The NPQH technical working group (TWG) conducted a situational analysis using a multi-pronged approach combining historical and new data collection to inform the development of NPQH. Table 1 illustrates the development process timeline, activities and key deliverables.
Technical working group (TWG)
The TWG was formed through expansion of the existing QA Technical Committee consisting of representatives from programmes involved with quality initiatives in the MOH. Technical guidance was provided by a WHO-appointed expert throughout the process, focusing primarily on situational analysis and stakeholder engagement, which further enhanced the contributions beyond the MOH participants.
The QA Technical Committee comprises appointed representatives from 12 programmes (Medical, Public Health, Pharmacy, Laboratory, Nursing, Allied Health Science, Food Quality and Safety, Planning, Engineering, Oral Health, Nutrition and Training Management) and key members of the Health Performance Unit. The committee had already been charged with monitoring the national QA Programme through the national indicator approach (NIA), which tracks performance across the MOH healthcare facilities. Each TWG member received an official letter of appointment from the Deputy- Director General (DDG) of Health for Research and Technical Support, indicating support for the initiative from the top level of the MOH.
This TWG was entrusted with the overall planning, design and conduct of the situational analysis, data analysis and facilitation of stakeholder consultative sessions. To accomplish these tasks, the TWG adopted a broad mix of communication methods to coordinate planned activities, including in-person meetings, virtual discussions, official letters and the exchange of emails.
A two-day design meeting involving TWG members with the WHO technical expert was held in January 2019, focusing on three primary objectives:
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(a)
To design a plan for a comprehensive situational analysis
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(b)
To design a plan of action for stakeholder engagements
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(c)
To determine the methodology for obtaining buy-in from stakeholders
Discussions also centred around how to frame questions to obtain the most useful input from stakeholders about their healthcare experiences and how the national health system can best promote quality of care at their respective levels. Following the MOH regulations, the new data collection and stakeholder engagement processes were approved by the Medical Research and Ethics Committee and registered with the National Medical Research Registry (NMRR-19-3522-50030).
Communication strategy for sensitization of stakeholders
To raise awareness and promote buy-in for the NPQH, the IHSR began communicating about the development of the new policy during all quality-related meetings and others that the IHSR staff attended, including the National QA Committee chaired by the DDG (Research and Technical Support) and the Innovation Steering Committee, which the Secretary-General and the DG of Health co-chair. The IHSR showcased the development of the NPQH in a plenary session during the National QA Convention in October 2019, attended by more than 800 participants from government, private and academic sectors. An information brief [6] was also distributed to attendees, highlighting the rationale for the NPQH and its methodology.
Guiding elements
The methodology for development of the NPQH was guided by the eight elements described in the WHO NQPS Handbook [4], which was adapted to the Malaysian context (Fig. 1). Two elements were emphasized for developing the policy: (1) stakeholder mapping, including identification of roles and responsibilities, and (2) situational analysis.
The eight elements applied in developing NPQH guided by the WHO NQPS
Stakeholder mapping
The TWG members identified potential stakeholders during their first meeting to determine which groups of stakeholders should be engaged. Engagement concentrated on community/patients and stakeholders in healthcare-related ministries involved in delivering healthcare and supporting health services. Existing communication channels, including quality-related meetings and platforms, were identified. Where no existing channels were identified, stakeholders were reached through online surveys. Table 2 outlines the stakeholders’ mapping.
Situational analysis
Situational analysis was conducted concurrently through three major methods: (i) review of quality-related documents within Malaysia, including regulations, policies and standards; (ii) stakeholder engagement through both in-person meetings and online surveys; and (iii) cataloguing of existing Quality Improvement Initiatives (QII).
Document review
A spreadsheet comprising all categories of documents as listed below was developed and distributed to the Head of the Programmes at the MOH level. Each programme identified related documents based on these categories and submitted their data to the research team. The documents included:
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i.
National health policies and plans and national quality strategies
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ii.
Quality-related legislations, regulations and statutes
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iii.
