International Journal of Health Care Quality Assurance Developing a hospital quality improvement initiative in Lesotho Joshua Berman Elizabeth Limakatso Nkabane Sebaka Malope Seta Machai Brian Jack William Bicknell
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To cite this document: Joshua Berman Elizabeth Limakatso Nkabane Sebaka Malope Seta Machai Brian Jack William Bicknell , (2014),"Developing a hospital quality improvement initiative in Lesotho", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 15 - 24 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-01-2012-0010 Downloaded on: 22 March 2015, At: 14:22 (PT) References: this document contains references to 19 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 180 times since 2014*
Users who downloaded this article also downloaded: Mosad Zineldin, Hatice Camgöz-Akda#, Valiantsina Vasicheva, (2011),"Measuring, evaluating and improving hospital quality parameters/dimensions – an integrated healthcare quality approach", International Journal of Health Care Quality Assurance, Vol. 24 Iss 8 pp. 654-662 http://dx.doi.org/10.1108/09526861111174215 Jaap van den Heuvel, Gerard C. Niemeijer, Ronald J.M.M. Does, (2013),"Measuring healthcare quality: the challenges", International Journal of Health Care Quality Assurance, Vol. 26 Iss 3 pp. 269-278 http:// dx.doi.org/10.1108/09526861311311454 Cecilia Mercieca, Sara Cassar, Andrew A. Borg, (2014),"Listening to patients: improving the outpatient service", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 44-53 http://dx.doi.org/10.1108/ IJHCQA-03-2012-0033
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Developing a hospital quality improvement initiative in Lesotho
Developing a hospital QI in Lesotho
Joshua Berman Department of Family Medicine, Boston University, Boston, Massachusetts, USA
15
Elizabeth Limakatso Nkabane Lesotho-Boston Health Alliance, Maseru, Lesotho
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Sebaka Malope
Received 15 January 2012 Revised 31 July 2012 Accepted 19 November 2012
Ministry of Health and Social Welfare, Lesotho, Lesotho-Boston Health Alliance, Leribe, Lesotho
Seta Machai Ministry of Health and Social Welfare, Lesotho, Leribe, Lesotho, and
Brian Jack and William Bicknell Department of Family Medicine, Boston Medical Center, Boston, Massachusetts, USA Abstract Purpose – Hospital-based quality improvement (QI) programs are becoming increasingly common in developing countries as a sustainable method of strengthening health systems. The aim of this paper is to present the results and lessons learned from a QI program in a large, rural, district hospital in Lesotho, Southern Africa. Design/methodology/approach – Over a 15-month period, a locally-relevant, hospital-wide QI program was developed and implemented. The QI program consisted of: planning meetings with district and hospitals staff; creation of multi-disciplinary QI teams; establishment of a QI steering committee; design and implementation of a locally appropriate QI curriculum; and monthly consultation from technical advisers. Initial QI programming was developed in three distinct areas: maternity care, out-patient care, and referral systems. Findings – Partogram documentation in the maternity department increased by 78 percent, waiting time for critically ill patients in the out-patient department was reduced by 84 percent, and emergency referral times were reduced by 58 percent. Originality/value – The design and early implementation of QI programs should focus on easily achievable, locally-relevant improvement projects. It was found that early successes helped to fuel further QI gains and the authors believe that the work building sustainable QI skill sets within hospital staff could be useful in the future when attempting to tackle larger national-level quality of care indicators. The findings add to the existing evidence suggesting that an increased use of locally-relevant quality improvement programming could help strengthen health care systems in low resource settings. Keywords Quality improvement, Continuous quality improvement, Developing country, Improvement models, PDSA Paper type Case study
Introduction The World Health Organization’s (WHO, 2007) Framework for Action for strengthening health systems identifies quality as an important factor in improving health service delivery. Healthcare quality improvement (QI) initiatives are
International Journal of Health Care Quality Assurance Vol. 27 No. 1, 2014 pp. 15-24 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-01-2012-0010
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increasingly used in resource-limited settings as a preferred method to improve quality and, in turn, improve health service delivery (Bradley and Igras, 2005; Mohammadi et al., 2007; Abdallah et al., 2002; Barker and McCannon, 2006; Catsambas et al., 2008). However, the literature on QI programming in sub-Saharan Africa, where the global disease burden is highest, is still limited (Liu et al., 2010). Lesotho-Boston University Health Alliance (LeBoHA) staff, working with Lesotho Ministry of Health and Social Welfare (MoHSW) staff, aimed to strengthen healthcare systems in Lesotho since the organization’s founding in 2003 (Babich et al., 2008). The LeBoHA has focused its work to-date on three pillars: in 2007, LeBoHA and the MoHSW initiated Lesotho’s first post-graduate physician training program in Family Medicine; in the same year, LeBoHA began an in-patient, competency-based, continuing education program for district nurses; and LeBoHA’s most recently developed pillar is a hospital management strengthening program realized through a QI initiative. Consequently, we describe the structure, results and lessons learned from this QI initiative, which was implemented in a large, rural, district hospital in Lesotho, Southern Africa. Methods Setting Motebang District Hospital, operated by Lesotho’s MoHSW, is Lesotho’s northern regional referral hospital and functions as the base for all three LeBoHA’s program pillars. Motebang bed occupancy for 2010 was 30 percent. The maternity ward had over 3,200 deliveries and outpatient department staff treated approximately 12,000 patients (Ministry of Health and Social Welfare, 2010). During this QI initiative, physicians varied from three to seven with nursing sisters varying between 50-62. Most Motebang Hospital nurses are Lesotho nationals trained at one of the countries’ four nursing schools. As Motebang Hospital is the base for the LeBoHA family medicine specialty training program, the physician cadre has a higher proportion of Lesotho nationals than elsewhere in the national healthcare system. QI initiative Over 15 months, a locally-relevant QI program was developed and implemented incorporating key district and hospital level stakeholders and staff. The QI initiative was built through a locally refined five-point strategy based on the Institute for Healthcare Improvement’s Model for Improvement (Langley et al., 2009). Joint QI planning meetings Through LeBoHA’s ongoing clinical training, staff confidence and competencies grew. As doctor and nurse clinical knowledge expanded, it became evident that limiting factors in improving patient outcomes at Motebang Hospital were inadequate intraand inter-departmental service delivery systems. In response, LeBoHA and Motebang senior hospital managers initiated planning meetings to jointly discuss interventions to target hospital systems strengthening. Planning meetings, facilitated by LeBoHA staff and attended by hospital leaders, concentrated on identifying weaknesses that would benefit from a QI initiative. A systematic prioritization matrix was developed using simple constructs: potential impact of improvement on health outcomes; improvement feasibility; ocal and national-level support; and the problem’s urgency, to prioritize areas of perceived greatest need. The inclusion criteria for individual QI
