Medical Sciences Project Topics

Factors Affecting Quality of Laboratory Services at Infectious Diseases Hospital, Kano – Nigeria

Factors Affecting Quality of Laboratory Services at Infectious Diseases Hospital, Kano – Nigeria

Factors Affecting Quality of Laboratory Services at Infectious Diseases Hospital, Kano – Nigeria

Chapter One

General and Specific Objectives

 General objective

To evaluate the quality of laboratory services among adult HIV/AIDS patients attending infectious diseases hospital (IDH) Kano.

Specific objectives

  1. To assess the satisfaction level and factors associated with the quality of laboratory services among adult HIV/AIDs patients attending
  2. To determine the barriers in accessing laboratory services among adults HIV/AIDs patients attending infectious diseases hospital (IDH) Kano State.
  3. To identify factors affecting quality of services from service providers‘



 Historical Perspectives about Concept of Quality

Quality has become an increasingly major part of our lives. People are constantly looking for quality products and services. The existence of this desire for quality has caused firms and organizations throughout the world to consider it as an essential component of any service and production process. Quality is a strategic differentiator tool for sustaining competitive advantage. Improving quality through improving structures and processes leads to a reduction of waste, rework, and delays, lower costs, higher market share, and a positive company image.6,7 As a result, productivity and profitability improve.8 Therefore, it is very important to define measure and improve quality of healthcare services.

Quality, because of its subjective nature and intangible characteristics, is difficult to define. Definitions vary depending on whose perspective is taken and within which context it is considered. No single universally accepted definition exists. Quality, therefore, has been defined as ‗value‘9 ‗excellence,‘10 ‗conformance to specifications,‘11 ‗conformance to requirements,‘12

‗fitness for use‘16; ‗meeting and/or exceeding customers‘ expectations‘13, and ‗consistently delighting the customer by providing products and services according to the latest functional specifications which meet and exceed the customer‘s explicit and implicit needs and satisfy producer/provider‘.14

Healthcare service quality is even more difficult to define and measure than in other sectors. Distinct healthcare industry characteristics such as intangibility, heterogeneity and simultaneity make it difficult to define and measure quality. Healthcare service is an intangible product and canot physically be touched, felt, viewed, counted, or measured like manufactured goods. Producing tangible goods allows quantitative measures of quality, since they can be sampled and tested for quality throughout the production process and in later use. However, healthcare service quality depends on service process, customer, and service provider interactions.15, 16 Some healthcare quality attributes such as timeliness, consistency, and accuracy are hard to measure beyond a subjective assessment by the customer.

It is often difficult to reproduce consistent healthcare services. Healthcare services can differ between producers, customers, places, and daily. This ‗heterogeneity‘ can occur because different professionals (e.g. physicians, nurses, etc.) deliver the service to patients with varying needs. Quality standards are more difficult to establish in service operations. Healthcare professionals provide services differently because factors vary, such as experience, individual abilities, and personalities.16 Healthcare services are simultaneously produced and consumed and cannot be stored for later consumption. This makes quality control difficult because the customer cannot judge ‗quality‘ prior to purchase and consumption.17 Unlike manufactured goods, it is less likely to have a final quality check. Therefore, healthcare outcomes cannot be guaranteed.

Definitions of terms pertaining to quality

Quality control: The collection of mechanisms used to determine accuracy, reliability and consistency of assays or tests in a clinical laboratory.

Internal Quality Control (IQC): It includes all methods which are performed every day by the laboratory personnel with the laboratory‘s materials and equipment. It checks primarily the precision (repeatability or reproducibility) of the method

External Quality Control (EQC): It includes all methods which are performed periodically (i.e. every month, every two months, and twice a year) by the laboratory personnel with the contribution of an external center (referral laboratory, scientific associations, diagnostic industry etc.). It checks primarily the accuracy of the laboratory‘s analytical methods. However, there are certain EQC schemes that check both the accuracy and the precision.

