Safety and acceptability in quality improvement

Of the three aspects of quality in our definition of quality (safety, effectiveness and acceptability) more attention has been placed on the component of effectiveness in quality improvement strategies for Maternal and Newborn Health (MNH) services. To redress this we will now briefly explore safety and acceptability as aspects of quality.

The side effects, dangers and harms of different interventions are an important consideration, as effective but unsafe strategies are not desirable. Similarly, investing in quality improvement strategies that are not acceptable to end users or other direct stakeholders, such as health workers and community mobilisers, is not acceptable unless they are accompanied by proven mitigation strategies.

A consideration of safety and acceptability issues highlights the need for an even broader evidence base for quality improvement interventions. It is likely that further information on the acceptability of services, specific to your settings, will be available in locally implemented studies and surveys. In particular, organisational and systems-wide perspectives are needed to capture these aspects.

Safety

It is important to note that in some dialogues the concept of increasing access to health services and to skilled birth attendants is considered as adequate to result in ‘safe motherhood’. However the relationship between the safe delivery of services and health outcomes is more complex and cannot be assumed. In Section B we gave a specific example of the potential safety concerns when using magnesium sulphate. Safety is also promoted as a consideration in many topical discussions such as taskshifting and the increased use of community based resources, for example community held misoprostol to treat haemorrhage, amongst other strategies

Emerging work on safety in health care contrast two approaches to the question of safety. Targeting the person focused on human errors emanating from forgetfulness, inattention, or moral weakness; and considering safety from a systems approach. The latter looks at the conditions under which individuals work and tries to avert errors. It is thought that safe, reliable organisations recognise human errors but focuses on ways to mitigate against them (Reason 2000).

While there has been some investigation into the effectiveness of quality improvement strategies, a lot less attention has been paid to exploring the role of safety in such strategies. Even less attention has been placed on the relationship between safety and health outcomes. Examples of studies that have been undertaken include looking at the relationship between maternity staffing and safety in the UK National Health Service (Sandall et al 2014) and a review of the impact of an established obstetric patient safety programme in the USA (Pettker et al 2014). The British Medical Journal has a dedicated Quality and Safety journal which offers access to a range of research and discussion, including some with an international focus.

To an extent, maternal and perinatal death audits and reviews encompass aspects of safety in their approach as they extract learning from highlighting events around critical incidents so as to make care safer. As noted earlier some countries compile results and learning from these. Many countries have or are developing guidelines and best practices specifically focused on improved safety. In some countries, such as the UK and USA, this is supported by regulatory strategies to publish safety statistics for health facilities. Organisations such as the UK based King’s Fund have produced safety-specific toolkits for maternity services.

Another example of emerging work is the use of safety checklists to manage complex tasks which if neglected or carried out in a disorganised fashion, could result in serious harm to patients. A checklist has been developed using 29 essential practices that target the major causes of childbirth-related mortality which is currently being evaluated (Spector et al 2012). We will look at this checklist again in the next learning .

Acceptability

The focus on clinical effectiveness has resulted in a relative neglect of the user perspective in quality improvement, especially in resource poor health systems. The acceptability of services and of quality improvement strategies may not have been given adequate consideration as a result.

Acceptability is a complex and multi-faceted issues which can be viewed from many perspectives. This may include what is acceptable within cultural, faith or social parameters along with an individual’s framework of acceptability which is likely to also be influenced by personal and peer experience. As a result there are many potential influences and potential areas of consideration and negotiation for individuals seeking care.

In addition, acceptability is often underpinned by perception. People’s perceptions of quality do not necessarily coincide with those of health providers or managers. The expectations of quality in health facilities, by end users and those influencing their decisions, may be low and as a result, there have been reports of high satisfaction levels and desire to attend the health facility again for their next pregnancy.

In depth research has raised different issues. Being treated badly by health professionals has been documented (D’Ambruoso et al 2005). Other areas of dissatisfaction include lack of information from health staff, delays in receiving treatment and the costs of care (Weeks et al 2005, Tuncalp et al 2012).

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