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initiatives was . 15 out of 20 in the prioritization matrix, with each construct being scored from 0-5 and then summed. These initial planning meetings brought together clinicians and managers, and benefited from active participation of multidisciplinary staff with various experience and expertise. At planning meeting conclusion, senior hospital leaders identified the three areas with a score of . 15 in the prioritization matrix: maternity care; outpatient department services; and referral systems. Instead of imposing a top-down approach to developing specific QI objectives within the Motebang senior management team, Motebang managers decentralized such specific objectives to multidisciplinary QI teams that would focus on each QI area exclusively. Forming multidisciplinary QI teams Having prioritized three general areas needing improvement, hospital leaders nominated staff from all cadres to form QI teams to develop specific objectives for each chosen area. These QI teams benefitted from having both multidisciplinary and frontline experience, which brought clinical and non-clinical perspectives. Over the next 12 months, focused, goal-driven QI projects were developed. Each QI team member attended a basic QI methods course, facilitated by LeBoHA staff using locally-relevant examples. For instance, process mapping techniques were first described using well-established hospital procedures with each QI team subsequently developing their individual QI process maps. Using these examples, QI tools, such as fishbone diagrams and simple worksheets, were developed. This just-in-time-training is an effective model for QI skill development (Quality Assurance Project, 2001). This strategy was also implemented in other important QI methods including developing goals with specific, measurable, attainable, realistic and time-bound (SMART) objectives, simple data capture systems and Plan-Do-Study-Act (PDSA) cycles. Creating a local QI steering committee In this initiative’s early stages, a QI steering committee was formed. This steering committee was developed to give frontline healthcare staff a chance to hone their QI skills and to promote local QI initiative ownership. Local leadership was promoted intentionally, which previous research suggests is imperative for successfully sustaining QI initiatives (Reinertsen et al., 2007). This committee met monthly and received written and verbal reports on each QI team’s progress, limitations and challenges. The steering committee acted as an accountability mechanism to hold QI teams responsible for meeting deadlines and encouraged each QI team’s efforts. This committee also provided a forum for mitigating issues that spanned the QI teams. Designing and implementing a locally applicable QI curriculum During the second half of each QI steering committee meeting, LeBoHA facilitators taught more advanced QI methods. A QI curriculum using local examples and interactive sessions was designed to promote lesson uptake. The six-session curriculum focused on the using methods and tools needed to sustain on-going QI initiatives. The six sessions were titled: (1) Identifying service-delivery bottlenecks. (2) Brainstorming and prioritizing goals and objectives. (3) Developing goals and creating SMART objectives.
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(4) Data capture, analysis and graph making. (5) Developing interventions and running plan-do change-cycles. (6) Motivation tools. Monthly consultation and mentorship As the three respective QI teams ran PDSA cycles, LeBoHA facilitators met monthly with each QI team to discuss results and lessons learned and develop additional PDSA cycles. Additionally, LeBoHA facilitators provided mentorship on QI methods and tools to staff while in their respective departments. Mentoring individual QI team members as they carried out more complex tasks, such as data analysis, was a crucial step in increasing their confidence. Working with QI teams in these small forums increased their understanding of system bottleneck root causes. Finally, QI technical assistance was tailored to groups and individuals’ specific needs. Instruction customization cemented the application of QI methods and tools by QI team members. Findings Participants Overall, 40 hospital staff (26 nurses or nursing assistants) were trained in QI methods and participated in the QI initiative; 12 QI steering committee members received more advanced training. Maternity department QI The maternity QI team selected improving partogram completion rates as their initial QI project. Partograms are a composite graphical record of key maternal and fetal data filled out by maternity ward staff during labour. Partogram completion is directed by the current MoHSW’s maternal treatment protocols. Motebang’s partogram base completion rate was 12 percent. During the QI program phase that ran for ten months, the maternity QI team developed and ran numerous PDSA cycles focused on raising this indictor. Specifically, dynamic staffing was introduced to bring nurses temporarily into the maternity ward at critical times from other less active wards. Additionally, short, in-service didactic sessions on the importance of completing the partograms were conducted by senior nurses and physicians who also provided on-going and on-the-job support and mentorship. These basic and low-cost interventions resulted in meaningful improvement. Although improvement was initially slow, partogram completion rose quickly as new interventions were sustained, surpassing the 60 percent completion rate goal in five months and rising to a 90 percent completion rate by month ten (Figure 1). Out-patient department QI With a large caseload and limited Out-Patient Department (OPD) personnel, staff perceived OPD waiting times to be unacceptably long. The OPD QI team prioritized lowering these waits and focused their efforts on high acuity patient queuing in the OPD. The OPD QI team developed a data collection tool that used a simple numbering system and check-off sheet for physicians. Using this newly developed tool, the OPD QI team found that, at baseline, high-acuity patients were waiting an average 179 minutes before being seen by staff. The QI team set their goal to decrease this indicator to less than 30 minutes. Over the next 11 months, numerous PDSA cycles were run.