Quality in healthcare system

Quality healthcare is a subjective, complex, and multi-dimensional concept. Donabedian defined healthcare quality as ‗the application of medical science and technology in a manner that maximizes its benefit to health without correspondingly increasing the risk.18 He distinguishes three components of quality: 1) technical quality, 2) interpersonal quality, and 3) amenities. Technical quality relates to the effectiveness of care in producing achievable health gain. Interpersonal quality refers to the extent of accommodation of patient needs and preferences. Amenities include features such as comfort of physical surroundings and attributes of the organization of service provision.19

Øvretveit defines quality care as the Provision of care that exceeds patient expectations and achieves the highest possible clinical outcomes with the resources available‘.20 He developed a system for improving the quality of healthcare based on three dimensions of quality: professional, client, and management quality. Professional quality is based on professionals‘ views of whether professionally assessed consumer needs have been met using correct techniques and procedures. Client quality is whether direct beneficiaries feel they get what they want from the services. Management quality is ensuring that services are delivered in a resource- efficient way.

According to Schuster et al., good healthcare quality means, ―providing patients with appropriate services in a technically competent manner, with good communication, shared decision making and  cultural  sensitivity‖.  21  For  Lohr,  quality  is  ―the  degree  to  which  healthcare  services  for individuals and population increases the likelihood of desired healthcare outcomes and is consistent with the current professional knowledge‖. 22

Mosadeghrad  defined  quality  healthcare  as  ―consistently  delighting  the  patient  by  providing efficacious, effective and efficient healthcare services according to the latest clinical guidelines and standards, which meet the patients needs and satisfies providers‖. 15 He identified 182 attributes of quality healthcare and grouped them into five categories: environment, empathy, efficiency, effectiveness and efficacy. Quality healthcare includes characteristics such as availability, accessibility, affordability, acceptability, appropriateness, competency, timeliness, privacy, confidentiality, attentiveness, caring, responsiveness, accountability, accuracy, reliability, comprehensiveness, continuity, equity, amenities, and facilities.17

Various healthcare stakeholders‘ perspectives, desires and priorities must be considered in any effort to define, measure, and improve quality of healthcare. While several empirical studies have been carried out to assess the quality of healthcare organizations,23, 24 few researches have been conducted to identify factors that affect quality of healthcare services.

Quality of care consist of ― …the degree to which health services for individuals and populations increase the likelihood of desired health outcomes, are consistent with current professional knowledge, and meet the expectations of healthcare users.‖25

Quality in laboratory medicine should be defined as the guarantee that each single step throughout the total testing process is correctly performed, thus assuring valuable medical decision-making and effective patient care.26

The concept of quality is elusive and different people interpret/define quality differently. David Garvin, in his book ‗managing quality‘ summarised five principal approaches to defining quality: transcendental view of quality, product-based view, user-based view, manufacturer-based view and value-based view.27

The three commonly used definition of quality of care are by Donabedian who defined quality as “That kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of expected gains and losses that attend the process of care‖.27




Study Area

Infectious Diseases Hospital (IDH) was established in the early 1960s‘ as an isolation unit for smallpox patients. Subsequently the unit was expanded into a fully-fledged hospital and caters for all epidemic diseases prevalent in the state, such as Measles, Meningitis, Cholera, Pertussis, TB as well as HIV/AIDS. At present, the hospital has 250-bed capacity with three wards (male, female and pediatrics) and a new MDR clinic. It has a laboratory, an X-ray unit and a pharmacy providing 24 hours dispensing services. A Medical Director heads this hospital, which has over 120 staff including four Medical officers, 48 Nurses, 27 PHC staff, 17 Laboratory personnel, 6 X-ray personnel, 5 Medical records, 6 Pharmacists and 44 other workers.

IDH provides comprehensive testing, treatment and care for HIV/AIDS under the support of USAID/PEPFAR implemented by FHI 360. The hospital offers HIV counseling and testing, ART services, treatment of STIs OIs including TB, and palliative care. The FHI 360 project has provided extensive infrastructural upgrade and refurbishing and power supply assistance in the main laboratory. FHI 360 provides support in the training of doctors, nurses, counselors and laboratory scientists, technicians to strengthen the delivery of ART and provides continuous monitoring and mentoring at all points of service. FHI 360 is also responsible for test-kits and drugs procurement, logistics and chain management strengthening.

Study Design

Mixed methods study comprising descriptive cross–sectional study among the adult HIV/AIDS clients attending ART clinic and accessing laboratory services, including laboratory service providers and a qualitative study among some HIV positive patients at IDH Kano was conducted.

