Quality assurance management methods applied to a local-level primary health care system in rural Nigeria

Introduction. Management of primary health care (PHC) systems in less developed countries is often impeded by factors such as poorly trained personnel, limited financial resources, and poor worker morale. This study explored the ability of local-level PHC supervisors in rural Nigeria to use quality assurance (QA) management methods to improve the quality of the PHC system. Methods. PHC supervisors from Bama Local Government Area were trained for 3 days in the use of QA methods and tools. The supervisors targeted the supervisory system and the health information system (HIS) for improvement. Health worker performance in diarrhoea case management was assessed, using a simulated case, to measure the impact of supervision. A HIS audit assessed data collection forms used by 17 PHC facilities. Gaps in quality were monitored over a 2-month study period and flaws in work processes were modified. Results. PHC supervisors introduced a checklist during monthly visits to facilities to monitor how workers managed cases of diarrhoea. Performance in history-taking, physical examination, disease classification, treatment and counselling improved over the evaluation period. The HIS audit found that a variety of reporting forms were used at PHC facilities. After HIS reporting was standardized, the number of health facilities using a daily disease registry significantly improved during the study period. Conclusions. QA management methods were used by PHC supervisors in Nigeria to improve supervision and the HIS. QA management methods are appropriate for improving the quality of the PHC in Nigeria and in other less developed countries where at least a minimal PHC infrastructure exists.     

Victoria M. Trasko: champion of state-based surveillance of occupational diseases in the United States, 1937 to 1971.

Victoria M. Trasko (1907-1979), a relatively unknown figure to many currently practicing occupational health specialists, was a pioneer in state-based surveillance of occupational diseases in the United States. To highlight her accomplishments during her career with the United States Public Health Service from 1937 to 1971, this report briefly reviews her publications on occupational disease surveillance. Her span of work includes guidelines for state industrial hygiene programs, numbers of workers in state occupational health programs, compilation of state and local laws related to industrial hygiene, proposals for standardized reporting of occupational disease, and analysis of trends in workers' compensation and mortality statistics for occupational diseases. She pilot tested the first state-based model system for occupational disease reporting in the United States. She documented the great difficulty experienced by states in getting physicians to report cases of occupational diseases, and pointed out that surveillance of other existing data sources was worthwhile, at least for some occupational diseases. She was the first to report on the distribution of silicosis cases in the United States by state, industry, and job title. She was the first to comment on mortality trends for the pneumoconioses and to document problems in comparability between different International Classification of Disease (ICD) periods.     

Capture-recapture analysis of all-cause mortality data in Bohol, Philippines

Background  

Despite the importance of mortality data for effective planning and monitoring of health services, official reporting systems rarely capture every death. The completeness of death reporting and the subsequent effect on mortality estimates were examined in six municipalities of Bohol province in the Philippines using a system review and capture-recapture analysis.     

Research gaps in routine health information system design barriers to data quality and use in low‐ and middle‐income countries: A literature review

Despite the potential impact of health information system (HIS) design barriers on health data quality and use and, ultimately, health outcomes in low‐ and middle‐income countries (LMICs), no comprehensive literature review has been conducted to study them in this context. We therefore conducted a formal literature review to understand system design barriers to data quality and use in LMICs and to identify any major research gaps related understanding how system design affects data use. We conducted an electronic search across 4 scientific databases—PubMed, Web of Science, Embase, and Global Health—and consulted a data use expert. Following a systematic inclusion and exclusion process, 316 publications (316 abstracts and 18 full papers) were included in the review. We found a paucity of scientific publications that explicitly describe system design factors that hamper data quality or data use for decision making. Although user involvement, work flow, human‐computer interactions, and user experience are critical aspects of system design, our findings suggest that these issues are not discussed or conceptualized in the literature. Findings also showed that individual training efforts focus primarily on imparting data analysis skills. The adverse impact of HIS design barriers on data integrity and health system performance may be even bigger in LMICs than elsewhere, leading to errors in population health management and clinical care. We argue for integrating systems thinking into HIS strengthening efforts to reduce the HIS design‐user reality gap.     

