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

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Listed:
  • Ralalicia Limato
  • Patricia Tumbelaka
  • Rukhsana Ahmed
  • Sudirman Nasir
  • Din Syafruddin
  • Hermen Ormel
  • Meghan Bruce Kumar
  • Miriam Taegtmeyer
  • Maryse Kok

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.

Suggested Citation

  • Ralalicia Limato & Patricia Tumbelaka & Rukhsana Ahmed & Sudirman Nasir & Din Syafruddin & Hermen Ormel & Meghan Bruce Kumar & Miriam Taegtmeyer & Maryse Kok, 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, Public Library of Science, vol. 14(12), pages 1-18, December.
  • Handle: RePEc:plo:pone00:0226804
    DOI: 10.1371/journal.pone.0226804
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    References listed on IDEAS

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    1. Kristin Geonnotti & Erin Fries Taylor & Deborah Peikes & Lisa Schottenfeld & Hannah Burak & Robert McNellis & Janice Genevro, "undated". "Engaging Primary Care Practices in Quality Improvement: Strategies for Practice Facilitators," Mathematica Policy Research Reports 724fa51ef57742c4bc4931ef9, Mathematica Policy Research.
    2. Kamal Gholipour & Jafar Sadegh Tabrizi & Mohammad Asghari Jafarabadi & Shabnam Iezadi & Ahmad Mardi, 2018. "Effects of customer self-audit on the quality of maternity care in Tabriz: A cluster-randomized controlled trial," PLOS ONE, Public Library of Science, vol. 13(10), pages 1-19, October.
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