COPE®

COPE® (client-oriented, provider-efficient services) is a relatively simple process for improving quality in health services. COPE encourages and enables service providers and other staff at a facility to assess the services they provide jointly with their supervisors. Using various tools, they identify problems, find the root causes, and develop effective solutions. Although going through this process of self-assessment is not training to perform tasks correctly, it makes the participants aware of good practices because the assessment guides are based on international standards. Equally important, the self-assessment approach creates involvement and ownership in the quality improvement process.

COPE is cost-effective and does not involve large investments of time because some activities may be conducted while staff carry out their routine work. It is also results-oriented.

The COPE tools include:

• A series of self-assessment guides, including a record-review checklist
  
• Client-interview guides
  
• Client-flow analysis
  
• Action plan
  

COPE was originally developed for family planning clinics in Kenya and Nigeria in 1988, and since then has been introduced in 50 countries around the world, with proven success. Over the years, the COPE tools have been adapted for a wide range of health services.

How Is COPE Implemented?
The first COPE exercise at a site is completed over a period of two to three days. A facilitator conducts the introduction with site supervisors, who, at the same time, learn to facilitate the process so that they will be able to conduct follow-up sessions and also introduce the COPE process elsewhere. The introduction begins with an exercise to define quality services by asking providers to articulate how they expect to be treated when seeking health services.

• Staff use 10 self-assessment guides containing several trigger questions. The guides are based on the clients' rights and staff's needs framework. At larger sites, the staff break up into teams assessing the services they provide according to one or two guides each. Small sites (fewer than 10 people) may conduct the self-assessment over a few weeks along with their regular work, using one or two guides at a time.
  
• The client interviews were developed to increase staff's understanding of the client perspective. To help staff "break the ice," COPE includes a guide for conducting interviews with clients. (Sites using COPE are increasingly expanding their definition of customers to include nonusers of the services and the community overall, and to solicit their opinions as well. In addition, internal customers--such as fellow workers not participating in the actual COPE exercise--may also be interviewed using the self-assessment guides.)
  
• The self-assessment guides and client interviews provide staff with information to identify problems related to the service-delivery process and to develop an action plan. Staff identify and state the problems, their root causes, and appropriate solutions. The action plan also contains information on assignments for staff to take responsibility for given actions and dates by when actions will be completed.
  

Finally, the institutionalization of COPE requires establishing a COPE committee. Some organizations have vested this responsibility with already existing committees or teams. Any type of quality improvement is a long-term process. To nurture this process, it is important to ensure site follow-up and management support.

EngenderHealth's COPE® Handbook: A Process for Improving Quality in Health Services, Revised Edition (2003) is a resource to help COPE facilitators orient managers, train site facilitators, guide facility staff in using the COPE tools, and adapt the COPE process and tools to best fit a facility's needs. This revised and improved version of the classic 1995 COPE handbook is more focused on the "how-to" aspects of performing COPE exercises and contains more information on orienting key managers, on helping facilitators prepare for the COPE process, and on enhancing facilitation skills.

To accompany the new COPE handbook, EngenderHealth has developed a number of content-specific COPE toolbooks containing the self-assessment guides, record-review checklists, client-interview guides, and client-flow analysis forms needed to conduct a COPE exercise. These toolbooks cover such areas as reproductive health, family planning, maternal health, adolescent reproductive health, cervical cancer screening, and HIV and sexually transmitted infection services.