Study Population

  1. Alladult PLWHA 18 years or older, who visited IDH ART clinic for at least three months and referred to ART-Laboratory for monitoring tests, including clinical chemistry (liver and renal function), haematology (Complete Blood Count, CD4 count) and fasting blood sugar (FBS).
  2. All laboratory service providers who perform bench work for investigations pertaining to HIV/AIDS



Baseline Socio-Demographic Data

Table 1: Socio-demographic characteristics of respondents in IDH, 2014 (n=212)



The overall satisfaction level on laboratory services was high, which is suggestive of good quality laboratory services. The overall satisfaction on ART laboratory services in IDH by HIV/AIDS patients was 97.6%; this reported result could be explained in two possible ways; one explanation could be due to introduction of social desirability biases by clients as clients might not be ready to tell their dissatisfaction status freely since interviews were conducted within the hospital setting. However, unless special precautions are taken, clients might be reluctant to reveal their opinions for fear of alienating their service providers as laboratory services are given free of charge.68 A similar study conducted by Million Belay et al on patients‘ satisfaction on ART laboratory service in selected Governmental hospitals, Sidamma zone, southern Ethiopia, showed 90.7 % satisfaction level.69




In conclusion, the satisfaction level of the clients on laboratory services received was high, which suggested acceptable quality of services offered. Form of visit to HF (follow-up visit), and

―waiting  time‖  before  clients  are  attended  by  service  providers,  were  found  to  be  the  factors associated with client satisfaction. Inadequate work force was identified as one of the major factors affecting quality of laboratory services by 80% of service providers, inadequate training of laboratory personnel (72%), lack of EQA and IQC on some tests (45%), interrupted power supply that led to frequent equipment breakdown (86%) and infrastructural inadequacy (space) to accommodate all the equipment, staff, as well as the patients (64%). The clients identified stigma, location of the laboratory distant from the ART clinic and lack of awareness on the importance of the laboratory tests in the management of the patient as barriers to accessing laboratory services.


  1. The State MoH should provide adequate work force to the laboratory and train each staffat least twice in a year for quality
  2. The facility in collaboration with SMoH should provide adequate space for the laboratoryto accommodate ever-increasing demand for laboratory services by HIV/AIDS patients on ART.
  3. The Ministry of health should look into the possibility of providing a separate samplingarea within the ART clinic to improve service uptake by the
  4. Counseling sessions should be organized and conducted monthly by the HOD laboratoryat the ART clinic on the importance of laboratory services to patients on ART to improve awareness and service


  • PettiCA, Polage CR, Quinn TC et al: Laboratory medicine in Africa: a barrier to effective health care. Clin Infect Dis. 2006; 42:377–382.
  • MindayeT, Taye B: Patient‘s satisfaction with laboratory services at antiretroviral therapy clinics in public hospitals, Addis Ababa, Ethiopia. BMC Research Notes 2012, 5:184.
  • AbimikuAG: Building laboratory infrastructure to support scale-up of HIV/AIDS treatment, care, and prevention. Am J Clin Pathol. 2009; 131:875-886.
  • End of project evaluation of Global HIV/AIDS Initiative Nigeria; Final Report, January-2011; pp: 68-74.
  • Roemer MI, Montaya-Aguilar C. Quality assessment and assurance in primary health Geneva, World Health Organization, 1998. Publication number 105: 82.
  • Lagrosen Y, Lagrosen S. The effects of quality management – a survey of Swedishquality  Intern J of Oper. & Prod Manag. 2005; 25: 940–52.
  • Rahman SB. A comparative study of TQM practice and organizational performance withand without ISO 9000  Int J of Qual. & Reliability Manag. 2001; 18: 35-49.
  • AlexanderJA, Weiner BJ, Griffith  Quality improvement and hospital financial performance. J of Organisational Behaviour. 2006; 27: 1003–29.
  • Feigenbaum AV. Quality control: Principles, practice, and administration 1951; NewYork: McGraw-Hill.
  • PetersT, Waterman  In search of excellence: lessons from America‟s best run companies 1982; New York: Harper and Rowe.
  • Gilmore Product conformance. Quality Progress 1974; 7: 16–9.