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Figure 1. Partogram completion
The two most successful QI interventions tested by the OPD QI team were dynamic staffing and visual cues to alert staff of high acuity patients. From their own data, the OPD QI team understood that most high acuity patients would arrive early each morning. However, during the early morning, the OPD had only one physician seeing patients as other physicians were seeing inpatients. Acknowledging the human resource limitations, the OPD QI team developed a short protocol, which brought a nearby physician from his or her normal inpatient service to the OPD should multiple high acuity patients present simultaneously. Red cardboard flags, which were given to all high acuity patients or their family members by the triage nurse, were also found to lower high acuity patient waiting times. These flags alerted OPD staff, which resulted in patients being brought into the consultation room more quickly. High acuity patient waits in the OPD was reduced to a 28 minute average by month 11 (Figure 2). Referral QI Internal preparation for inter-hospital emergency referrals was identified as a significant weakness among the referral QI team members. This internal referral preparation time, defined by this QI team as the time from when a physician decides to refer an emergency patient to when the patient departs from the referring facility in an ambulance was 114 minutes at baseline. Over eight months, several PDSA cycles were tested. Data analysis revealed that the two interventions that showed the greatest improvement were the allocating daytime referral nurse and developing/disseminating an internal referral protocol. The daytime referral nurse was mandated to run all daytime emergency referrals rather than the previous system that assigned referral responsibilities to the nurse that was providing the in-patient care and treatment to the referred patient. Repetition allowed the daytime referral nurse to acquire proficiency within the process. The internal referral protocol and process map laid out specific roles and responsibilities for referral team members and provided an easily accessible
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Figure 2. High-acuity outpatient waiting time
visual representation of the referral process. The referral QI team lowered the internal hospital preparation time for emergency referrals by more than 50 percent to an average 49 minutes over the eight-month project (Figure 3). Discussion Over a 15-month QI initiative, three distinct processes were notably improved with limited additional resources. All three QI teams reached their initial objectives. Early
Figure 3. Internal emergency referral preparation time
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successes motivated hospital staff to continue pursuing additional QI projects. Prior to this initiative, hospital staff often voiced discouragement over intra- and interdepartmental service delivery, openly discussing the perceived insurmountable nature of these complex problems. This QI initiative and the resulting change in important hospital indicators have begun to alter the Motebang Hospital staff’s mind-set. Several factors may have led to this initiative’s early success. Each QI project was systemically prioritized and chosen by front-line hospital staff. Allowing local development of QI priorities increased initial stakeholder input to the QI initiative. An additional factor in this program’s success was the LeBoHA team’s long-term presence prior to the QI initiative, which allowed trusted QI facilitators to advise and mentor hospital staff in a comfortable and unobtrusive manner. Recent literature demonstrates similar QI approaches that were used successfully to strengthen more narrow programming such as highly active antiretroviral treatment (HAART) coverage in South Africa and Mozambique (Webster et al., 2012; Doherty et al., 2009; Ciampa et al., 2012), tuberculosis screening in Thailand (Thanprasertsuk et al., 2012) and reproductive health services in Uganda (Agha, 2010). Achievable early results Our results suggest that when designing and implementing QI initiatives in low resource settings, program staff should focus on easily achievable, locally-relevant improvement projects. We found that initial positive results helped to bolster motivation and participation among staff that are stretched thin by under-resourcing while caring for populations with large disease burdens. External technical assistance in developing QI initiatives should focus on facilitation that supports local staff to prioritize improvement projects. Technical assistance should also focus on mentoring staff through locally developed PDSA cycles rather than donor-imposed or otherwise externally driven priorities. Building upon early successes with locally prioritized QI projects can build QI capacity and motivation within hospital structures. This increased capacity will likely benefit hospital staff as they tackle larger-scale national QI programming. For example, facility accreditation is currently being prioritized in several sub-Saharan African countries, including Lesotho. This QI program will position Motebang Hospital to be more successful within this accreditation process. Performance visibility Throughout the numerous PDSA cycles developed and tested by all three QI teams, the intervention that showed the greatest effect was making QI data visible to providers and patients. This type of intervention has been beneficial in other resource-limited settings (Kotagal et al., 2009). In all three QI projects, run charts were used to visual mark progress for patients and staff. These run charts were completed by each QI team and were placed in administrative blocks and patient wards. This simple, yet effective intervention, motivated QI team members and also allowed senior level hospital staff to observe each team’s current status and provide consultative feedback to respective team members. Following each data collection interval, small unveiling ceremonies of the new data point were held, which brought staff members together and reinforced the QI initiative’s hospital-wide nature. These ceremonies further motivated and acknowledged the QI team’s efforts.