Quality-related government documents (professional training materials, protocols and guidelines)
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iv.
Performance data
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v.
Technical and vertical programme reports
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vi.
Resources to support national quality efforts (domestic budgets, local implementation partners, external agencies and aligned technical programmes)
In addition to the documents submitted by the programmes, the research team also conducted searches within the publication section of the MOH official website. All relevant documents listed were thoroughly reviewed to identify existing regulations and policies to inform the updated NPQH. Furthermore, input was sought from each programme’s focal persons to determine whether specific documents should be considered for inclusion.
The TWG gathered and reviewed a total of 443 documents. They were divided into eight groups to extract data into an Excel template to answer elements in Fig. 1 as below:
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Current national health directions or specific or disease-based programme priorities to guide the NPQH development (Element 2)
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Existing explicit local quality definition or quality domains (Element 3)
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Governance and organizational structure (Element 4)
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Improvement methods and interventions (Element 5)
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Health management information system/data systems (Element 6)
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Set of quality indicators and core measures currently monitored and its performance (Element 7)
Findings from this review were triangulated with other data sources to inform the development of the NPQH. Details of the methods and findings of this document review will be reported in a separate publication.
Quality improvement initiatives (QII) mapping/cataloguing
In the Malaysian context, a quality improvement initiative (QII) is defined as “a continuous change process that is data-driven and based on systematically planned action to increase the likelihood of optimal quality of care measured by improved healthcare processes, outcomes and client experience” [8]. Currently, these QIIs address patient safety, effectiveness, people-centeredness, timeliness of service provided, efficiency, accessibility and equity, which are applied throughout the continuum of care from community services through quaternary facilities or life cycles.
A pre-formatted spreadsheet with pre-determined variables was distributed to quality leads in the MOH who oversee QIIs led by the MOH. The specific variables corresponded to Element 4 (governance and organizational structure), Element 5 (improvement methods and interventions), Element 6 (health management information and data system) and Element 7 (quality indicators and core measures). We did not survey initiatives led by other Ministries in the government, in the private sector or those that were specific to health facilities.
The information gathered on each QII was analyzed to understand the extent of implementation and achievements and any identified gaps. They were grouped based on the following categories: (1) leading programme/division; (2) implementation and monitoring level; (3) governance structure; and (4) potential domain of impact on quality: (a) system environment; (b) reducing harm; (c) clinical care improvement; and (d) engagement or empowerment of patient, family or community. Key indicators used in each QII were mapped according to local quality domains. Details of the methods and findings of this QII mapping will be reported in a separate publication.
Stakeholder engagement
Stakeholder representatives were divided into three groups for convening: (1) general healthcare providers, (2) public/community, and (3) a targeted group of health leaders from the private, military and education sectors. Engagement of the first two groups was conducted between February and May 2019 through online surveys to obtain opinions from a wide group of healthcare workers and the public who would not be reachable through in-person engagement. The survey links and QR codes were disseminated through various channels, including email, MOH postmasters, Facebook, the official MOH website and WhatsApp groups, among other platforms. The WhatsApp group is used to distribute the survey to family members and the network of the researchers, including quality network at the national and state levels. Table 3 summarizes key stakeholders’ engagement sessions and activities.
Online survey among general healthcare providers
General healthcare providers were asked two questions about the implementation of quality improvement initiatives and what can be improved. Convenience sampling was applied. Respondent characteristics were collected, including age, sex, type of health sector and place of work.
Online survey among community
An online survey was conveniently distributed to the target sample of Malaysian people aged 18 years old and above with three open-ended questions on the areas that matter most during healthcare facility visits, strengths of the healthcare facilities and suggestions for improvement. Respondent characteristics were collected, including age, sex, estimated income and type of healthcare facility usually used.
