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Improving the quality of care and patient safety in the Eastern Mediterranean Region

Health care quality in the EMR: current situation

People attending health care facilities, whether in primary care or hospital, deserve to receive quality health care. Fundamental to health care quality is patient safety. No patient should be at risk of being harmed by the very process of health care.

Member States of the Eastern Mediterranean Region (EMR) have expressed high commitment to improving quality of care. In 2009 they endorsed a Regional Committee resolution EM/RC56/R.6 on improving hospital performance in the Eastern Mediterranean Region (EMR) that recalled resolution EM/RC50/R.9 in 2003, specifically those aspects relating to accreditation of hospitals, and requested WHO to provide technical support and guidance to Member States to improve hospital performance through all available tools, including the WHO framework of management and leadership, and develop a strategic plan for strengthening hospital service management.

However, follow-up activities in the area of quality improvement programmes have been minimal. Few countries have shown progress with the ownership of quality and developed national agencies for monitoring and improving quality. For three countries in the Region the national standards in quality have been approved by Isqua; others have adopted international standards. Some of middle- and low-income countries have started structural and organization preparations for quality improvement.

Most of the work that has been done has addressed patient safety which is noted as a priority for most of the EMR countries in their operational plans. Some progress has been achieved to promote patient safety in EMR; for example, the regional research study on the magnitude and scope of adverse events in 6 EMR countries, as well as the following patient safety interventions being undertaken in the Region and coordinated in WHO-EMRO.

“Save Lives: Clean Your Hands” where countries are encouraged to register through the WHO website to show their commitment to address health-care acquired infection (HAI) and to use the WHO hand hygiene self-assessment framework for HAI, as well as implement guidelines to prevent and reduce the incidence of HAI.

“Safe Surgery Saves lives” that aims to reduce the incidence of adverse events in surgery by the compliance with specific standards and the implementation of the WHO safe surgery checklist.

The WHO-EMRO patient safety friendly initiative whose objective is to develop a culture which approaches patient safety as a comprehensive programme addressing patient safety domains, such as leadership and management, evidence-based practices, patient and family involvement, environmental safety and lifelong learning. This initiative comprises 140 standards classified as critical, core or developmental. An updated version of the Patient safety friendly hospitals initiative assessment manual is now finalized and being expanded throughout the EMR countries.

The patient safety tool kit that includes the methodology that field teams may refer to and a set of tools (solutions) to support them in reducing patient safety gaps at the institutional level. It includes the most needed patient safety tools to assist teams at the field level especially in the field HAI, safe surgery, medication safety, surgical site infections, inculcating a patient safety culture, and implementing successful incident reporting systems.

Other interventions address education issues, such as the multi-professional patient safety curriculum guide that is being implemented in some universities in the Region, and the Patient for Patient safety that aims to identify and build the capacities of patient safety champions as advocates for a safer care.

Despite these initiatives and tools, much work remains to be done in the Region. More commitment and leadership for the ownership and actual implementation of patient safety initiatives at the field level is required. There is a huge gap in our knowledge of the status of current quality improvement programmes and indeed the quality in health care in the Region. We need an evaluation of health care quality in the Region and what quality improvements have been made that not only identifies the challenges and gaps, but also the priorities and needed future action.

Addressing the issue

Given the need for information and direction on improving health care quality in the Region, WHO EMRO, in partnership with the Saudi Central Board for Accreditation of Healthcare Institutions, held a regional consultation in Jeddah, Saudi Arabia, in June 2014 to address improving the quality of care and patient safety in EMR countries. The consultation was attended by representatives from the majority of countries of the Region, as well as relevant WHO staff and external experts. The meeting aimed to review the current status of quality and safety of health care in EMR, the initiatives taken and the existing challenges and gaps in information, discuss various approaches to improving the quality of health care, share successful experiences of selected countries from within and outside the Region and agree concrete actions to be taken to help improve the quality of care in EMR countries.

Challenges identified in the EMR

Although a comprehensive picture for quality and safety is difficult to draw, some of the factors identified as responsible for the suboptimal state of safety and quality in many countries of the Region include:

The heavy burden of non-quality unsafe care, highly preventable maternal mortality, limited access to healthcare services in some areas, the prevalence of health care associated infections and adverse events.

The absence of a clear vision and strategic direction to guide and support the implementation of quality and safety interventions.

The growing role of the private sector, public/private division of the funding and delivery of services.

The focus on advanced and tertiary care, primarily hospital care, and low interest in primary and preventive health care.

The focus on disease-centred practices rather than a patient/community-centred approach.

The absence of institutionalization of quality and safety.

The consultation also addressed quality and patient safety challenges more specifically for the 3 groups of EMR countries, which are summarized in Table 1. EMR countries have been categorized into three groups based on population health outcomes, health system performance and level of health expenditure. Group 1 comprises countries where socioeconomic and health development has progressed considerably over the past decades (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates). Group 2 comprises largely middle‐income countries which have developed extensive public health infrastructure but face resource constraints (Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, Syrian Arab Republic and Tunisia). Group 3 comprises countries which face constraints in improving population health outcomes as a result of lack of resources, political instability and other complex development challenges (Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen).

The way forward

Progress on improving health care quality and patient safety in the Region has not been optimal. The recommendations below that arose from the consultation provide the countries and WHO with clear and concrete actions to undertake in order to advance health care quality and patient safety in the Region. Committing to and implementing these recommendations should be a priority for both the countries and WHO.

Actions agreed to move forward

1. Build on the previous efforts by the patient safety friendly hospital initiative.
2. Ministries of health to nominate 1-2 hospitals as pilots for patient safety friendly hospital initiative;
3. WHO to provide the tools and technical assistance for supporting implementation and disseminate the patient safety assessment manual and complete the patient safety toolkit.
4. Remap the status of health care accreditation in EMR.
5. WHO to update the regional status of accreditation based on standardized assessment instrument. Countries to provide the requested information on the status of accreditation.
6. Consider the role of clinical governance as a complementary approach to strengthening quality of care and patient safety.
7. Countries to initiate in pilot hospitals: support the introduction of clinical governance as an approach to reinforce quality and safety, organize appraisal meetings, set up clinical governance committee, establish a feedback process, develop a communication strategy for all staff, set up a group to look at causes of mortality and one to review clinical procedures and practice;
8. WHO and its external experts to provide the technical back-up and support.
9. WHO to raise the issue of quality and safety at the policy level in EMR countries.
10. Develop policy briefs on quality and safety and disseminate these widely;
11. Present the issue of quality and safety in policy forums, such as the Regional Committee;
12. Bring quality and safety for discussion in national ministerial level forums.
13. Undertake research in the area of quality and safety.
14. WHO to identify priority areas for research in quality and safety for the three groups of EMR countries
15. WHO to provide the technical support in undertaking these activities
16. Countries and WHO to undertake joint efforts at mobilizing resources for research on patient safety.
17. Intensify efforts to establish networks on quality and safety
18. WHO to establish a network of civil societies from the Region that are engaged in the work on quality and safety and build their capacity in raising the voice of patients and population at the country level
19. WHO to revive the network of quality and safety experts from the Region in order to provide technical support to countries in establishing quality and safety programmes.

Table 1 Challenges and needed actions to improve quality and safety identified by the participants for the three groups of EMR countries based on population health outcomes, health system performance and level of health expenditure