Analysis of the degree of implementation of the HEALTHQUAL program

In evaluations of quality improvement programs, there is often a tendency to focus directly on outcomes or effects without first examining whether the program was fully implemented, only partially executed, or not implemented at all. In many cases, evaluators conclude that the program had little or no effect. However, it is difficult, if not impossible, to achieve meaningful results when the degree of implementation is low or nonexistent. This underscores the importance of assessing the degree of implementation as a prerequisite for explaining outcome gaps, analyzing the implementation process, and understanding the interaction between implementation level, context, and results. Generally, the higher the level of implementation, the more significant the potential outcomes. Nevertheless, evaluating the degree of implementation remains a methodological challenge. The objective of this article is to rigorously assess the level of operationalization or implementation of a national quality improvement initiative, the HEALTHQUAL-Haiti program. The HEALTHQUAL-Haiti program focuses on quality measurement, quality improvement activities, and the development of quality infrastructure, with the goal of enhancing patient and client satisfaction, strengthening health system performance, and improving the overall quality of care.

We developed the logic model for the HEALTHQUAL-Haiti program. Building on this model, we selected twelve key dimensions or components for qualitative assessment of the program's degree of implementation. These dimensions include: identification and measurement of patient needs and expectations; patient involvement; creation of partnerships; multidisciplinary teams/quality committees; use of scientific methods; process management; fact-based management; coaching and mentoring; staff involvement; leadership involvement; development and implementation of the quality plan; and quality program evaluation. Using explicit criteria, these components served as the basis to judge the level of implementation of the HEALTHQUAL program.

The degree of implementation of the HEALTHQUAL program varies across health facilities: Some demonstrate a low level of implementation, while others have achieved a medium level. No health facility reached a high degree of implementation.

It is important to consider these findings when planning and implementing the HEALTHQUAL program. Identifying and addressing strategies to improve the degree of implementation, particularly by targeting the underlying factors that influence it, is essential. Further research is needed to better understand and clearly define both the degree of implementation and the factors that influence it.