医院传染病、死亡病例及其他疾病监测智能报告系统的研究概况

本研究总结描述了国内外基于网络的疾病监测系统,及目前我国医疗机构院内传染病、死亡病例等疾病监测报告系统存在的各种问题,指出传统的报告流程已经完全不能适应当前工作的需要。提出设计与开发"医院传染病、死因病例及其他疾病监测智能报告系统",阐明实现医院信息系统(HIS)与中国疾病预防控制系统、广东省急性传染病监测信息平台系统及深圳市疾病控制信息管理系统数据交换的必要性和可行性。     

Improving health information systems for decision making across five sub-Saharan African countries: Implementation strategies from the African Health Initiative

Background

Weak health information systems (HIS) are a critical challenge to reaching the health-related Millennium Development Goals because health systems performance cannot be adequately assessed or monitored where HIS data are incomplete, inaccurate, or untimely. The Population Health Implementation and Training (PHIT) Partnerships were established in five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) to catalyze advances in strengthening district health systems. Interventions were tailored to the setting in which activities were planned.

Comparisons across strategies

All five PHIT Partnerships share a common feature in their goal of enhancing HIS and linking data with improved decision-making, specific strategies varied. Mozambique, Ghana, and Tanzania all focus on improving the quality and use of the existing Ministry of Health HIS, while the Zambia and Rwanda partnerships have introduced new information and communication technology systems or tools. All partnerships have adopted a flexible, iterative approach in designing and refining the development of new tools and approaches for HIS enhancement (such as routine data quality audits and automated troubleshooting), as well as improving decision making through timely feedback on health system performance (such as through summary data dashboards or routine data review meetings). The most striking differences between partnership approaches can be found in the level of emphasis of data collection (patient versus health facility), and consequently the level of decision making enhancement (community, facility, district, or provincial leadership).

Discussion

Design differences across PHIT Partnerships reflect differing theories of change, particularly regarding what information is needed, who will use the information to affect change, and how this change is expected to manifest. The iterative process of data use to monitor and assess the health system has been heavily communication dependent, with challenges due to poor feedback loops. Implementation to date has highlighted the importance of engaging frontline staff and managers in improving data collection and its use for informing system improvement. Through rigorous process and impact evaluation, the experience of the PHIT teams hope to contribute to the evidence base in the areas of HIS strengthening, linking HIS with decision making, and its impact on measures of health system outputs and impact.

     

Capture-recapture analysis of all-cause mortality data in Bohol, Philippines

Background

Primary health care is recognized as a main driver of equitable health service delivery. For it to function optimally, routine health information systems (HIS) are necessary to ensure adequate provision of health care and the development of appropriate health policies. Concerns about the quality of routine administrative data have undermined their use in resource-limited settings. This evaluation was designed to describe the availability, reliability, and validity of a sample of primary health care HIS data from nine health facilities across three districts in Sofala Province, Mozambique. HIS data were also compared with results from large community-based surveys.

Methodology

We used a methodology similar to the Global Fund to Fight AIDS, Tuberculosis and Malaria data verification bottom-up audit to assess primary health care HIS data availability and reliability. The quality of HIS data was validated by comparing three key indicators (antenatal care, institutional birth, and third diptheria, pertussis, and tetanus [DPT] immunization) with population-level surveys over time.

Results and discussion

The data concordance from facility clinical registries to monthly facility reports on five key indicators--the number of first antenatal care visits, institutional births, third DPT immunization, HIV testing, and outpatient consults--was good (80%). When two sites were excluded from the analysis, the concordance was markedly better (92%). Of monthly facility reports for immunization and maternity services, 98% were available in paper form at district health departments and 98% of immunization and maternity services monthly facility reports matched the Ministry of Health electronic database. Population-level health survey and HIS data were strongly correlated (R = 0.73), for institutional birth, first antenatal care visit, and third DPT immunization.

