A new approach to quality improvement in Kenyan health facilities

Small steps can lead yield big improvements in health service quality

Since March of this year, something remarkable has happened at the Port Florence Community Hospital in Kisumu: the average number of outpatients seen per day has doubled, from approximately 40 to 80. Matron Evelyne, the Administrator and Nursing In-Charge at this Level 3 private hospital, is clear about the reasons behind this growth. Ever since the hospital became involved in a quality improvement project implemented by Amref Health Africa, with support from the GIZ Health Sector Support Programme, clinical staff have begun paying much more attention to waiting times in an effort to prioritise patient-centred care.

The actions they have taken have cost nothing, but they have had a huge impact. According to Evelyne, the clinical staff now make a point to greet all the clients they see and to ask whether they have been served yet. If they see someone who has been waiting a long time, they ask if they can be of help.

By showing interest in patients’ needs and paying more attention to waiting times, the clinical staff have made clients feel more welcome at the facility. They are now seen more promptly, and the positive effects in terms of patient ‘traffic’ are clear for all to see. ‘The hospital management has seen the improvement in the client flow and are fully in support of the QI initiative,’ says Evelyne. ‘They are now looking at employing more staff.’

Getting to the bottom of quality challenges.

Over the past 15 years Kenya has made marked progress in improving key health outcomes, but much remains to be done to improve the quality of care provided at both public and private facilities across the country. Management deficiencies, personnel and financial constraints, lack of adherence to hygiene standards, and shortages of medical equipment are among the factors which undermine the quality of care.

This, in turn, leads to low utilisation of health services, particularly by the millions of Kenyans who do not have health insurance and must pay directly for care.

On behalf of Germany’s Federal Ministry for Economic Cooperation and Development, GIZ has been working since 2001 on the development and implementation of quality management strategies for the health sector in Kenya. This year, in partnership with Amref Health Africa, it is supporting a new approach aimed at institutionalising the Kenya Quality Model for Health (KQMH) – the national standards for health care endorsed by the Ministry of Health – in the routine operations of health facilities.

Between March and October of this year, quality improvement focal points from 47 facilities in Kisumu, Kwale, Siaya and Vihiga counties are being trained in KQMH and quality improvement concepts, and then supported through monthly mentoring visits by Amref trainers to implement practical quality improvement projects in their facilities. Quality improvement teams learn to assess their own performance against the KQMH standards, entering scores via tablet or computer into a web-based KQMH tool, and to identify areas of strength and weakness in core services or processes. Work Improvement Teams then meet to analyse the gaps in their own areas of responsibility and toidentify simple, low-cost interventions they can undertake to address some of these challenges.

What is special about this approach is the focus on getting to the ‘root causes’ of problems and tackling them systematically, rather than simply reacting to crises as they arise. This allows quality improvement teams to be more strategic in their efforts to improve quality. Small successes build on one another and generate positive momentum for change.

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‘We want to become a facility of excellence’
At the Vihiga County Referral Hospital, members of the quality improvement team are engaging enthusiastically with the process. In late June, the Amref mentors visited the hospital to present the results of the baseline assessment which had been carried out the previous month. The news was both motivating and sobering. On the one hand, the hospital scored very high on the ‘leadership’ dimension of the KQMH standards and on the provision of specific services, such as neonatal care and safe deliveries. On the other, there were certain areas, such supplies and equipment management, where there is clearly work to be done.

Mr. Francis Nyota, the Nursing In-Charge and Quality Focal Point at the hospital, listened carefully to the mentors’ report and asked detailed questions to clarify the findings. He saw that the hospital had failed to meet a number of KQMH standards because they were failing to document their work properly. For example, specific policies and protocols were not readily available, even if staff believed that they were familiar with their contents. Mr. Nyota saw that, while certain challenges, such as a lack of human resources, could not be easily remedied by the quality improvement team, other things could be: having formal job descriptions for all staff, keeping employee files complete and up-to-date, and printing out copies of standards and policies and displaying them in the relevant places within the hospital.

The first mentorship meeting lasted nearly 6 hours, but afterwards Mr. Nyota expressed that it had been a very effective use of time: ‘We have the baseline assessment and now it is us who have to act. We want to become a facility of excellence, and this begins with quality.”

Work Improvement Teams carry the process forward
The 47 facilities participating in the QI project have now moved into the next stage of the process: prioritising problems and designing mini-projects to address them. The Amref mentors are guiding Work Improvement Teams in each facility to select high-priority, low-cost interventions which they can carry out over a relatively short time frame to tackle gaps in their areas of responsibility. They are encouraging the teams to formulate ‘smart’ goals which are specific and measurable, and to think about how they will measure whether their intervention has been a success.

The desire to act is palpable. At a Quality Improvement Team meeting at Vihiga County Referral Hospital in early July, the departments presented a short list of ‘priority gaps’ – such as reducing the drug expiry rate in the pharmacy, or setting up a back-up system for the health management information system – and described their ideas about how to tackle them. The Medical Superintendent attended the meeting, throwing his weight behind the quality improvement process. All the department representatives stayed until the very end, keen to share their ideas and to learn from others.

At Port Florence Community Hospital, which has until now never been part of a quality improvement initiative, the baseline assessment and mentoring visits seem to have opened up health worker perspectives about what is possible. The clinical staff are moving to introduce a differentiated model of care for HIV-positive patients, in which ‘stable’ patients receive their medication from community health workers, rather than having to visit the hospital. This frees up much more time for hospital-based staff to meet with newly-diagnosed patients or, for example, to audit complex cases such as those with multi-drug resistant TB. The laboratory has also introduced changes to the way it stores and transports blood samples to reduce the frequency with which it needs to draw blood from patients.
‘We feel lucky to be chosen among many facilities to be part of this journey,’ says Matron Evelyne.

Horizontal learning, motivation and recognition
Between now and October the Amref mentor teams will visit each facility at least two more times to monitor the Work Improvement Teams’ projects and to help them assess the results of their efforts. County-level review meetings are planned in which representatives from the Quality Improvement Teams at participating facilities will come together and share experiences with one another. An endline assessment will allow the facilities to see what progress they have made towards compliance with KQMH standards. At the end of the project , all the facilities which participated in the project will come together at a sharing and awarding forum to be recognised for their achievements, where rewards will be provided to those which have performed particularly well.

The combination of training, continuous mentoring and a clear, structured set of standards appears to be motivating for many of the facilities. As Mr. Nyota at Vihiga County Referral Hospital put it, ‘Quality improvement only happens with passion. We need to have this passion to continue.’

July 2018

By Amref and GIZ