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

• Authors: Ralalicia Limato, Eijkman Institute for Molecular Biology, Jakarta; Patricia Tumbelaka, Eijkman Institute for Molecular Biology, Jakarta; Rukhsana Ahmed, Eijkman Institute for Molecular Biology, Jakarta; Sudirman Nasir, Universitas Hasanuddin; Din Syafruddin, Eijkman Institute for Molecular Biology; Hermen Ormel, KIT Royal Tropical Institute; Meghan B Kumar, Emory University; Miriam Taegtmeyer, Liverpool School of Tropical Medicine; Maryse Kok, KIT Royal Tropical Institute, Amsterdam
• Journal Title: PLOS ONE
• Volume: Volume 14, Number 12
• Publisher: PUBLIC LIBRARY SCIENCE | 2019-12-20, Pages e0226804-e0226804
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1371/journal.pone.0226804
• Subjects: Health Sciences, Public Health
• Keywords: Science & Technology; Multidisciplinary Sciences; Science & Technology - Other Topics; IMPROVING QUALITY; STRATEGIES; PROGRAM

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.