Patient involvement in quality improvement in primary health care

[摘要] IntroductionThere has been little published in South Africa regarding quality improvement in health andin particular the involvement of patients in this intervention. There is evidence globally thatboth quality improvement efforts and particularly the engagement of the users adds value tohealth services.Three projects were conceived around this core concept as explained below.1. Systematic review. Patients’ involvement in improvement initiatives: a qualitativesystematic reviewAfter a search was done of databases, 5121 papers were found to be potentiallyrelevant. After screening and critical appraisal for eligibility, it was found that 31articles qualified for analysis. These were then assessed using JBI software and 5categories and 2 metasynthesised findings were documented. In summary, therewere enablers and barriers to involving patients. The five categories which lead tothese 2 findings were the following: (1) although patient participation in QI isacknowledged and encouraged by many policies and documents globally, it isdifficult to implement; (2) there are differing views between patients and providers asto the process; (3) on the positive side, different levels of involvement of patients inQI were demonstrated; 4) practical, appropriate and innovative results emerged; (5)individual or group support and incremental development through skills andenablement contributed towards success2. The Integration of Non Communicable Chronic Diseases (NCDs) and HIV/Aids andmental health care through the involvement of chronically ill patients usingEmpowerment Evaluation (EE).At 9 primary care clinics, the process of EE was followed with chronically ill stablepatients and appropriate healthcare workers. This was an additional intervention inan ongoing QI cycle on the integration of all chronic illnesses into one model, basedon Lean principles.Steps followed were '’taking stock’’ ie assessing patients’ and HCWs’ impressions ofthe services at the clinic in a measured way, creating a vision and using this as ayardstick for the project and then problems and solutions being co-managed by thecollaborative team. A total of 37 interventions were discussed and 23 implemented inthe time frame. Innovative solutions were implemented and teams were empoweredby the potential they experienced.3. An exploration of childhood nutrition and wellness in a subdistrict by patientinclusivity in QI using experience based codesign (EBCD) with mothers/caregivers ofmalnourished children .Following the steps of EBCD, staff and patients exposed to health services regardingill children, were interviewed, feedback was given of the findings separately and thenin a combined meeting and co-design teams were created to work with theprioritised quality improvement interventions. Touch points in the system wereexamined through emotional mapping, video interviews and observations. Within the10 month period of the project, 38 interventions were identified and 25 accepted andimplemented at different levels.ConclusionThe methodologies were chosen to fit with the qualitative aspect of the research.There were concrete appropriate improvement outcomes due to the engagement ofservice users in both the primary care clinics serving chronically ill patients and thepaediatric system in one subdistrict eg the flow of patients improved, logisticalimprovements like direct admissions for very ill children, school and libraryopportunities for admitted ill children etc occurred. Subjective gains like theacknowledgement of their power role by patients and a flattening of the healthcareworker hierarchy were also experienced in the research. Other findings were thatunexpected roleplayers were identified, the timeframe of such QI cycles needs to beconsidered especially regarding the resilience of patients and resources were not animportatn limitation. However some modifications would have to be considered tomake these research approaches common practice.The particular research methodologies have not been published in a South Africancontext before and have also not been used for paediatric or integrated chronicillness research and therefore contribute both content and process information tohealth systems research in South Africa.

[发布机构] University of the Witwatersrand