Conclusions

Our results suggest that in this setting, HIS data are both reliable and consistent, supporting their use in primary health care program monitoring and evaluation. Simple, rapid tools can be used to evaluate routine data and facilitate the rapid identification of problem areas.     

Assessing a computerized routine health information system in Mali using LQAS

BACKGROUND: Between 1987 and 1998 Save the Children conducted a child survival programme in Mali with the goal of reducing maternal and child morbidity and mortality. An integral part of this programme was a computerized demographic surveillance and health information system (HIS) that gathered data on individuals on an on-going basis. OBJECTIVE: To assess the overall coverage and quality of the data in the HIS, to identify specific health districts that needed improvements in data collection methods, and to determine particular areas of weakness in data collection. METHODS: Random samples of 20 mothers with children <5 years were selected in each of 14 health districts. Mothers were interviewed about pregnancies, live births, deaths of children <5, and children's growth monitoring and immunization status. The Lot Quality Assurance Method (LQAS) was used to identify districts in which records and interview results did not meet predetermined levels of acceptability. Data collected in the interviews were combined to estimate overall coverage and quality. RESULTS: When all variables were analyzed, all 14 lots were rejected, and it was estimated that 52% of all events occurring in the community were registered in ProMIS. Much of this poor performance was due to immunization and growth monitoring data, which were not updated due to printer problems. Coverage of events increased (92%) when immunizations and growth monitoring were excluded, and no lots were rejected. When all variables were analyzed for quality of data recorded, six lots were rejected and the overall estimation was 83%. With immunizations and growth monitoring excluded, overall quality was 86% and no lots were rejected. CONCLUSIONS: The comprehensive computerized HIS did not meet expectations. This may be due, in part, to the ambitious objective of complete and intensive monitoring of a large population without adequate staff and equipment. Future efforts should consider employing a more targeted and streamlined HIS so that data can be more complete and useful.     

Reporting of skin cancer risks in the house-building industry: alternative approaches to the analysis of categorical data

BACKGROUND: Increasing incidence of skin cancer is of concern to public health. Working predominantly outside, construction workers are at increased risk of sunburn and certain forms of skin cancer. The objective of this paper was to explore these concerns via use of alternative approaches to categorical data analysis by considering the relationship between the size of house-building companies, use of risk assessments and the system for reporting sunburn. METHODS: The survey population was speculative house-building companies. A self-administered questionnaire was sent to health and safety advisors in house-building companies. Questions related to the number of house units built, inclusion of adverse weather in the risk assessment, and the presence or absence of a system for reporting sunburn were analysed. Alternative approaches to conventional chi(2) tests were used in order to investigate a multiway data structure. A loglinear model was employed using Statistical Package for Social Sciences to explain data in three-way tables. RESULTS: The questionnaire achieved a response rate of 31% (n=94). A significant association identified in a two-way study of the mechanisms of reporting sunburn also appeared at the sublevels introduced by the inclusion of a third method of categorization. Finally, correspondence analysis was used to present a graphical insight into the study. CONCLUSIONS: In the two-way analysis, the size of house-building company had a significant impact on the presence of a system for reporting sunburn, although this was not translated into the three-way analysis. The establishment of systems within risk assessments to incorporate exposure of construction workers to ultraviolet radiation, and reporting of incidents of sunburn, is essential if this public health issue is to be addressed.     