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Physician involvement The literature suggests that it is difficult to engage physicians in on-going QI programming; however, once engaged, their participation is imperative to the program’s success (Mohammadi et al., 2007; Ovretveit and Gustafson, 2002). Acknowledging these realities at the program’s onset, each QI team developed specific measures to engage physicians and include them in the QI team’s early work. The QI meetings were planned around physician schedules; senior physicians promoted the QI team’s goals to more junior physicians and those physicians who participated actively were recognized for their involvement through facilitator feedback and encouragement. Even with these measures in place, physician involvement in the QI programs was limited. As such, additional methods to promote physician involvement in low-resource, high-burden environments should be sought, with an emphasis on innovative engagement. Technical assistance exit strategies Exit strategies for QI technical assistance should be jointly planned by the external QI provider and the facility-based staff from the outset of the QI program development process. Engaging in joint exit planning assists stakeholders in setting realistic expectations as well as setting the stage for improved capacity building after the external assistance team leave. This program developed local leaders, through the QI steering committee, to build internal QI capacity and ownership within the hospital. A QI staff framework was also developed that integrated QI responsibilities into existing senior level job descriptions. Limitations Exclusively using process rather than outcome measures in this QI initiative is a limitation. However, obtaining easily achievable early results may further long-term QI efforts where outcome measures could be sought. Further research regarding patient outcomes will be important in solidifying our current results. Additionally, balancing measures were not integrated into QI data collection systems. Balance measures would have allowed QI teams to show if interventions that improved one indicator may have negatively affected another. Using a stepwise approach, as this QI initiative matures, it will be important to incorporate balance measures into existing QI data collection systems. Conclusion As the global health community focuses on strengthening health systems in low resource settings, locally-relevant QI initiatives may be one strategy to promote improved health service delivery. Physician involvement in QI initiatives and joint technical assistance exit planning are the QI initiative’s essential components that promote sustainability. Utilizing established, but locally revised and relevant QI methods, this QI initiative showed improvement in three self-identified, hospital process measures. Importantly, this QI initiative was built with no preconditions set out by a donor or an external organization, which allowed this initiative to be based on frontline healthcare providers’ experiences, which motivated staff and encouraged participation. These findings add to the evidence suggesting that locally relevant QI programming can help to strengthen healthcare systems in resource limited settings.
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Acknowledgements The authors thank the Motebang Hospital Senior Management team: Dr Bennett Obi, Nthabiseng Khang, Mpinane Letsie and Pulane Koatla for leading this quality improvement (QI) initiative. The Motebang staff were instrumental in this initiative’s success. The authors acknowledge the staff support from the Institute for Healthcare Improvement when planning this QI initiative and acknowledge the Quality Assurance Department, Ministry of Health and Social Welfare, for its support and encouragement. The authors also express their heartfelt gratitude to Dr William Bicknell and his family. Dr Bicknell, Lesotho-Boston Health Alliance Director and Professor of International Health and Family Medicine at Boston University, died in June 2012. He guided the Lesotho’s first family medicine residency program and the QI initiative described in this article. His drive and determination to strengthen health systems throughout the world lives on in his North America African students. References Abdallah, H., Chernobrovkina, O., Korotkova, A., Massoud, R. and Burkhalter, B. (2002), “Improving the quality of care for women with pregnancy-induced hypertension reduces costs in Tver, Russia”, Operations Research Results, Vol. 2 No. 4, pp. 1-20. Agha, S. (2010), “The impact of a quality-improvement package on reproductive health services delivered by private providers in Uganda”, Student Family Planning, Vol. 41 No. 3, pp. 205-215. Babich, L.P., Bicknell, W., Culpepper, L. and Jack, B.W. (2008), “Social responsibility, international development, and institutional commitment: lessons from the Boston University experience”, Academic Medicine, Vol. 83 No. 2, pp. 143-147. Barker, P. and McCannon, J. (2006), “A structured improvement process sustains change in health service delivery and enables future improvement”, Bulletin of the World Health Organization, Vol. 84 No. 8, p. 663. Bradley, J. and Igras, S. (2005), “Improving the quality of child health services: participatory action by providers”, International Journal for Quality in Health Care, Vol. 17 No. 5, pp. 391-399. Catsambas, T.T., Franco, L.M., Gutmann, M., Knebel, E., Hill, P. and Lin, Y. (2008), “Evaluating health care collaboratives: the experience of the quality assurance project”, University Research Co, LLC (URC) for USAID Health Care Improvement Project, available at: www. hciproject.org/node/1058 (accessed October 2011). Ciampa, P.J., Tique, J.A., Juma, N., Sidat, M., Moon, T.D., Rothman, R.L. and Vermund, S.H. (2012), “Addressing poor retention of infants exposed to HIV: a quality improvement study in rural Mozambique”, Journal of Acquired Immune Deficiency Syndromes, Vol. 60 No. 2, pp. e46-e52. Doherty, T., Chopra, M., Nsibande, D. and Mngoma, D. (2009), “Improving the coverage of the PMTCT programme through a participatory quality improvement intervention in South Africa”, BMC Public Health, Vol. 9, p. 406. Kotagal, M., Lee, P., Habiyakare, C., Dusabe, R., Kanama, P., Epino, H.M., Rich, M.L. and Farmer, P.E. (2009), “Improving quality in resource poor settings: observational study from rural Rwanda”, British Medical Journal, Vol. 339, p. b3488. Langley, G., Moen, R. and Nolan, K. (2009), The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed., Jossey-Bass, San Francisco, CA.
