This guide is designed for African ministries of health creating a community level quality of care scorecard management tool. If you are from an African ministry of health, we can support you through this process. Contact us, at ALMA, for support.
If you are not from an African ministry of health, you can still follow this process to create a new community level quality of care scorecard management tool and adapt it for your needs.
We offer an online course on creating a new scorecard management tool. The course includes 2 specific lessons on quality of care community scorecard tools. It is free to enrol and you can learn at your own pace.
Process for creating a new quality of care community scorecard management tool
This process shows 8 common steps countries have taken to introduce a quality of care community scorecard tool:
- Get support and advocacy for the scorecard tool from different stakeholders and encourage them to become advocates
- Choose suitable indicators for your community’s priorities
- Integrate the scorecard tool into existing community structures and processes
- Set up a regular review process and create a standard operating procedure
- Create paper based reporting forms for scoring
- Integrate reporting into the national health management information system (HMIS)
- Create training material and train stakeholders on how to use the scorecard process
- Monitor and support the implementation of the scorecard tool
We can help and guide this process. However, the process must be country led and community led to make sure the scorecard management tool reflects your vision and priorities.
Step 1: Get support and advocacy for the scorecard tool from different stakeholders and encourage them to become advocates
You need support and advocacy from a variety of stakeholders for the quality of care community scorecard tool to be a success. You should try to involve:
- political leaders (at national, regional and district level)
- ministry of health programme leaders and technical officers
- partner organisations in your country
- sub national stakeholders such as regional or district level directors and officers
- community leaders
Your stakeholders should understand:
- what a scorecard management tool is
- what the benefits are of creating a scorecard management tool
- how it will help improve health outcomes in their community
- how they can be involved to help to make the scorecard management tool a success
A diverse group of stakeholders representing a wide range of views helps to create a scorecard tool that is a true reflection of your needs and priorities.
Step 2: Choose suitable indicators for your community’s priorities
You should involve stakeholders – including community members – when choosing indicators for the quality of care community scorecard. You should speak with stakeholders to understand their views and concerns about the services at primary health facilities. This will help you to collectively identify indicators that can address these concerns.
Countries generally choose indicators that reflect their priorities based on their national quality of care protocols and their community health strategies. They also focus on quality of care indicators that are not usually available in health management information systems.
Indicators should be easy to understand and scorable by community members. The most common examples include:
- caring, respectful and compassionate healthcare
- waiting times
- availability of medicines, supplies and services
- ambulance management and services
- clean and safe health facilities
- facility infrastructure
While there is no limit to how many indicators can be on your quality of care community scorecard tool, we believe around 8 indicators is appropriate. You don’t want to have too many indicators as it might make it difficult for community members to finish the scoring.
Step 3: Integrate the scorecard tool into existing community structures
Your quality of care community scorecard tool will be more successful if there are specific people who are responsible for:
- organising community scorecard meetings
- facilitating the scoring session
- facilitating the action plan sessions
If you align the scorecard tool with your country’s existing national community strategies and structures, they might include people who could take on these responsibilities. Using existing structures (such as local community forums) will help increase the sustainability of the scorecard tool.
If no suitable community structures exist, you could identify existing community groups where local issues are discussed and addressed.
Ethiopia’s experience creating new structures
The Federal Democratic Republic of Ethiopia government created client councils to manage the community scorecard tool process. Client council members are responsible for organising scorecard tool meetings with a group of around 30 citizens living within a health facility’s catchment area.
Client councils include around 7 community members. To make sure the councils reflect the diversity of the communities, council members are selected based on diverse criteria such as:
Client council members should also be:
- regarded as leaders by the community
- willing to be part of the council for at least 1 year
Ghana’s experience using existing structures
In the Republic of Ghana, the community scorecard tool was integrated into the national community strategy. This strategy is known as Community based Health Planning and Services (CHPS).
The strategy led to the creation of community health management committees. These committees are responsible for encouraging community members into being more active participants in planning and improving health services.
These community health management committees organise the community scorecard tool meetings and facilitate the scoring and action plan sessions.
Step 4: Set up a regular review process and create a standard operating procedure
How often community members should score indicators
To increase the sustainability of your quality of care scorecard, you should decide how often you want community members to score the indicators. Many countries score their indicators every 3 months. The countries find it works well because it:
- is regular enough so people remember to do it and how to do it
- is not too often though that it becomes too much work for everyone involved in the process
- gives participants 3 months to try and resolve an action that might be underperforming
Roles and responsibilities of stakeholders
You should make clear what you expect from all your different stakeholders. If you have national , regional and district level officials involved, consider how they can help you introduce and maintain the quality of care community scorecard tool.
