Implementing a nationwide quality improvement approach in health services.
OBJECTIVE
The purpose of this paper is to present an innovative quality improvement intervention developed in Morocco and discuss its implementation. Until 2004, the Moroccan Ministry of Health (MoH) encouraged pilots of quality improvement approaches but none of them were revealed to be sustainable. Internal assessments pinpointed factors such as lack of recognition of the participating team's efforts and lack of pressure on managers to become more accountable. In 2005, Morocco opted for an intervention called "Quality Contest" (QC) targeting health centres, hospitals and health district offices and combining quality measurement with structures ranking, performance disclosure and reward system.


METHODS
The QC is organized every 18 months. After the self-assessment and external audit step, the participating structures are ranked according to their scores. Their performances are then disseminated and the highest performing structures are rewarded.


RESULTS
The results showed an improvement in performance among participating structures, constructive exchange of successful experiences between structures, as well as communication of constraints, needs and expectations between MoH managers at central and local levels; the use of peer-auditors was appreciated as it enabled an exchange of best practices between auditors and audited teams but this was mitigated by the difficulty of ensuring their neutrality; and the recognition of efforts was appreciated but seemed insufficient to ensure a sense of justice and maintain motivation.


CONCLUSIONS
This intervention is an example of MoH leadership that has succeeded in introducing transparency and accountability mechanisms (ranking and performance disclosure) as leverage to change the management culture of the public health services; setting up a reward system to reinforce motivation and adapting continuously the intervention to enhance its sustainability and acceptability.
School of Public Health, Université Libre de Bruxelles, Brussels, Belgium and Direction des Hôpitaux et des Soins Ambulatoires, Ministry of Health, Rabat, Morocco.
Amina
A
Sahel
Vincent
V
DeBrouwere
Bruno
B
Dujardin
Guy
G
Kegels
Nejoua
N
Belkaab
Abdelali
A
Alaoui Belghiti
D003906:Developing Countries; D006296:Health Services / Q000706:statistics & numerical data*; D006801:Humans; D009018:Morocco; D011634:Public Health / Q000379:methods*; D058996:Quality Improvement
Leadership; Management; Quality