The Evaluation Centre for Complex Health Interventions, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
Bill and Melinda Gates Foundation, Munirka, Delhi, India.
Glob Health Action. 2021 Jan 1;14(1):1882182. doi: 10.1080/16549716.2021.1882182.
: The Lancet Global Health Commission (LGHC) has argued that quality of care (QoC) is an emergent property that requires an iterative process to learn and implement. Such iterations are required given that health systems are complex adaptive systems.: This paper explores the multiple roles that evaluations need to play in order to help with iterative learning and implementation. We argue evaluation needs to shift from a summative focus toward an approach that promotes learning in complex systems. A framework is presented to help guide the iterative learning, and includes the dimensions of clinical care, person-centered care, continuum of care, and 'more than medicine. Multiple roles of evaluation corresponding to each of the dimensions are discussed.: This paper is informed by reviews of the literature on QoC and the roles of evaluation in complex systems. The proposed framework synthesizes the multiple views of QoC. The recommendations of the roles of evaluation are informed both by review and experience in evaluating multiple QoC initiatives.: The specific roles of different evaluation approaches, including summative, realist, developmental, and participatory, are identified in relationship to the dimensions in our proposed framework. In order to achieve the potential of LGHC, there is a need to discuss how different evaluation approaches can be combined in a coherent way to promote iterative learning and implementation of QoC initiatives.: One of the implications of the QoC framework discussed in the paper is that time needs to be spent upfront in recognizing areas in which knowledge of a specific intervention is not complete at the outset. This, of course, implies taking stock of areas of incompleteness in knowledge of context, theory of change, support structures needed in order for the program to succeed in specific settings. The role of evaluation should not be limited to only providing an external assessment, but an important goal in building evaluation capacity should be to promote adaptive management among planners and practitioners. Such iterative learning and adaptive management are needed to achieve the goals of sustainable development goals.
柳叶刀全球健康委员会（LGHC）认为，医疗质量（QoC）是一种新兴的特性，需要通过迭代过程来学习和实施。鉴于卫生系统是复杂的自适应系统，需要进行这种迭代。本文探讨了评估需要发挥的多种作用，以帮助进行迭代学习和实施。我们认为，评估需要从总结性重点转向促进复杂系统学习的方法。提出了一个框架来帮助指导迭代学习，包括临床护理、以患者为中心的护理、护理连续性和“超越医学”等维度。讨论了与每个维度相对应的评估的多种作用。本文以 QoC 和评估在复杂系统中的作用的文献综述为依据。所提出的框架综合了 QoC 的多种观点。评估作用的建议既来自于对多个 QoC 计划的评估，也来自于评估经验。不同评估方法的具体作用，包括总结性、现实主义、发展性和参与性，都在我们提出的框架的维度中被确定。为了实现 LGHC 的潜力，需要讨论如何以一种连贯的方式结合不同的评估方法，以促进 QoC 计划的迭代学习和实施。本文讨论的 QoC 框架的一个含义是，需要在一开始就投入时间来认识到某个特定干预措施的知识在某些方面并不完整。这当然意味着要了解特定环境中知识的不完整性、变革理论、成功实施计划所需的支持结构等方面。评估的作用不应仅限于提供外部评估，而是在建立评估能力方面的一个重要目标应该是促进规划者和实践者之间的适应性管理。需要进行这种迭代学习和适应性管理，以实现可持续发展目标。