Accuracy of the health information system on malaria surveillance in Vietnam

The health information system (HIS) is a key component of control programs and its accuracy is necessary for the assessment of disease risks, the formulation of priorities and the evaluation of the cost-effectiveness of different interventions. In order to assess the quality of the HIS in estimating malaria morbidity in Vietnam, we compared data obtained by a 2-year active (ACD) and passive case detection (PCD) study with those routinely collected at the local commune health centres (CHC) at three sites having different malaria epidemiology. The majority of malaria cases (80-95%) detected by ACD were missed by the HIS. Similarly, most malaria cases (50-90%) detected by PCD were also missed by the HIS, and this was proportional to the number of active private practitioners. Reasons for this low sensitivity are low CHC attendance, high attendance at private health facilities, widespread self-medication and attendance at central health facilities. In conclusion, although malaria has sharply decreased in Vietnam over the past 10 years, the current HIS greatly underestimates the malaria burden. Involvement of the private sector and the establishment of sentinel sites might improve the quality of data and the relevance of HIS in malaria control.     

Health observation compared to health reporting: findings from a pilot study in Florence

PURPOSE: Both health interview surveys (HISs) and health examination surveys (HESs) are used to describe the health status of populations. In Italy, to determine the feasibility of conducting a national-level HES, a pilot HES was conducted in the city of Florence among participants of a previous national-level HIS. The aim of the present analysis was to compare the results of the two surveys. METHODS: The study population consisted of the 343 Florence residents 35 to 74 years of age who participated in both surveys (sample drawn with probabilistic criteria). We compared the self-reported HIS data to the HES health measurements for diabetes, hypertension, osteoporosis, smoking, height, weight, and body mass index. For categorical variables, contingency tables were used, calculating symmetric and asymmetric indices. For the continuous variables, Student's t test for matched samples was used. RESULTS: The prevalence of the most important pathologic conditions and risk factors determined with HES measurements was significantly higher than that based on self-reported HIS data. CONCLUSIONS: The results stress that individuals have poor knowledge of their own health; therefore health measurements need to be taken.     

医院感染管理中的信息化管理

目的充分利用医院现有信息系统(HIS),努力开发个性化医院感染管理功能,提高感染控制工作的主动性、针对性和及时性,做好医院感染管理工作。方法引入、应用及深入开发医院信息系统(HIS),改变手工报表工作效率低、准确率低的情况,使感染控制信息采集、传送简单化,工作效率显著提高。结果医院信息系统(HIS)的应用,淘汰了纸质"医院感染报告卡",节省了医师手工填写、人工传递时间;医院感染报告中大部分信息可以从临床工作站直接获得,使工作快捷、简单,提高医院感染报告的及时性、准确性;对医院感染隐患、暴发和流行趋势真正做到早发现、早报告、早控制,同时上报医院感染网,达到降低医院感染率及漏报率的目的。结论利用、开发医院局域网平台之后,大大提高了感染监测的准确性和效率,使医院感染病例监测工作实现质的飞跃;实现医疗信息共享,更好地作出分级预警,尽早防止医院感染及聚集性的发生,使医院感染监控系统更加完善。     

Linking the integrated management of childhood illness (IMCI) and health information system (HIS) classifications: issues and options

Differences in the terms used to classify diseases in the Integrated Management of Childhood Illness (IMCI) guidelines and for health information system (HIS) disease surveillance could easily create confusion among health care workers. If the equivalent terms in the two classifications are not clear to health workers who are following the guidelines, they may have problems in performing the dual activities of case management and disease surveillance. These difficulties could adversely affect an individual's performance as well as the overall effectiveness of the IMCI strategy or HIS surveillance, or both. We interviewed key informants to determine the effect of these differences between the IMCI and HIS classifications on the countries that were implementing the IMCI guidelines. Four general approaches for addressing the problem were identified: translating the IMCI classifications into HIS classifications; changing the HIS list to include the IMCI classifications; using both the IMCI and HIS classification systems at the time of consultations; and doing nothing. No single approach can satisfy the needs of all countries. However, if the short-term or medium-term goal of IMCI planners is to find a solution that will reduce the problem for health workers and is also easy to implement, the approach most likely to succeed is translation of IMCI classifications into HIS classifications. Where feasible, a modification of the health information system to include the IMCI classifications may also be considered.     

