Quality of Care

Just after dawn, Vivej arrives at the hospital with her newborn under her arm to see you. She is 21 years old, two days postpartum, and exhausted after 36 hours of protracted labor. She is worried because she cannot get her firstborn, Esmile, to breastfeed. You learn that she delivered at a birthing clinic near her home and tells you that, even after her water broke, it took more than a day before the birth attendant could deliver her son. Your examination reveals a dire clinical picture: Esmile is lethargic and hypotonic, he has a poor suck reflex, his temperature is 39.8°C, his pulse is 180, and his breathing is labored. You check his white blood count, confirming leukocytosis. A spinal tap shows pleocytosis. You start him on fluids and antibiotics for neonatal sepsis with likely meningitis and quickly turn your attention to Vivej. Her situation is easier to diagnose but no less urgent: she is febrile and tachycardic, her blood pressure is 85/50. You give her fluids and start her on antibiotics. Ultimately, despite your efforts, both mother and child die. What went wrong? This chapter looks narrowly at these situations—the critical points after access and availability (including affordability) are already accomplished, when patients are in health care facilities that are staffed and equipped with appropriate technology. These are the situations in which the inputs are brought together and it is up to the provider to improve the health of the patient. Simply put, this chapter looks at the decisions and actions of the provider when seeing a patient. It is at this critical moment when we expect the doctor or nurse, or whoever is caring for the patient, to provide the best possible care by skillfully combining the available resources and technologies with the best clinical evidence and professional judgment. Esmile and Vivej received poor-quality care at the time of delivery. Several clinical steps were not taken. The prolonged rupture of membranes was not diagnosed in a timely manner. Vivej needed either to have her labor induced or, failing that, to be referred for a cesarean section. Prophylactic antibiotics should have been administered. Just as important, the provider at the birthing center needed support and professional oversight, with guidelines, supervision, or default referral systems in place to provide a path to the best care possible. The multiple failures in this case led to puerperal and neonatal sepsis. At worst, these conditions have a fatality rate greater than one in four; at best, they lead to protracted care, recovery, and clinical expense that could have been avoided. It is possible, however, to imagine providers in a different setting, with the same physical resources, giving better care and avoiding this tragic scenario. In the next section, we answer the questions raised in this scenario and in countless clinics and hospitals around the world. How much variation is there in the quality of care? How do we measure clinical practice? How and where has quality been systematically improved and practice variation reduced? What elements of care variation can be addressed by policy and what are the costs? Most important, what can be done to elevate the care given by providers in developing country settings? Our focus, therefore, is on the steps that can be taken to optimize the quality of care for patients like Esmile in pediatrics, Vivej in obstetrics, and other patients receiving care for the clinical conditions considered throughout the nine volumes of the third edition of ().