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Liu, C., Babigumira, J., Chiunda, A., Katamba, A., Litvak, I., Miller, L., Namagembe, I., Sekandi, J., Seicean, A., Seicean, S. and Neuhauser, D. (2010), “Finding the best examples of healthcare quality improvement in Sub-Saharan Africa”, BMJ Quality & Safety, Vol. 19, pp. 416-419. Ministry of Health and Social Welfare (2010), Annual Joint Review Report 2009/10 FY, Government of Lesotho, Maseru, Lesotho. Mohammadi, S., Mohammadi, S.F., Hedges, J., Zohrabi, M. and Ameli, O. (2007), “Introduction of a quality improvement program in a children’s hospital in Tehran: design, implementation, evaluation and lessons learned”, International Journal for Quality in Health Care, Vol. 19 No. 4, pp. 237-243. Ovretveit, J. and Gustafson, D. (2002), “Evaluation of quality improvement programmes”, Quality and Safety in Health Care, Vol. 11 No. 3, pp. 270-275. Quality Assurance Project (2001), Core Training Series: Coaching and Team Building Participant Manual, Center for Human Services, Bethesda, MD. Reinertsen, J., Gosfield, A., Rupp, W. and Whittington, J.W. (2007), “Engaging physicians in a shared quality agenda”, IHI innovation series white paper, Institute for Healthcare Improvement, available at: www.ihi.org/knowledge/Pages/IHIWhitePapers/Engaging PhysiciansWhitePaper.aspx (accessed October 2011). Thanprasertsuk, S., Supawitku, S., Lolekha, R., Ningsanond, P., Agins, B.D., McConnell, M.S., Fox, K.K., Srisongsom, S., Chunwimaleung, S., Gass, R., Simmons, N., Chaovavanich, A., Jirajariyavej, S., Leusaree, T., Akksilp, S., Mock, P.A., Chasombat, S., Lertpiriyasuwat, C., Tappero, J.W. and Levine, W.C. (2012), “HIVQUAL-T: monitoring and improving HIV clinical care in Thailand, 2002-08”, International Journal for Quality in Health Care, Vol. 24 No. 4, pp. 338-347. Webster, P., Sibanyoni, M., Malekutu, D., Mate, K., Fancois Veter, W.D., Barker, P. and Moleko, W. (2012), “Using quality improvement to accelerate highly active antiretroviral treatment coverage in South Africa”, BMJ Quality & Safety, Vol. 21 No. 4, pp. 315-324. WHO (2007), “Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action”, World Health Organization, Geneva. Corresponding author Joshua Berman can be contacted at: [email protected]
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To cite this document: Joshua Berman Elizabeth Limakatso Nkabane Sebaka Malope Seta Machai Brian Jack William Bicknell , (2014),"Developing a hospital quality improvement initiative in Lesotho", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 15 - 24 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-01-2012-0010 Downloaded on: 22 March 2015, At: 14:22 (PT) References: this document contains references to 19 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 180 times since 2014*
Users who downloaded this article also downloaded: Mosad Zineldin, Hatice Camgöz-Akda#, Valiantsina Vasicheva, (2011),"Measuring, evaluating and improving hospital quality parameters/dimensions – an integrated healthcare quality approach", International Journal of Health Care Quality Assurance, Vol. 24 Iss 8 pp. 654-662 http://dx.doi.org/10.1108/09526861111174215 Jaap van den Heuvel, Gerard C. Niemeijer, Ronald J.M.M. Does, (2013),"Measuring healthcare quality: the challenges", International Journal of Health Care Quality Assurance, Vol. 26 Iss 3 pp. 269-278 http:// dx.doi.org/10.1108/09526861311311454 Cecilia Mercieca, Sara Cassar, Andrew A. Borg, (2014),"Listening to patients: improving the outpatient service", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 44-53 http://dx.doi.org/10.1108/ IJHCQA-03-2012-0033
Access to this document was granted through an Emerald subscription provided by 374558 []
For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service information about how to choose which publication to write for and submission guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation. *Related content and download information correct at time of download.
The current issue and full text archive of this journal is available at www.emeraldinsight.com/0952-6862.htm
Developing a hospital quality improvement initiative in Lesotho
Developing a hospital QI in Lesotho
Joshua Berman Department of Family Medicine, Boston University, Boston, Massachusetts, USA
15
Elizabeth Limakatso Nkabane Lesotho-Boston Health Alliance, Maseru, Lesotho
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Sebaka Malope
Received 15 January 2012 Revised 31 July 2012 Accepted 19 November 2012
Ministry of Health and Social Welfare, Lesotho, Lesotho-Boston Health Alliance, Leribe, Lesotho
Seta Machai Ministry of Health and Social Welfare, Lesotho, Leribe, Lesotho, and
Brian Jack and William Bicknell Department of Family Medicine, Boston Medical Center, Boston, Massachusetts, USA Abstract Purpose – Hospital-based quality improvement (QI) programs are becoming increasingly common in developing countries as a sustainable method of strengthening health systems. The aim of this paper is to present the results and lessons learned from a QI program in a large, rural, district hospital in Lesotho, Southern Africa. Design/methodology/approach – Over a 15-month period, a locally-relevant, hospital-wide QI program was developed and implemented. The QI program consisted of: planning meetings with district and hospitals staff; creation of multi-disciplinary QI teams; establishment of a QI steering committee; design and implementation of a locally appropriate QI curriculum; and monthly consultation from technical advisers. Initial QI programming was developed in three distinct areas: maternity care, out-patient care, and referral systems. Findings – Partogram documentation in the maternity department increased by 78 percent, waiting time for critically ill patients in the out-patient department was reduced by 84 percent, and emergency referral times were reduced by 58 percent. Originality/value – The design and early implementation of QI programs should focus on easily achievable, locally-relevant improvement projects. It was found that early successes helped to fuel further QI gains and the authors believe that the work building sustainable QI skill sets within hospital staff could be useful in the future when attempting to tackle larger national-level quality of care indicators. The findings add to the existing evidence suggesting that an increased use of locally-relevant quality improvement programming could help strengthen health care systems in low resource settings. Keywords Quality improvement, Continuous quality improvement, Developing country, Improvement models, PDSA Paper type Case study
Introduction The World Health Organization’s (WHO, 2007) Framework for Action for strengthening health systems identifies quality as an important factor in improving health service delivery. Healthcare quality improvement (QI) initiatives are
