To the Editor:
Quality improvement (QI) principles have been systematically applied in resource-limited settings for more than a decade. While we agree with the conclusions in the recent report by Umar and others1 that integrating local context into quality improvement initiatives is essential for success and long-term sustainability, the analysis could benefit from a broader reference to methods that are at the forefront of current efforts to implement and improve care programs in resource-limited settings, and a clearer sense of how quality improvement and accreditation are interlinked.
The best known method underlying most modern QI approaches is the Model for Improvement (MFI), a data-driven approach that closes performance and outcome gaps by deploying a systematic process for testing small changes to improve system functioning over a defined period of time.2 The "Little Steps" model that the authors describe in detail is not different from the process for testing and implementing change, called the "Plan-Do-Study-Act" (PDSA) cycle, which is the central change strategy in the MFI. This model (MFI and PDSA cycles) is widely accepted and heavily used to improve health systems in high-income countries and has more recently been applied to improving health systems in a number of low- and middle-income countries.3-6 USAID supports a number of programmes that utilize these methods to improve the delivery of HIV care.7,8 We have previously reported on how these methods can also be used to address the challenges of scaling up health care delivery in poor countries.9
Finally, the authors seem to place benchmarking, accreditation, and results-based financing mechanism in one unified basket of quality improvement. We see these processes working together in a cycle where accreditation measures facilities and providers against benchmarks, and quality improvement processes ensure that these entities improve performance. As the system improves, new benchmarks will be needed and the cycle of quality continues.
--Kedar Mate
Institute for Healthcare Improvement, Cambridge, MA, Weill-Cornell Medical College, New York
-Pierre Barker
Institute for Healthcare Improvement, Cambridge, MA, University of North Carolina at Chapel Hill, Chapel Hill
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