In Ghana, there are set roles for different people to support the running of the community scorecard tool:
- Chair of the Community Health Management Committee convenes and facilitates the scoring sessions
- Sub district health directorates provide the pencils and scoring forms. They also provide routine supervision to make sure scoring sessions are happening
- CHPS coordinators (as part of the district and regional health offices) supervise sub districts and use the scorecard tool to inform higher level actions
Rules for meetings
There will be different meetings as part of the regular scorecard tool process, including:
- scoring sessions
- action plan sessions
When establishing rules for meetings, you should consider:
- the minimum number of people who should attend (this is known as quorum)
- who will lead the meetings
- how long the meetings will last for
For the scoring sessions, the facilitator:
- explains the objectives and definitions of each indicator
- guides the group discussion for each indicator
Scoring sessions and action plan sessions usually take 1 to 2 hours.
Rules for scoring indicators
You should also establish rules for scoring indicators. There are different approaches to scoring and you should find the best one to suit your community. For example, Ghana and Ethiopia have chosen 2 different methods, but both are successful.
In Ghana, community members vote on each indicator on a scale of 1 to 3 (where 1 is bad and 3 is good). For each indicator, the score that receives the most votes is recorded.
In Ethiopia, community members vote by holding up coloured paper representing different scores:
- red: bad
- amber: average
- green: good
The coloured paper that receives the most votes is recorded on the scoring sheet.
Creating action plans
Action plans are one of the most important parts of the scorecard tool process. They help increase action and improve accountability. You should think about how you will create action plans:
- Who should be involved in creating action plans?
- Who is responsible for writing up the action plan?
- Who is responsible for monitoring the implementation of actions?
- Where will the action plans be discussed? (at community, district and regional levels)
The process you choose should be:
- easy to understand by everyone involved in the process
- written as guidelines to set up a standard operating procedure
This is the process used in Ghana for creating action plans:
- Community members create action plans immediately after the scoring sessions
- Chair of the Community Health Management Committee writes down the actions on a paper form
- Chair of the Community Health Management Committee shares the action plan with the health facility
- Health information officer puts the action plans into the Scorecard Web Platform for monitoring the progress of the actions
Step 5: Create paper based reporting forms for scoring
You will need to create paper based reporting forms for community members to do the indicator scoring. A form should be easy to understand and simple for people to fill in and complete.
To help you get started, we have created a simple reporting form you can adapt for your own quality of care community scorecard tool. Download the Microsoft Word template.
You can customise this template by including the:
- government or ministry crest or coat of arms
- name of your quality of care community scorecard tool (if you have one)
- indicators you have chosen from step 2 of this process
Step 6: Integrate reporting into the national health management information system (HMIS)
It can be useful to add the scoring data into your national health management information system, such as DHIS2, if possible.
There are many benefits to integrating this data into these systems, such as:
- aggregating the data at higher levels to see quality of care performance at district, regional and national levels
- increasing sharing of the data and improving transparency
- providing real time access to scorecard data to anyone with access to Scorecard Web Platform
Step 7: Create training material and train stakeholders on how to use the scorecard process
You should train everyone involved in the scorecard process to make sure they understand how to:
- score indicators
- create actions that follow the SMART criteria (specific, measurable, assignable, realistic and time bound)
- track the progress of actions being implemented
Create training material
Good training uses a mix of theory and practice. When creating training material, you should consider:
- what the training will include
- what type of materials are needed (such as training guides, videos and PowerPoint presentations)
- who will lead the training sessions
Train everyone involved
After you have created the training material, you can introduce and train everyone involved in the scorecard process.
It is important that you provide training the trainer courses to ministry of health officials at national , regional and district level so they can provide support to others as part of their job.
We also recommend you train:
- community leaders who will help the community scoring and action plan sessions
- partner organisations so they can support the process and help track the progress of actions
In Ghana, the training takes 2 days. The training is provided to:
- community members (CHMCs)
- health professionals
- key regional and district staff
On the first day, the training includes:
- how to conduct a scoring session
- how to develop action plans
- a simulation exercise to assess participant understanding
On the second day, participants go to their communities and conduct a real scoring session and develop action plans. The community members do this with the support of national, regional, and district staff to guide them and help if necessary.
Most training sessions have been done in district capital cities with no more than 50 people. At these sessions, 5 communities are trained with a maximum of 10 participants from each community.
Step 8: Monitor and support the implementation of the scorecard tool
You should regularly check and support people involved to make sure they are using the scorecard tool process effectively.
We recommend you have regular discussions with:
- community leaders
- district level national officers
- other relevant sub national officers
Through these discussions, you can:
- make sure they are confident using the scorecard tool process, scoring indicators and creating and tracking actions
- provide help to increase their scorecard tool skills and improve the use of the scorecard tool in their community
In Ghana, the regional and district level CHPS coordinators check the progress of the scorecard tool as part of their quarterly supervisions. These supervisions help make sure the community members are doing the scoring and action plan sessions. They will also provide support where needed.
Summary and next steps
Following these 8 steps will help you create an effective and sustainable quality of care community scorecard tool that will improve health outcomes across your communities.
You can customise and change these 8 steps so they are relevant to your country’s processes. Your scorecard tool will be more successful if the process is:
- country led and community led
- reflects your vision and priorities
If you’re from an African ministry of health, we can support you through this process. Contact us, at ALMA, for support.