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increasingly used in resource-limited settings as a preferred method to improve quality and, in turn, improve health service delivery (Bradley and Igras, 2005; Mohammadi et al., 2007; Abdallah et al., 2002; Barker and McCannon, 2006; Catsambas et al., 2008). However, the literature on QI programming in sub-Saharan Africa, where the global disease burden is highest, is still limited (Liu et al., 2010). Lesotho-Boston University Health Alliance (LeBoHA) staff, working with Lesotho Ministry of Health and Social Welfare (MoHSW) staff, aimed to strengthen healthcare systems in Lesotho since the organization’s founding in 2003 (Babich et al., 2008). The LeBoHA has focused its work to-date on three pillars: in 2007, LeBoHA and the MoHSW initiated Lesotho’s first post-graduate physician training program in Family Medicine; in the same year, LeBoHA began an in-patient, competency-based, continuing education program for district nurses; and LeBoHA’s most recently developed pillar is a hospital management strengthening program realized through a QI initiative. Consequently, we describe the structure, results and lessons learned from this QI initiative, which was implemented in a large, rural, district hospital in Lesotho, Southern Africa. Methods Setting Motebang District Hospital, operated by Lesotho’s MoHSW, is Lesotho’s northern regional referral hospital and functions as the base for all three LeBoHA’s program pillars. Motebang bed occupancy for 2010 was 30 percent. The maternity ward had over 3,200 deliveries and outpatient department staff treated approximately 12,000 patients (Ministry of Health and Social Welfare, 2010). During this QI initiative, physicians varied from three to seven with nursing sisters varying between 50-62. Most Motebang Hospital nurses are Lesotho nationals trained at one of the countries’ four nursing schools. As Motebang Hospital is the base for the LeBoHA family medicine specialty training program, the physician cadre has a higher proportion of Lesotho nationals than elsewhere in the national healthcare system. QI initiative Over 15 months, a locally-relevant QI program was developed and implemented incorporating key district and hospital level stakeholders and staff. The QI initiative was built through a locally refined five-point strategy based on the Institute for Healthcare Improvement’s Model for Improvement (Langley et al., 2009). Joint QI planning meetings Through LeBoHA’s ongoing clinical training, staff confidence and competencies grew. As doctor and nurse clinical knowledge expanded, it became evident that limiting factors in improving patient outcomes at Motebang Hospital were inadequate intraand inter-departmental service delivery systems. In response, LeBoHA and Motebang senior hospital managers initiated planning meetings to jointly discuss interventions to target hospital systems strengthening. Planning meetings, facilitated by LeBoHA staff and attended by hospital leaders, concentrated on identifying weaknesses that would benefit from a QI initiative. A systematic prioritization matrix was developed using simple constructs: potential impact of improvement on health outcomes; improvement feasibility; ocal and national-level support; and the problem’s urgency, to prioritize areas of perceived greatest need. The inclusion criteria for individual QI
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initiatives was . 15 out of 20 in the prioritization matrix, with each construct being scored from 0-5 and then summed. These initial planning meetings brought together clinicians and managers, and benefited from active participation of multidisciplinary staff with various experience and expertise. At planning meeting conclusion, senior hospital leaders identified the three areas with a score of . 15 in the prioritization matrix: maternity care; outpatient department services; and referral systems. Instead of imposing a top-down approach to developing specific QI objectives within the Motebang senior management team, Motebang managers decentralized such specific objectives to multidisciplinary QI teams that would focus on each QI area exclusively. Forming multidisciplinary QI teams Having prioritized three general areas needing improvement, hospital leaders nominated staff from all cadres to form QI teams to develop specific objectives for each chosen area. These QI teams benefitted from having both multidisciplinary and frontline experience, which brought clinical and non-clinical perspectives. Over the next 12 months, focused, goal-driven QI projects were developed. Each QI team member attended a basic QI methods course, facilitated by LeBoHA staff using locally-relevant examples. For instance, process mapping techniques were first described using well-established hospital procedures with each QI team subsequently developing their individual QI process maps. Using these examples, QI tools, such as fishbone diagrams and simple worksheets, were developed. This just-in-time-training is an effective model for QI skill development (Quality Assurance Project, 2001). This strategy was also implemented in other important QI methods including developing goals with specific, measurable, attainable, realistic and time-bound (SMART) objectives, simple data capture systems and Plan-Do-Study-Act (PDSA) cycles. Creating a local QI steering committee In this initiative’s early stages, a QI steering committee was formed. This steering committee was developed to give frontline healthcare staff a chance to hone their QI skills and to promote local QI initiative ownership. Local leadership was promoted intentionally, which previous research suggests is imperative for successfully sustaining QI initiatives (Reinertsen et al., 2007). This committee met monthly and received written and verbal reports on each QI team’s progress, limitations and challenges. The steering committee acted as an accountability mechanism to hold QI teams responsible for meeting deadlines and encouraged each QI team’s efforts. This committee also provided a forum for mitigating issues that spanned the QI teams. Designing and implementing a locally applicable QI curriculum During the second half of each QI steering committee meeting, LeBoHA facilitators taught more advanced QI methods. A QI curriculum using local examples and interactive sessions was designed to promote lesson uptake. The six-session curriculum focused on the using methods and tools needed to sustain on-going QI initiatives. The six sessions were titled: (1) Identifying service-delivery bottlenecks. (2) Brainstorming and prioritizing goals and objectives. (3) Developing goals and creating SMART objectives.
