By Sarah Mintz, Program Director, Aceso Global, and member of the HSG Thematic Working Group on Quality in Universal Health and Health Care.
In February, I attended the first Africa Forum on Quality and Safety in Healthcare in Durban, where the quality of care revolution that is advancing across the continent was given center-stage. There were some very clear and tangible examples that demonstrate how to improve quality in healthcare.
Global health luminaries, including Donald Berwick, President Emeritus of IHI, Muhammad Pate, former Minister of Health of Nigeria, and Vuyiseka Dubula, Director of the Africa Center for HIV/AIDS Management at Stellenbosch University in South Africa, delivered keynotes; elsewhere at the Forum presenters discussed quality of care initiatives ranging from single facility interventions, to nationally scaled programs, to public sector-wide strategies that push quality onto national agendas.
Change management improves quality
In 2013, Frere Provincial Hospital in East London, South Africa, faced many challenges, including poor quality of care, labor instability, poor infrastructure and low public confidence. The new CEO, Dr. Rolene Wagner instituted a change management process that focused on quality of care; the key components of her turnaround strategy were patient-centered care and efficiency of care.
Working with her Executive Management Team (EMT), Dr. Wagner started systematically tackling issues, examining what was broken and why, and developing cost effective solutions. Interestingly, efforts to improve efficiency initially focused on social issues, such as team culture and making sure that employees felt valued. Dr. Wagner noted that organizations are organic, social spaces, so there was emphasis on cultivating the “Frere Family”. The EMT identified desired behaviors to define their work culture: no blame, respect, reflection and interdependence. The shift toward a culture of quality spread across the staff.
Now, every hospital manager thinks about improving patient safety. Teams analyze data such as falls and infection rates, and whenever these rates spike they consider avoidable factors. Clinicians and nurses are collaborating to develop an open source Electronic Patient Record system and staff are routinely collecting, analyzing and using data to drive outcomes.
Frere Provincial Hospital’s focus on quality extends to addressing patient concerns, and Dr. Wagner has been actively responding to patient concerns and comments on the hospital’s Facebook page.
Project Fives Alive scales nationally
In 2008, Project Fives Alive! (PFA!) launched in Ghana, aiming to reduce infant and child mortality. The initiative employed a Quality Improvement methodology through which local providers and system leaders used data to identify gaps and pursue a rapid cycle of testing and scaling solutions.
Dr. Ernest Asiedu, Head of Ghana’s National Quality Management Unit, discussed the evolution of the initiative. PFA! benefitted from different innovations emanating from frontline workers, which combined well with adaptive program design and steadfast commitment from leadership. Importantly, PFA! started small and was able to scale quickly by leveraging a package of change ideas validated in local health systems.
Online resources about Ghana’s successful PFA! include a Lessons Learned Guide.
Malawi institutionalizes quality management
In 2014, Malawi set-up a Quality Management Unit in the Ministry of Health, which was formalized two years later into the Quality Management Directorate (QMD). The QMD provides strategic leadership and coordination of quality management initiatives across the health sector. Dr. Andrew Likaka, Director of the QMD, discussed factors that are important in leading a quality agenda at the national level.
There needs to be alignment between implementers and policymakers. Influencing change from within the system helps to establish a pathway to sustainability; whereas creating change from without risks discordance and inefficiency. This often requires working with processes and tools that may need improvement, but it’s better to fix the current infrastructure as opposed to bringing in a new system that will not be used in the long run.
Also, country-led efforts are critical. These efforts include a thoughtful planning and design process that aligns quality programs with national strategies. Engagement of front-line workers is also key, as is including patient input throughout a program’s life. Finally, instituting a learning strategy to share knowledge across the health system and internationally is also important.
Looking forward to next year
At next year’s Africa Forum there will hopefully be a greater focus on large-scale, systematic measurement of quality. Measurement is a key component of the quality equation, yet evidence on quality of care at any level of the health system is often minimal.
As the quality revolution gains momentum, systematic measurement deserves to be at the center of the evolving agenda to produce reliable and comparable data. Without such measurement efforts to underpin and guide quality improvement, raising, and then scaling, quality will be difficult.
Are you currently conducting – or are you aware of – large-scale quality measurement efforts in Africa? If so, please share.