Widening the scope of research on quality of care

• Leveraging the strengths of different methodologies to widen the scope of research on quality of care enhances the range of tools and approaches for quality improvement. • Health provider perspectives on implementing quality metrics can be captured through embedded implementation research and used to strengthen and contextualize metrics while also addressing risk factors for burnout. • The evidence base on quality of care would benefit from further research on topics such as the use of quality metrics in interprofessional teams, quality of care in emergencies, and equity in the design and implementation of metrics.

The last decade of health system strengthening has seen a shift from target-driven interventions motivated by the Millennium Development Goal to resilience-building and a focus on universal health coverage (UHC) as part of the Sustainable Development Goals. UHC requires that 'all people and communities have access to and can use the high-quality promotive, preventive, curative, rehabilitative and palliative health services that are appropriate to their needs and expectations, while not exposing the user to financial hardship' [1].
Despite being a central tenet of Universal Health Coverage, quality of care is often the most neglected aspect of expanding access to care. Initiatives such as the Lancet Global Health Commission on High-Quality Health Systems in the SDG Era are part of an effort to address this gap by better defining quality, metrics, and structural approaches for action [2].
Recommendations to improve quality considerations have included a focus on health information systems to capture relevant quality indicators and patient outcomes, training and supervision for human resources for health to deliver quality services, and better capturing equity aspects of quality within health financing arrangements [3][4][5].
As health systems across the world continue to grapple with the COVID-19 pandemic in addition to the existing challenges of climate change, growing inequality, and increasing complexity in management of chronic disease, meaningful evidence to inform improvements in the delivery of quality care within resources constraints is an ethical imperative. While quantitative metrics gathered in health information systems and health facility surveys offer essential data, they are not sufficient in providing a robust picture of the complexities in management and delivery of quality health services. Purely quantitative metrics are also more likely to obscure inequities and miss unintended negative consequences of well-intentioned practices or policies.
Qualitative and mixed methods research on quality of care can provide more nuanced explanations of unexpected quantitative findings and reveal trends, processes, and outcomes to which traditional metrics are less sensitive. In addition to offering valuable insight into patient experiences and satisfaction, qualitative research can also address an often-missing piece of evidence on quality of care-its impact on providers. Availability of effective decision support tools, appropriate training and supervision, mental health support, and sufficient resources all influence the ability of the health workforce to deliver quality services while maintaining provider well-being, self-efficacy, and motivation. When quality of care metrics are exclusively quantitative or contributing to context-blind standardization, there may be a potentially demoralizing effect on health providers who are likely dealing with significant challenges in their efforts to improve metrics with limited resources [6]. Qualitative evidence on provider experiences and recommendations for quality improvement can help identify practice and policy adjustments with a widespread impact on the overall quality of care while also empowering providers and reflecting their daily realities more accurately.
Further, as interprofessional teams are increasingly leveraged to improve health outcomes, quality metrics facilitate their communication, priority setting, and process mapping. Therefore, the appropriateness and representativeness of these metrics will have a significant impact on patient outcomes. Implementation science tools can offer insight into how these metrics can be designed effectively and applied in practice to enhance collaborative competencies, patient outcomes, and provider satisfaction.
The COVID-19 pandemic is a critical example of the importance of capturing provider experiences to identify bottlenecks and opportunities in managing the delivery of quality essential services in emergencies while capturing the risk of burnout and potential mitigation strategies [7][8][9]. Studies assessing the link between provider mental health, burnout, and quality of care suggest small to medium negative effects of burnout on safety and quality of care as well as longer-term effects on retention and health system performance [10][11][12]. Evidence on practical approaches to mitigating these challenges remains limited. Qualitative evidence and implementation science can provide an enhanced understanding of contextual factors contributing to burnout and reveal levers for interventions and policies to improve working conditions and mental health.
Additionally, qualitative and mixed methods research can bring more opportunities for boundary-spanning hypothesis generation and testing. While quantitative metrics are embedded in current knowledge around what determines quality, access, and equity, qualitative approaches may reveal alternative theories of change and innovations in enhancing quality by identifying concerns, opportunities, and process improvement strategies outside the scope of existing benchmarks. These can then be incorporated into existing metrics, strengthening them. When diverse perspectives are systematically captured, equitable and multilevel approaches to addressing quality challenges are more likely. Embedded implementation research can provide decision-makers with context-specific information regarding what high-quality care means for patients, providers, and systems, highlighting the roles and experiences of different cadres of health workers and types of patients. This is important in ensuring that health systems are appropriately meeting needs across the subpopulations they serve.
The need for a range of methodological approaches to inform policy and practice for equitable access to high-quality care is evident. Widening the scope of published literature on quality of care leverages the strengths of different disciplines to build on quality metrics, inform multilevel approaches for quality improvement, improve implementation efforts, and create space for innovation.

Data availability
The author confirms that the evidence used in support of this commentary is available within the article.