ISQUA17-3337IMPROVING CARE IN COMPLEX HUMANITARIAN CRISES: A PROCESS EVALUATION OF MÉDECINS SANS FRONTIÈRES’ APPROACH TO QUALITY

Abstract

Objectives: Medecins Sans Frontieres - France (MSF-OCP) works in 5 world regions and over 30 countries with extremely challenging contexts. Its medical portfolio is diverse, with >9,000 staff caring for patients with a variety of medical conditions, including obstetrical emergencies, malnutrition, infectious disease, traumatic injury, and chronic illness. Patients may be from areas affected by conflict or violence, may be displaced, or may reside in stable contexts that simply lack adequate health systems. Though the MSF movement is at times lauded for providing high-quality medical care in precarious situations, the sheer diversity of MSF-OCP's work presents a unique challenge in quality measurement, reporting, and improvement. Methods: In order to describe MSF-OCP's institutional approach to quality, a qualitative process evaluation was conducted to determine staff knowledge, attitudes, and practices on the topic. A limited and selective literature review was done, as well as an analysis of existing MSF-OCP quality tools. Additionally, 47 semi-structured interviews were conducted with a purposively-selected sample of medical, operational, and support staff from October-December 2016. Participant selection attempted maximum heterogeneity of medical specialties, experience levels, and staff location (headquarters and field sites). Data was compiled into 10 thematic codes and analyzed using a grounded theory method to highlight strengths and weaknesses, as well as to identify specificities of MSF-OCP's work as it relates to quality. Results: The analysis shows that quality is an organizational priority, even in complex humanitarian contexts, as evidenced by standardized clinical protocols, strict recruitment processes, in-house expert technical support, and rigorous logistical and pharmaceutical supply practices. Weaknesses of MSF-OCP's approach to quality diverged into three areas. First, staff perceive a lack of unified quality concept, language, and metrics across MSF-OCP working environments. This contributes to variation and person-dependence in the way that care is delivered, examined, and improved among MSF-OCP projects. Second, concerns with clinical care were highlighted, particularly regarding integration of necessary elements of care and care coordination both within MSF-OCP structures and with other actors. Further, care is not always viewed as patientcentered. Finally, variability in human resource management, including staff support and the individual review process, undermines MSF-OCP's capacity to consistently deliver high-quality care. Conclusion: This survey shows an inconsistent approach to quality management at MSF-OCP. Due to the diverse and challenging nature of providing assorted health services in a variety of demanding contexts, traditional approaches to quality improvement may not be adapted to MSF-OCP. A strategic framework for quality is being developed with an objective of harmonizing the approach across the organization while still allowing for adaptability to different contexts and challenges.