Crossing the quality chasm in resource-limited settings

A young school-age boy with severe respiratory distress presented to the remote hospital. Previously, the boy had been seen by untrained private clinicians in the community three times over four days. At presentation to the hospital, the child was evaluated by a mid-level practitioner who provided an initial course of antibiotics. Despite the child's ill appearance, supportive treatment including intravenous fluids and supplemental oxygen were not provided until discussion with the Medical Director three hours later. Later that evening, the electric nebulizer and oxygen concentrator became unusable after the hospital lost power owing to a blackout of the public electric grid and malfunctioning of the hospital’s backup generator. The regulator for the backup oxygen canister could not be found. At this juncture, without the ability to provide oxygen, the medical team recommended transfer. The family did not agree to transfer due to the high costs of other regional health facilities (our facility provides free services). That evening, after not being examined for over two hours by on-call staff, the child was found unresponsive with a thready pulse. Cardiopulmonary resuscitation was not initiated for over ten minutes as the midwife managing the ward did not know the procedure and the bag valve mask was not at the bedside. Following fifteen minutes of unsuccessful resuscitation, the child was declared dead.Health care providers in resource-limited settings must do better [1]. Globally, resource-limited settings have received increasing funds over the last decade for the scaling up of health programs. These resources have generally been focused on the quantity of services provided. The quality of many of the resultant services, however, has often times been low or poorly understood. Since the 1980s, quality improvement (QI) research and implementation have taken steps towards reducing the “quality chasm” [2,3] that exists in developed-country settings [4-7]. If increased