What factors do make quality improvement work in primary health care? Experiences of maternal health quality improvement teams in three Puskesmas in Indonesia

Gholipour, Kamal, Limato, Ralalicia, Tumbelaka, Patricia, Ahmed, Rukhsana, Nasir, Sudirman, Syafruddin, Din, Ormel, Hermen, Bruce Kumar, Meghan, Taegtmeyer, Miriam ORCID: https://orcid.org/0000-0002-5377-2536 and Kok, Maryse (2019) 'What factors do make quality improvement work in primary health care? Experiences of maternal health quality improvement teams in three Puskesmas in Indonesia'. PLoS ONE, Vol 14, Issue 12, e0226804.

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Abstract

Background
Indonesia has been shifting from ensuring access to health services towards improving service quality. Accreditation has been used as quality assurance (QA) mechanism, first in hospitals and subsequently in primary health care facilities, including Puskesmas (community health centres). QA provides measures of whether services meet quality targets, but quality improvement (QI) is needed to make change and achieve improvements. QI is a cyclical process with cycles of problem identification, solution testing and observation. We investigated the factors which influenced the process of QI based on experience of maternal health QI teams in three Puskesmas in Cianjur district, West Java province, Indonesia.

Methods
Qualitative data were collected using 28 in-depth interviews at two points of time: pre- (April 2016) and post- QI intervention (April 2017), involving national, provincial, district and Puskesmas managers; and Puskesmas QI team members. Thematic analysis of transcripts was conducted.

Results
We found four main factors contributed to the process of QI: 1) leadership, including awareness and attitude of leader(s) towards QI, involvement of leader(s) in the QI process and decision-making in budget allocation for QI; 2) staff enthusiasm and multidisciplinary collaboration; 3) a culture where QI is integrated in existing responsibilities; and 4) the ongoing Puskesmas accreditation process, which increased the value of QI to the organisation.

Conclusion
Making QI a success in the decentralised Indonesian system requires action at four levels. At individual level, leadership attributes can create an internal quality environment and drive organisational cultural change. At team level, staff enthusiasm and collaboration can be triggered through engaging and tasking everyone in the QI process and having a shared vision of what quality should look like. At organisational level, QI should be integrated in planned activities, ensuring financial and human resources. Lastly, QI can be encouraged when it is implemented by the wider health system as part of national accreditation programmes.

Item Type:	Article
Subjects:	W General Medicine. Health Professions > Health Services. Patients and Patient Advocacy > W 84.4 Quality of Health Care W General Medicine. Health Professions > Health Services. Patients and Patient Advocacy > W 84 Health services. Delivery of health care WA Public Health > Health Problems of Special Population Groups > WA 310 Maternal welfare WA Public Health > Health Problems of Special Population Groups > WA 395 Health in developing countries WQ Obstetrics > WQ 100 General works
Faculty: Department:	Clinical Sciences & International Health > Clinical Sciences Department Clinical Sciences & International Health > International Public Health Department
Digital Object Identifer (DOI):	https://doi.org/10.1371/journal.pone.0226804
Depositing User:	Rachel Dominguez
Date Deposited:	16 Jan 2020 16:32
Last Modified:	17 Jan 2020 10:32
URI:	https://archive.lstmed.ac.uk/id/eprint/13534

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