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(4) Data capture, analysis and graph making. (5) Developing interventions and running plan-do change-cycles. (6) Motivation tools. Monthly consultation and mentorship As the three respective QI teams ran PDSA cycles, LeBoHA facilitators met monthly with each QI team to discuss results and lessons learned and develop additional PDSA cycles. Additionally, LeBoHA facilitators provided mentorship on QI methods and tools to staff while in their respective departments. Mentoring individual QI team members as they carried out more complex tasks, such as data analysis, was a crucial step in increasing their confidence. Working with QI teams in these small forums increased their understanding of system bottleneck root causes. Finally, QI technical assistance was tailored to groups and individuals’ specific needs. Instruction customization cemented the application of QI methods and tools by QI team members. Findings Participants Overall, 40 hospital staff (26 nurses or nursing assistants) were trained in QI methods and participated in the QI initiative; 12 QI steering committee members received more advanced training. Maternity department QI The maternity QI team selected improving partogram completion rates as their initial QI project. Partograms are a composite graphical record of key maternal and fetal data filled out by maternity ward staff during labour. Partogram completion is directed by the current MoHSW’s maternal treatment protocols. Motebang’s partogram base completion rate was 12 percent. During the QI program phase that ran for ten months, the maternity QI team developed and ran numerous PDSA cycles focused on raising this indictor. Specifically, dynamic staffing was introduced to bring nurses temporarily into the maternity ward at critical times from other less active wards. Additionally, short, in-service didactic sessions on the importance of completing the partograms were conducted by senior nurses and physicians who also provided on-going and on-the-job support and mentorship. These basic and low-cost interventions resulted in meaningful improvement. Although improvement was initially slow, partogram completion rose quickly as new interventions were sustained, surpassing the 60 percent completion rate goal in five months and rising to a 90 percent completion rate by month ten (Figure 1). Out-patient department QI With a large caseload and limited Out-Patient Department (OPD) personnel, staff perceived OPD waiting times to be unacceptably long. The OPD QI team prioritized lowering these waits and focused their efforts on high acuity patient queuing in the OPD. The OPD QI team developed a data collection tool that used a simple numbering system and check-off sheet for physicians. Using this newly developed tool, the OPD QI team found that, at baseline, high-acuity patients were waiting an average 179 minutes before being seen by staff. The QI team set their goal to decrease this indicator to less than 30 minutes. Over the next 11 months, numerous PDSA cycles were run.
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Figure 1. Partogram completion
The two most successful QI interventions tested by the OPD QI team were dynamic staffing and visual cues to alert staff of high acuity patients. From their own data, the OPD QI team understood that most high acuity patients would arrive early each morning. However, during the early morning, the OPD had only one physician seeing patients as other physicians were seeing inpatients. Acknowledging the human resource limitations, the OPD QI team developed a short protocol, which brought a nearby physician from his or her normal inpatient service to the OPD should multiple high acuity patients present simultaneously. Red cardboard flags, which were given to all high acuity patients or their family members by the triage nurse, were also found to lower high acuity patient waiting times. These flags alerted OPD staff, which resulted in patients being brought into the consultation room more quickly. High acuity patient waits in the OPD was reduced to a 28 minute average by month 11 (Figure 2). Referral QI Internal preparation for inter-hospital emergency referrals was identified as a significant weakness among the referral QI team members. This internal referral preparation time, defined by this QI team as the time from when a physician decides to refer an emergency patient to when the patient departs from the referring facility in an ambulance was 114 minutes at baseline. Over eight months, several PDSA cycles were tested. Data analysis revealed that the two interventions that showed the greatest improvement were the allocating daytime referral nurse and developing/disseminating an internal referral protocol. The daytime referral nurse was mandated to run all daytime emergency referrals rather than the previous system that assigned referral responsibilities to the nurse that was providing the in-patient care and treatment to the referred patient. Repetition allowed the daytime referral nurse to acquire proficiency within the process. The internal referral protocol and process map laid out specific roles and responsibilities for referral team members and provided an easily accessible
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Figure 2. High-acuity outpatient waiting time
visual representation of the referral process. The referral QI team lowered the internal hospital preparation time for emergency referrals by more than 50 percent to an average 49 minutes over the eight-month project (Figure 3). Discussion Over a 15-month QI initiative, three distinct processes were notably improved with limited additional resources. All three QI teams reached their initial objectives. Early
Figure 3. Internal emergency referral preparation time
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successes motivated hospital staff to continue pursuing additional QI projects. Prior to this initiative, hospital staff often voiced discouragement over intra- and interdepartmental service delivery, openly discussing the perceived insurmountable nature of these complex problems. This QI initiative and the resulting change in important hospital indicators have begun to alter the Motebang Hospital staff’s mind-set. Several factors may have led to this initiative’s early success. Each QI project was systemically prioritized and chosen by front-line hospital staff. Allowing local development of QI priorities increased initial stakeholder input to the QI initiative. An additional factor in this program’s success was the LeBoHA team’s long-term presence prior to the QI initiative, which allowed trusted QI facilitators to advise and mentor hospital staff in a comfortable and unobtrusive manner. Recent literature demonstrates similar QI approaches that were used successfully to strengthen more narrow programming such as highly active antiretroviral treatment (HAART) coverage in South Africa and Mozambique (Webster et al., 2012; Doherty et al., 2009; Ciampa et al., 2012), tuberculosis screening in Thailand (Thanprasertsuk et al., 2012) and reproductive health services in Uganda (Agha, 2010). Achievable early results Our results suggest that when designing and implementing QI initiatives in low resource settings, program staff should focus on easily achievable, locally-relevant improvement projects. We found that initial positive results helped to bolster motivation and participation among staff that are stretched thin by under-resourcing while caring for populations with large disease burdens. External technical assistance in developing QI initiatives should focus on facilitation that supports local staff to prioritize improvement projects. Technical assistance should also focus on mentoring staff through locally developed PDSA cycles rather than donor-imposed or otherwise externally driven priorities. Building upon early successes with locally prioritized QI projects can build QI capacity and motivation within hospital structures. This increased capacity will likely benefit hospital staff as they tackle larger-scale national QI programming. For example, facility accreditation is currently being prioritized in several sub-Saharan African countries, including Lesotho. This QI program will position Motebang Hospital to be more successful within this accreditation process. Performance visibility Throughout the numerous PDSA cycles developed and tested by all three QI teams, the intervention that showed the greatest effect was making QI data visible to providers and patients. This type of intervention has been beneficial in other resource-limited settings (Kotagal et al., 2009). In all three QI projects, run charts were used to visual mark progress for patients and staff. These run charts were completed by each QI team and were placed in administrative blocks and patient wards. This simple, yet effective intervention, motivated QI team members and also allowed senior level hospital staff to observe each team’s current status and provide consultative feedback to respective team members. Following each data collection interval, small unveiling ceremonies of the new data point were held, which brought staff members together and reinforced the QI initiative’s hospital-wide nature. These ceremonies further motivated and acknowledged the QI team’s efforts.