The Use of Cremation Data for Timely Mortality Surveillance During the COVID-19 Pandemic in Ontario,Canada: Validation Study

BackgroundEarly estimates of excess mortality are crucial for understanding the impact of COVID-19. However, there is a lag of several months in the reporting of vital statistics mortality data for many jurisdictions, including across Canada. In Ontario, a Canadian province, certification by a coroner is required before cremation can occur, creating real-time mortality data that encompasses the majority of deaths within the province.ObjectiveThis study aimed to validate the use of cremation data as a timely surveillance tool for all-cause mortality during a public health emergency in a jurisdiction with delays in vital statistics data. Specifically, this study aimed to validate this surveillance tool by determining the stability, timeliness, and robustness of its real-time estimation of all-cause mortality.MethodsCremation records from January 2020 until April 2021 were compared to the historical records from 2017 to 2019, grouped according to week, age, sex, and whether COVID-19 was the cause of death. Cremation data were compared to Ontario’s provisional vital statistics mortality data released by Statistics Canada. The 2020 and 2021 records were then compared to previous years (2017-2019) to determine whether there was excess mortality within various age groups and whether deaths attributed to COVID-19 accounted for the entirety of the excess mortality.ResultsBetween 2017 and 2019, cremations were performed for 67.4% (95% CI 67.3%-67.5%) of deaths. The proportion of cremated deaths remained stable throughout 2020, even within age and sex categories. Cremation records are 99% complete within 3 weeks of the date of death, which precedes the compilation of vital statistics data by several months. Consequently, during the first wave (from April to June 2020), cremation records detected a 16.9% increase (95% CI 14.6%-19.3%) in all-cause mortality, a finding that was confirmed several months later with cremation data.ConclusionsThe percentage of Ontarians cremated and the completion of cremation data several months before vital statistics did not change meaningfully during the COVID-19 pandemic period, establishing that the pandemic did not significantly alter cremation practices. Cremation data can be used to accurately estimate all-cause mortality in near real-time, particularly when real-time mortality estimates are needed to inform policy decisions for public health measures. The accuracy of this excess mortality estimation was confirmed by comparing it with official vital statistics data. These findings demonstrate the utility of cremation data as a complementary data source for timely mortality information during public health emergencies.     

医院内法定传染病信息推送平台开发与实现

目的通过试点开发医疗机构法定传染病信息推送平台,实现医院内传染病信息与中国疾病预防控制信息系统(大疫情网)的直接连通,提高医院传染病报告的效率和质量。方法依据国家统一的接口规范,以医院管理信息系统(HIS)数据库Oracle10.2作为后台数据库存储系统,使用Power Builder 11.2作为开发工具,完成医院HIS系统的接口及流程改造。结果建立医院传染病报告管理系统与大疫情网接口连通的网络通道,完善传染病管理相关系统界面设计,规范系统功能流程,实现从医生工作站到大疫情网的接口上报,提高报告质量、及时性、工作效率和监管力度。结论医疗机构法定传染病信息推送平台的顺利实施,是未来全国传染病监测体系构建的发展方向。     

Evaluating the Use of an Electronic Death Registration System for Mortality Surveillance During and After Hurricane Sandy: New York City, 2012

