Evaluation of a Collaborative Approach and of ISO Certification to Improve Quality of Maternal-Neonatal Health Care Services in Guatemala: A Comparative Cost Analysis | Guatemala

The USAID Health Care Improvement project (HCI) has supported two initiatives in Guatemala focused on improving the quality of health care. The ProCONE Maternal and Neonatal Health Care Improvement Collaborative was developed by the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) and focuses improving prenatal, delivery, postpartum, and neonatal care. The approach of ProCONE (Promoción y Cuidados Obstétricos Neonatales Esenciales) was to engage health center staff in quality improvement (QI) teams to monitor compliance with clinical norms and records and improve care through training and coaching, providing Information Education and Communication (IEC) materials and job aids, proving opportunities for shared learning through Collaborative sessions, introducing health improvement activities, and documentation and review of best practices that proved effective in improving process indicators. The demonstration phase was implemented between March 2007 through September 2008 in the department of San Marcos in western Guatemala. In this study, facilities participating in the ProCONE collaborative are referred to as ProCONE alone facilities.

The International Organization for Standards (ISO) is a non-governmental organization that develops and continually updates standards for quality management systems called ISO 9000. These standards are used by objective ISO auditors to audit and certify that formalized processes conform with up-to-date standards. With support from HCI, the MOH committed to the ISO certification process to evaluate health care QI at Permanent Attention Center San Pedro Sacatepequez (San Pedro CAP), which also participated in the ProCONE demonstration collaborative. Activities to prepare for ISO certification were introduced in October 2009 and continued through July 2010. The audit was conducted and certification provided in October 2010. The audit identified 5 minor areas requiring improvement. The MOH and URC are taking actions to fully comply with the established standards and the CAP is scheduled for re-audit in October, 2011. In this study, the San Pedro CAP is referred to as the ISO+ProCONE facility.
This study compares the cost-effectiveness of the ISO and ProCONE strategies on essential maternal and neonatal health care best practices and their mediating factors to determine how the Ministry of Health can best leverage each of these strategies in improving and maintaining quality of care.
Research questions/objectives:
The primary objective of the study is to elaborate how the ProCONE and ISO approaches affect process (mediating) variables, including purchasing, availability of supplies, equipment maintenance, staff competence and training, record keeping and planning, the coverage of care (numbers of patients), compliance with MNH best practices, patient satisfaction and the incremental cost-effectiveness. This information will help to determine whether and where the integration of these two strategies is beneficial. To meet the study objectives, the study will answer the following specific research questions:
  1.  What are the current differences in processes (mediating variables) that theoretically affect outcome (coverage, effectiveness and cost-effectiveness)?
  2.  What are the relative differences between ISO+ProCONE and ProCONE alone in MNH patient coverage?
  3.  What are the differences between ISO+ProCONE and ProCONE alone in MNH best practices?
  4.  What is the incremental cost-effectiveness (ICE) of ISO+ ProCONE compared with ProCONE alone; and
  5.  What drivers (mediating variables) affect the success of each method?

A quasi-experimental research design will be used because the ISO+ProCONE and ProCONE alone study groups were not randomly allocated. The quasi-experimental design takes advantage of the data equally available from both study groups. Data collected in May 2011 in an all-facilities endline cross sectional survey of process variables, patient satisfaction, and patient-provider observation and associated clinical records review. These will be compared with data previously collected in 2009 and 2007.


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