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Physician involvement The literature suggests that it is difficult to engage physicians in on-going QI programming; however, once engaged, their participation is imperative to the program’s success (Mohammadi et al., 2007; Ovretveit and Gustafson, 2002). Acknowledging these realities at the program’s onset, each QI team developed specific measures to engage physicians and include them in the QI team’s early work. The QI meetings were planned around physician schedules; senior physicians promoted the QI team’s goals to more junior physicians and those physicians who participated actively were recognized for their involvement through facilitator feedback and encouragement. Even with these measures in place, physician involvement in the QI programs was limited. As such, additional methods to promote physician involvement in low-resource, high-burden environments should be sought, with an emphasis on innovative engagement. Technical assistance exit strategies Exit strategies for QI technical assistance should be jointly planned by the external QI provider and the facility-based staff from the outset of the QI program development process. Engaging in joint exit planning assists stakeholders in setting realistic expectations as well as setting the stage for improved capacity building after the external assistance team leave. This program developed local leaders, through the QI steering committee, to build internal QI capacity and ownership within the hospital. A QI staff framework was also developed that integrated QI responsibilities into existing senior level job descriptions. Limitations Exclusively using process rather than outcome measures in this QI initiative is a limitation. However, obtaining easily achievable early results may further long-term QI efforts where outcome measures could be sought. Further research regarding patient outcomes will be important in solidifying our current results. Additionally, balancing measures were not integrated into QI data collection systems. Balance measures would have allowed QI teams to show if interventions that improved one indicator may have negatively affected another. Using a stepwise approach, as this QI initiative matures, it will be important to incorporate balance measures into existing QI data collection systems. Conclusion As the global health community focuses on strengthening health systems in low resource settings, locally-relevant QI initiatives may be one strategy to promote improved health service delivery. Physician involvement in QI initiatives and joint technical assistance exit planning are the QI initiative’s essential components that promote sustainability. Utilizing established, but locally revised and relevant QI methods, this QI initiative showed improvement in three self-identified, hospital process measures. Importantly, this QI initiative was built with no preconditions set out by a donor or an external organization, which allowed this initiative to be based on frontline healthcare providers’ experiences, which motivated staff and encouraged participation. These findings add to the evidence suggesting that locally relevant QI programming can help to strengthen healthcare systems in resource limited settings.
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Acknowledgements The authors thank the Motebang Hospital Senior Management team: Dr Bennett Obi, Nthabiseng Khang, Mpinane Letsie and Pulane Koatla for leading this quality improvement (QI) initiative. The Motebang staff were instrumental in this initiative’s success. The authors acknowledge the staff support from the Institute for Healthcare Improvement when planning this QI initiative and acknowledge the Quality Assurance Department, Ministry of Health and Social Welfare, for its support and encouragement. The authors also express their heartfelt gratitude to Dr William Bicknell and his family. Dr Bicknell, Lesotho-Boston Health Alliance Director and Professor of International Health and Family Medicine at Boston University, died in June 2012. He guided the Lesotho’s first family medicine residency program and the QI initiative described in this article. His drive and determination to strengthen health systems throughout the world lives on in his North America African students. References Abdallah, H., Chernobrovkina, O., Korotkova, A., Massoud, R. and Burkhalter, B. (2002), “Improving the quality of care for women with pregnancy-induced hypertension reduces costs in Tver, Russia”, Operations Research Results, Vol. 2 No. 4, pp. 1-20. Agha, S. (2010), “The impact of a quality-improvement package on reproductive health services delivered by private providers in Uganda”, Student Family Planning, Vol. 41 No. 3, pp. 205-215. Babich, L.P., Bicknell, W., Culpepper, L. and Jack, B.W. (2008), “Social responsibility, international development, and institutional commitment: lessons from the Boston University experience”, Academic Medicine, Vol. 83 No. 2, pp. 143-147. Barker, P. and McCannon, J. (2006), “A structured improvement process sustains change in health service delivery and enables future improvement”, Bulletin of the World Health Organization, Vol. 84 No. 8, p. 663. Bradley, J. and Igras, S. (2005), “Improving the quality of child health services: participatory action by providers”, International Journal for Quality in Health Care, Vol. 17 No. 5, pp. 391-399. Catsambas, T.T., Franco, L.M., Gutmann, M., Knebel, E., Hill, P. and Lin, Y. (2008), “Evaluating health care collaboratives: the experience of the quality assurance project”, University Research Co, LLC (URC) for USAID Health Care Improvement Project, available at: www. hciproject.org/node/1058 (accessed October 2011). Ciampa, P.J., Tique, J.A., Juma, N., Sidat, M., Moon, T.D., Rothman, R.L. and Vermund, S.H. (2012), “Addressing poor retention of infants exposed to HIV: a quality improvement study in rural Mozambique”, Journal of Acquired Immune Deficiency Syndromes, Vol. 60 No. 2, pp. e46-e52. Doherty, T., Chopra, M., Nsibande, D. and Mngoma, D. (2009), “Improving the coverage of the PMTCT programme through a participatory quality improvement intervention in South Africa”, BMC Public Health, Vol. 9, p. 406. Kotagal, M., Lee, P., Habiyakare, C., Dusabe, R., Kanama, P., Epino, H.M., Rich, M.L. and Farmer, P.E. (2009), “Improving quality in resource poor settings: observational study from rural Rwanda”, British Medical Journal, Vol. 339, p. b3488. Langley, G., Moen, R. and Nolan, K. (2009), The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed., Jossey-Bass, San Francisco, CA.
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