Objectives. We evaluated the use of New York City’s (NYC’s) electronic death registration system (EDRS) to conduct mortality surveillance during and after Hurricane Sandy.Methods. We used Centers for Disease Control and Prevention guidelines for surveillance system evaluation to gather evidence on usefulness, flexibility, stability, timeliness, and quality. We assessed system components, interviewed NYC Health Department staff, and analyzed 2010 to 2012 death records.Results. Despite widespread disruptions, NYC’s EDRS was stable and collected timely mortality data that were adapted to provide storm surveillance with minimal additional resources. Direct-injury fatalities and trends in excess all-cause mortality were rapidly identified, providing useful information for response; however, the time and burden of establishing reports, adapting the system, and identifying indirect deaths limited surveillance.Conclusions. The NYC Health Department successfully adapted its EDRS for near real-time disaster-related mortality surveillance. Retrospective assessment of deaths, advanced methods for case identification and analysis, standardized reports, and system enhancements will further improve surveillance. Local, state, and federal partners would benefit from partnering with vital records to develop EDRSs for surveillance and to promote ongoing evaluation.New York City’s (NYC’s) Health Department introduced an electronic death registration system (EDRS) in 2005, allowing medical providers, funeral directors, and Health Department registration staff to voluntarily report deaths and access death records through a Web-based system. Since then, local mandates for EDRS use and timeliness resulted in nearly complete electronic reporting and accelerated the processing of death certificates and the availability of population mortality data.1 Across the United States, 46 of 57 vital event jurisdictions have implemented EDRSs, creating new opportunities to use mortality data for the timely surveillance of emerging public health concerns.2,3 For example, fatalities are a commonly used indicator of the public health impact of natural disasters, including extreme heat events, floods, tornadoes, and hurricanes.4 Recently, lead US health agencies have called for greater research and evaluation of disaster-related systems and processes to address challenges faced by government and public health agencies, hospitals and clinicians, and academic researchers.5 The evaluation of local systems after disasters is therefore critical for identifying and addressing knowledge gaps for future events.On October 29, 2012, posttropical cyclone Sandy (Hurricane Sandy) made landfall approximately 100 miles south of NYC, causing a record-breaking storm surge throughout coastal areas of the city.6 Extensive flooding and wind damage caused widespread power outages, transportation shutdowns, medical facility and residential evacuations, and disruptions to health care access.7 Environmental risks persisted in the days and weeks following the storm, especially in residential buildings with damage to electrical, heating, elevator, and potable water systems. This raised concerns not only for direct-injury–related fatalities but also for all-cause deaths attributable to hazardous conditions. In response, the NYC Health Department used its EDRS to conduct mortality surveillance during and after Hurricane Sandy. Surveillance objectives were to (1) identify and characterize Sandy-related deaths, and (2) examine all-cause mortality during the storm and identify poststorm hazards. To assess performance of the disaster mortality surveillance system, we evaluated key system attributes, identified strengths and limitations, and made recommendations for system improvements.     

Excess mortality monitoring in England and Wales during the influenza A(H1N1) 2009 pandemic

We present the results from a novel surveillance system for detecting excess all-cause mortality by age group in England and Wales developed during the pandemic influenza A(H1N1) 2009 period from April 2009 to March 2010. A Poisson regression model was fitted to age-specific mortality data from 1999 to 2008 and used to predict the expected number of weekly deaths in the absence of extreme health events. The system included adjustment for reporting delays. During the pandemic, excess all-cause mortality was seen in the 5-14 years age group, where mortality was flagged as being in excess for 1 week after the second peak in pandemic influenza activity; and in age groups >45 years during a period of very cold weather. This new system has utility for rapidly estimating excess mortality for other acute public health events such as extreme heat or cold weather.     

探讨医保系统对死因监测系统补充作用

[目的]探索依靠医保系统的资料提高死因监测系统报告工作数量和质量的可行性。[方法]使用某市医保部门中部分参保对象因死亡原因停止医保的记录,对同时期死因监测系统中网上上报记录通过身份证号、姓名、生日等进行查找匹配,以发现疾病监测系统的死亡漏报及错误信息报告。[结果]41659人中因死亡终止医保记录327条,死因监测系统中同人群死亡记录307条,死亡漏报18条,漏报率5.5%,姓名、出生日期、身份证号码等个人信息错误39项,错误率12.7%。医保上报平均延迟时间明显高于网上直报平均延迟时间(P﹤0.05)。[结论]医保数据是死因监测工作的有力补充,疾控部门应定期和医保部门开展此类合作,以提高死因监测数据的数量及质量。