Findings for both online surveys were analyzed separately using content analysis to identify major categories of responses for each question. Two TWG members independently reviewed the responses and coded them manually into appropriate main themes and sub-themes of each question asked. After comparing the coding, the teams agreed on the main themes and sub-themes and discussed any areas of disagreement. When consensus could not be reached, a third member was consulted to resolve the matter. Details of the methods and findings of these online surveys will be reported in separate publications.
Targeted key stakeholders
Targeted key stakeholder groups were convened twice in 2019 and 2021, respectively. The TWG identified stakeholders based on their roles and expertise in planning, implementing, monitoring and evaluating quality improvement initiatives at their programmes or facilities. The first session was held in-person in July 2019 as part of a 2-week workshop during which all three specific groups were convened separately. Sessions aimed to obtain these groups’ buy-in and seek their input about priorities for quality activities.
The second session was organized virtually in February 2021 to share the NPQH development progress and to obtain feedback on the key content areas of the draft policy and strategies. In both sessions, participants were divided into small groups to discuss a set of predetermined questions. Discussions were summarized and reported back to the entire group. TWG members facilitated and documented these sessions.
The TWG reviewed discussion summaries, meeting notes and groups’ slides presentations to familiarize themselves with the data. Two TWG members independently extracted and coded the data manually following thematic analysis. Results were compared, and any disagreements were discussed with a third member. The relationship between the key findings under each theme was mapped using the Strengths, Weaknesses, Opportunities, Threats (SWOT) framework.
Data from the document review, online surveys and QII mapping were also triangulated in the SWOT analysis to confirm the findings. The preliminary SWOT analysis of the themes underwent many iterations through the inductive process with regrouping before the TWG agreed upon the final version. We noticed the relationship of a few themes: (i) governance for quality and resources; (ii) stakeholder engagement and knowledge exchange, communication and coordination among programmes; and (iii) health management information, quality monitoring and feedback system, and quality indicators and core measures. However, we decided to maintain those as individual areas of concern to be able to see their own SWOT analysis clearly.
Drafting and refining of the policy
The NPQH first draft was prepared by the IHSR before its circulation to the TWG for comments and input in 2020. The document was organized into four key chapters, shown in Table 4.
The primary focus of writing was Part 3, in which the policy and strategic plan elements were described, shaped by the NQPS guiding principles and envisioned through the lens of a 5-year time span. This process required many rounds of monthly virtual discussions among the TWG over 1 year to negotiate, deliberate and rationalize each objective, indicator and action plan with consideration of available resources. Feedback from the second engagement sessions in 2021 identified areas of improvement among others, and included refinements of the local quality definition, action plans and indicators were incorporated in the subsequent draft.
The Strategies section was displayed with a clear operational plan covering short, medium and long-term actions, divided into yearly targeted plans, with clearly defined roles at national, state and facility levels and indicators to track progress and achievement.
Part 4 of the document focuses on the mechanism for implementing and monitoring the NPQH. It involves three major components: (i) clearly defined roles and responsibilities of MOH leadership and managers, leaders of QII, leaders and managers at healthcare facilities level, healthcare providers and citizens/clients; (ii) wide distribution of the new policy; and (iii) monitoring and evaluation of the new policy. The plan delineates the roles and responsibilities of the key groups for each area of the plan. Access to the policy will be ensured through various means, including official hard copy distribution and online sources. Close monitoring of implementation will occur through regular meetings of the existing QA Committee with additional members where appropriate. Terms of Reference of existing committees at different levels will be amended to specifically include monitoring of the NPQH achievements and the implementation of the action plan.
Senior leadership approval
Approval by senior leadership for the NPQH was required at several key points in the development process, including permission to develop the plan. Once underway, input and approvals were obtained for preliminary findings, proposed content and the strategies for communicating with stakeholders. Periodic progress updates were presented to the National QA Committee. The final presentation took place at the Director-General Special Meeting in early April 2021 to obtain input and approval from the top leadership at both the ministry and state levels. External experts and internal reviewers then reviewed the final draft policy before being officially released and launched by the Director-General of Health in October 2021 during the National Seminar for Quality in Healthcare.
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