The process dimensions relate to whether appropriate care and management of the patient is carried out. Many of the aspects of safety and effectiveness are captured as processes. For example:
- What harm might a pregnant women and her baby be exposed to if she receives too many internal examinations during labour?
- What are the attitudes of staff toward pregnant women?
- Has the management of a case of eclampsia fulfilled all the essential criteria included in evidence based standards?
In comparison to structural dimensions, which tend to relate to the availability of resources, process dimensions can be more subjective and therefore rely on a broader range of data sources. Some of the approaches already discussed can provide information on processes of care. For example, the fourth group of questions answered by the SPA surveys assesses the satisfaction of clients and service providers with the service delivery environment.
We will look at two examples of the process dimensions of quality and management next:
- The acceptability of care, which we looked at briefly in Section C.
- The provision of care.
Acceptability can be measured quantitatively, for example by using waiting times or prolonged labour as a proxy. Other aspects of acceptability can be captured using qualitative approaches as we shall see on the next page.
Acceptability of services
The acceptability of services generally refers to the acceptability to the client, which is likely to have an impact on their use of a service. However, other stakeholders may also have constructs of acceptability, whether stated or not, which could have impact on the quality of services provided and accessed.
These may include cultural, such as gender-based, and/or faith based constructs, and expectations at a community or community leadership level. They may also include professional or individual service provider constructs of the acceptability of certain services and/or certain client groups.
In such instances guidelines and standards should be in place to clarify expectations of service providers but social and professional ‘norms’ and biases can develop, for example around the provision of family planning or safe abortion care services to younger clients.
Capturing acceptability to clients implies that we are looking to understand needs and expectations, behaviours and how choices are made. The experiences that women and their families have of maternity care and other factors can affect decision making.
Some aspects of acceptability can be measured using quantitative approaches, for example by measuring waiting times or prolonged labour as a proxy and comparing these to a benchmark of what is acceptable to clients and other stakeholders. In these instances there may also be standards and guidelines in place and acceptability can be assessed against these expectations.
Other aspects of client acceptability need to be captured qualitatively. Aspects of acceptability such as understanding attitudes and experiences may be more suited to qualitative approaches.
Studies to explore issues of acceptability aim to inform the development of MNH services that will increase the use of services and meet the needs of women and their families. Such studies can have a varied scope, looking for example at the acceptability of one particular service with a package of services or the acceptability of the concept of a service such as the use of family planning or facility based delivery.
Increasingly the information available from studies is being used to develop toolkits and best practices guidelines to promote client participation and acceptance. For example, the UK Royal College of Obstetricians and Gynaecologists have developed Service Standards for Sexual and Reproductive Healthcare informed by a patient experience and feedback survey.
The setting of standards, with participatory reviews, increases the ability to measure and assess acceptability and other aspects of quality improvement strategies. CDC in the USA have produced a toolkit for ensuring the inclusion of patient perspectives in HIV screening.
Provision of care
Measuring the quality of the actual provision of care can also require both qualitative and quantitative methodologies. In most instances guidelines and operating procedures will be in place to outline expected minimum standards and/or best practices in the provision of services. These will cover specific clinical care and may also include other expectations such as client flows and ‘customer servicing’ aspects of the provision of care. The latter can form quality indicators and, as with acceptability of services, qualitative methods can be used to assess these.
Capturing and quantifying data and information on the correct provision of services, from a clinical and safety perspective, can be challenging. Some facility assessments will include this and provide a snapshot at that time. Similarly, clinical audits and other forms of assessment or observation can provide data and information; some of which can form the basis for trend analysis if undertaken routinely.
Reviewing and analysing clinical complication rates, where records and other limiting factors allow, is used in many instances as a proxy indicator for the quality of care provided: Often with the assumption that high clinical complication rates are indicative of poor quality services. This assumption should be viewed with caution in settings where the reporting of clinical complications may not be accurate or in referral centres receiving complex clinical cases.
We have looked at audit and maternal death reviews in an earlier learning unit as a mechanism to improve professional practice and quality of care (see Section B). Audit studies seek to understand what and how care is provided, usually by an expert panel reviewing clinical records and assessing recorded practices against standards or norms.
The unique feature of audit is that it has a dual function: improving quality as well as capturing different processes. An audit can assess effectiveness, for instance by capturing provider practice, as measured against standards. Audit can also give insights into whether services are safe or acceptable. If healthcare providers are conducting unnecessary internal examinations during labour, this could be an indication of unsafe practice (because it introduces infection) or unacceptable practice (as women find it uncomfortable). Community audits, where members of the community rather than health professionals conduct audit, can provide valuable insights into issues of accessibility and acceptability. Read more about community audits (further reading).
Audit findings can either be reported qualitatively, as a description of events, or quantitatively.
- Centers for Disease Control and Prevention (CDC), (2012) Evaluation Toolkit: Patient and Provider Perspectives about Routine HIV Screening in Health Care Settings
- Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists, (2013) Service Standards for Sexual and Reproductive Healthcare
- The DHS Program, (Website) Service Provision Assessment (SPA) survey