Table 2 Recommendations for improvement of the WHO integrated quality of care assessment tool

Shorten the tool

Because it is so comprehensive, the tool can be adapted to suit local disease and population profiles and used to assess different levels of care. However, the adapted assessment tool applied in Malawi is over 200 pages long. A shorter tool, focused on priority areas of care, may be more appropriate for use in busy clinical environments.

Combine the CEmOC and BEmOC tools

There are currently two versions of the tool and the only difference is that the CEmOC tool assesses management of Caesarean section (including pre-, intra- and post-operative procedures), paediatric wards and paediatric surgery and rehabilitation. It should be possible to combine the tools into one, with separate modules for assessing the standards relevant to CEmOC facilities only.

Streamline data sources and revise instructions for data collection

The data sources could be streamlined, and clearer instructions for conducting the various components of the assessment provided. The number of data collection methods and lack of clear guidance on when and how they should be used is potentially confusing to assessors who have limited time to complete facility visits.

Simplify the assessment of availability of drugs and equipment

The assessment of drugs, equipment and supplies could be simplified for example by focusing on fewer ‘tracer’ essential drugs and obtaining information on stock outs or unavailability rather than amount and quality of drugs.

Link the assessment tool to existing quality of care frameworks and indicators

It needs to be made clear how the tool and the components assessed map onto the new quality of care framework and indicators being developed by WHO as well as other maternal and newborn health indicators being developed to measure quality of care at facility level.

Consider alternatives to external assessors

Given the potential for assessor bias and for the presence of an external assessor to produce changes in provider behaviour (the Hawthorn or observer effect), the tool may produce more valid data if completed by staff working at the facilities.

Revise the action planning process

An important drawback for practical use of the assessment data is that facility action plans were not completed It may be that this exercise is best coordinated at district level, where common problems with quality of care can be identified and resources targeted towards supporting facilities to make improvements. Staff at individual facilities may become overwhelmed if they try to tackle all the areas of care identified as in need of improvement. The colour coded dashboard (Fig. 1) may be a useful template for displaying data and could be used as a basis for discussion and prioritisation of problems for immediate and longer term action.