A systemic approach to quality improvement in public health services.

Purpose - The purpose of this paper is to discuss the results of the first four years of implementation of a quality program called "Quality Contest" (QC). This program was implemented from 2007 onward to improve the quality of hospital services by the Moroccan Ministry of Health. The peculiarity of this intervention, held every 18 months, is that it combines several approaches (self-evaluation, external audits with feedback, hospital ranking, awards and performance disclosure) and focuses on the quality of management. Design/methodology/approach - The assessment tool used to evaluate the quality of hospital management consists of 80 items. In each contest, a score is attributed to each item based on the score given for self-evaluation and the score given by external auditors. The sum of these scores allows the global performance score of the hospital to be obtained. To compare the performances over time and among hospitals, Wilcoxon signed-rank, Wilcoxon-Mann-Whitney and Kruskal-Wallis statistical tests were used. Findings - The results of the QC organized between 2007 and 2010 revealed that the hospitals participating in all the three contests had significantly improved their performance levels in terms of the quality of management. There was also a significant association between the number of times hospitals participated in the QC and the performance scores attained. Originality/value - The paper reports an original quality improvement approach in a developing country that succeeded in triggering sustainable improvement dynamics by combining support (feedback) with reward (prizes) and pressure measures (ranking, performance disclosure).