Table 1 Types of quality improvement interventions to assign for reviewing the impact of QI interventions on perinatal outcomes in health facilities

 Public reporting

Public reporting and comparative benchmarking are used to increase transparency and accountability on issues of quality and cost in health care systems by providing consumers, payers, health care organizations and providers with comparative information on performance.

 Performance-based financing and contracting

Performance-based financing and contracting includes interventions that feature at least one of (i) financial incentives for providers or patients, (ii) system-wide changes in reimbursement, and (iii) changes to provider licensing or institutional accreditation requirements.

There are two main types of financial incentives:

• Financial incentives for health care providers include pay-for-performance, budgets that reward providers for making savings or penalize them for overspending, and incentives for practising in underserved areas or selecting vocation where there is a shortage of health professionals.

• Financial incentives for recipients of health care include for specific types of behaviour (such as preventive behaviour), voucher schemes, and caps or co-payments for drugs or services that are covered by health insurance.

 Change of organizational culture

Strategies to change organizational culture.

 Continuous quality improvement and Plan-Do-Study-Act (PDSA) cycle

Continuous quality improvement aims to improve health care by (i) improving organizational processes, (ii) using structured problem-solving processes with statistical methods and measurement to diagnose problems and monitor progress, (iii) using teams of employees from multiple departments and different levels to assess quality, (iv) empowering employees to identify quality problems and improvement opportunities and to act on them, and (v) an explicit focus on clients.

This covers any intervention that includes at least team or personnel changes, communications or case discussions, or total quality management and continuous improvement.

 Continuing education meetings and workshops

Educational meetings are used for the continuing health care education of health workers to improve professional practices. Educational meetings include courses, conferences, lectures, workshops, seminars and symposia.

 Facilitation

Facilitation means supporting groups of stakeholders to identify problems and responses including identifying key stakeholders who need to be engaged in order to implement changes. It involves clarifying the tasks at hand, i.e. making sense of what is going on and managing group dynamics including handling emotions in the group. Facilitators support groups to work together in a structured way and to create a climate where openness, integrity and personal values are respected.

 Printed educational materials

Printed recommendations for clinical care, including clinical practice guidelines can be delivered personally or through mass mailings.

 Audit and feedback

Audits and feedback include any summary of performance of health care providers or institutions.

Audit and feedback processes measure professional practice or performance and then compare it to professional standards or targets to audit professional performance.

 Reminders

Reminders are any patient or clinical encounter-specific information to prompt clinicians to recall information or consider a specific process of care.

Manual paper reminders do not use computers in the production or delivery of reminders or in selecting target patients. They range from simple notes attached to the front of charts (‘static’ prompts) to more sophisticated reminders given under specific conditions for specific types of patients (‘dynamic’ prompts).

Computer generated paper reminders are those where a computer is used either to generate paper reminders or to identify patients for whom health professionals should receive a paper reminder.

Point-of-care computer reminders are those where computer reminders are delivered through a computer to health workers while they are engaged in the concerned activity.

 Internet-based or computerized educational materials

The distribution of electronic recommendations for clinical care, including clinical practice guidelines. The materials are usually delivered through mass mailings and/or published on websites.

 Outreach visits and mentoring

One way to improve health worker practices is to provide educational outreach visits. Trained personnel visit health workers at their points of practice and inform them how to improve their practice. The information given may include feedback about their performance, or may be based on overcoming obstacles to change. These face-to-face interactions have also been referred to as ‘university-based educational detailing’, ‘academic detailing’ and ‘educational visiting’.

 Multifaceted interventions

The combinations of two or more strategies to improve practices.

 Local opinion leaders

The identification and use of local opinion leaders to promote the implementation of guidelines.

 Local consensus processes

Formal or informal local consensus processes to promote the implementation of guidelines.