health conditions, where other assessment tools are unworkable.

Quality of care: measuring a neglected driver of improved health

“…The tools available for assessment of provision of clinical care include standardized patients, clinical vignettes, abstraction of medical records, simulations or clinical drills, and direct clinical observations 42 . Standardized patients are trained actors who make an unannounced visit to a health-care facility and present symptoms of a simulated condition; they complete an assessment checklist on the clinical actions of the provider after the visit 42 . In clinical vignettes, practitioners follow a written clinical case, responding to questions that replicate certain stages of an actual clinic visit, such as taking a history, ordering tests and prescribing a treatment plan.…”

“…Abstraction of medical records to identify standards-based practice is a common way of evaluating clinical performance; however, its validity is undermined by the lack and inconsistency of records in resource-constrained settings. Also these data are often collected by trained health personnel, making it an expensive tasks 42 . Audits, such as morbidity and mortality reviews, can also provide valuable insights into quality failures.…”

Private sector delivery of health services in developing countries: a mixed-methods study on quality assurance in social franchises

“…Process quality, the interactions between a patient and client, is more likely to explain a variance in health outcomes than is structural quality [17] and there are a number of tested methodologies for assessing process quality that would be applicable in settings where franchises operate. The use of clinical vignettes and observed simulated patients (OSP) are two methodologies that have been used successfully in low-resource and rural settings that may be practical tools for franchises to assess process quality [18-20]. Many franchises also used clinical audits as part of their quality assurance process; audits are widely used in low-resource settings [21], and can provide a measure of some clinical practices, such as what treatments are prescribed [22].…”

Development of a human-like neurologic model to simulate the influences of diseases for neurologic examination training

“…As an individual who is trained to act as a real patient, SPs can simulate series of symptoms and give the trainee an active training [6]. Taking advantage of SPs, more benefits are brought to the medical training.…”