The assessment methods involve structural, procedural and outcome quality measures of the health care facility in the area of the Emergency Department of a Low or Middle Income Country (LMIC).

The methodology encompasses five different aspects to triangulate the quality of performance. This includes observations, inspections, file reviews, interviews and collection of outcome data.

To value the key processes and structures, a scoring system (Linkert Scale 0-1-2) is used. Selected items were scored 0 if they were not performed, not available or not existing, 1 if they were irregularly performed or available but not functioning, and 2 if they were well performed or fully available and functioning. The quantitative was analysed and results were presented as percentages of the expected performance level (e.g. adherence to local policies, or accepted international guidelines).

  • Structural quality (setup and equipment) is inspected, compared to an expected level (WHO standards, international expectations) and rated following the described method with the Linkert Scale.
  • For process quality assessment, a quality-indicator based observation of care is performed. A measurement of individual processes against target standards (EBM guidelines, WHO standards, international guidelines, local policies) is conducted and rated following the described method with the Linkert Scale.
  • Review of key documents such as patient files and service schedules were performed.
  • Outcome quality data was collected and analysed.
  • Semi-structured interviews were performed with patients, staff and management.

This kind of triangulation is conducted to enhance the validity of the data. This method determines the quality of inputs and processes in the system. It results in the development of an information package to be used for action either immediately or later.

The bundle of methods used in this assessment is feasible and effective in judging quality of care. One assessor can effectively evaluate an Emergency Department in less than 10 working days.

After the assessment, a comprehensive picture of quality of care in these departments would be presented to the management and staff, showing strengths and areas of improvement.

By presenting the motivation and attitude of health workers, it is possible to explain some of the findings.

Recommendations would be presented, showing possible ways for improvement whenever possible and appropriate.

Adherence to policies is a major aspect of the measurement of process and structure quality in this assessment.

As the results often suggest, adherence to policies could have room for improvement. As the target standards for different areas were chosen from international guidelines, it is sometimes impossible for some processes to score a high level due to a lack of structural adherence to guidelines. This approach was selected intentionally to show the gap between High-Income-Countries (HIC) estimated health care levels and local performance (what does not mean that HIC reach their own standards).

The evaluation can help to develop and prioritise interventions, activities and action plans. It can be one of the entry points into a Quality Improvement (QI) program as a purposeful step by step process to close the gap between current and expected performance.

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