Driving Quality Improvement in Gynecology - A Quality Indicator System for China's County-Level Hospitals

Gynecologic diseases are a significant yet often underrecognized global health burden, negatively impacting women's quality of life. In China, county-level public hospitals serve as the primary providers of care or first line of defense for managing these conditions, highlighting the urgent need for improved service quality. However, a systematic framework with specific quality indicators for gynecologic care remains underdeveloped both in China and internationally. Compared with obstetrics, progress in gynecologic care quality assessment has lagged, creating a gap between evidence and practice. The authors aimed to develop and preliminarily implement a quality indicator system to guide gynecologic care quality improvement efforts.

Quality indicators were identified through a comprehensive literature review and refined using a two-round modified Delphi survey (January-April 2024) involving 29 experts. Expert consensus on the importance and feasibility of each indicator was obtained. Based on this indicator system, the authors conducted the China Gynaecological Healthcare Quality Survey, a national cross-sectional survey across 31 provinces in mainland China (April-December 2024), sampling 435 hospitals of different types and levels. After data cleaning, a final sample of 178 hospitals was included for analysis. A hybrid weighting approach combining subjective expert judgment (percentage weight and multiplicative methods) with objective empirical data (entropy weight method) was applied. The TOPSIS (Technique for Order of Preference by Similarity to Ideal Solution) method was used to derive a comprehensive quality score (closeness coefficient [C_i]) for each hospital.

The Delphi process yielded a final framework comprising three first-level, 16 second-level, and 43 third-level indicators. Mean importance scores ranged from 7.69 to 8.97 on a nine-point scale, with variation coefficients between 0.02 and 0.20. Kendall's W coefficients increased from 0.149 to 0.220 between rounds, indicating growing consensus. The average authority coefficient across experts was 0.90, supporting the reliability of the results. The combined weights assigned to structure, process, and outcome domains were 0.455, 0.301, and 0.245, respectively. In the national survey, 178 hospitals (84 county-level and 94 provincial and municipal) were analyzed. Provincial and municipal hospitals achieved significantly higher comprehensive quality scores than county-level hospitals (median C_i: 0.421 vs. 0.397; z=-5.533, P<0.001). A significant regional difference was observed, with the eastern region scoring higher than the central and western regions (median C_i: 0.425, 0.407, and 0.402; χ²=12.214, P=0.002). No significant differences were found among hospital types (χ²=4.174, P=0.124).

The authors established mainland China's first validated indicator system for gynecologic care quality. National implementation across 178 hospitals demonstrates the framework's practical utility while revealing significant quality differences across hospital tiers and regions. This standardized evaluation framework provides a practical tool for targeted quality assessment and precision improvement in primary gynecologic care.