People still ask me how quality improvement helped accelerate such an incredible reduction in mortality of children under 5 years old in Ghana.
It’s not that others don’t work hard. Neither is it a question of not being motivated by a higher purpose. It’s rather that not all are similarly possessed with a relentless focus on results as Project Fives Alive! Or on course correction, when the glaring need to adapt original designs stares them in the face. I’ve interacted with other well-funded projects that were seriously consumed with activities, yet failed to draw that critical connection between project inputs, outcomes, and impact.
At its peak scale, Project Fives Alive! engaged 80 percent of all public hospitals in Ghana, leading to a 34.5 percent reduction in under-5 deaths. This was attributable to changes targeting earlier care-seeking, prompt provision of care within hospitals, and improved adherence to treatment protocols for high-burden diseases such as malaria.
The lessons from this project are clear. When leaders create a burning platform for change, and when frontline workers are empowered to measure and improve the care they deliver, the QI approach makes a difference.
How did PFA do it? One of the keys to success, which we published in a practical handbook, the Project Fives Alive! Lessons Learned Guide, was that we planned for scale from the beginning.
Here are a few of the tactics we used to set ourselves up for success at such a large scale.
- Co-design and co-implementation — An important early question that needs to be answered at the highest levels is whether projects with pre-set designs are going to be rammed down the throats of unsuspecting health system leaders, or, alternatively, if local expertise is going to be honored through a process of co-design and co-implementation. We would argue that the latter is the only true path to sustainability in implementation and outcomes. Co-design and co-implementation help remove any abiding suspicions about an externally driven and externally imposed agenda. There is no better feeling, both among partners and national leaders, than the sense that an intervention is fully aligned to national, regional, and local priorities, thus providing every motivation for integration into existing structures.
- Setting ambitious goals — We set ambitious goals in collaboration with the key stakeholders involved in implementing the project. This can be a long iterative process, since most public servants are used to being given annual targets that are a few percentage points above previous performance. Inviting frontline workers to contribute to the goal-setting process and encouraging them to be ambitious seemed unusual to them, initially. But we were clear that this was not about setting outrageously ambitious goals for their context, but rather goals that were ambitious yet achievable if they were willing to entertain a fundamental redesign of their processes and systems. This required some suspension of disbelief initially, but as they became more engaged in the improvement work, and small tests of changes resulted in measurable improvement, this process got easier and easier. Their degree of belief in the changes grew and grew.
- Building capacity, both deep and wide — Your aim should not be to replicate the health system by building a comprehensive external implementation machinery that will not outlive a project. Instead, it’s essential to identify, develop, and nurture a talent pool within the existing health system. Through years of work, we learned to calibrate the right dose of training to the right cadre — senior leaders, district managers, data officers, and frontline providers. Never succumb to the defeatist thinking that the public sector health providers cannot operate at the same level of professionalism and commitment as private sector providers. Finally, it fast became obvious to us that while process improvement is critical, transformational results require a combination of process improvement methods and effective clinical skills.
- Consistent communication — We communicated to key stakeholders clearly and consistently about the project goals, scope, and boundaries. Consistency across the project team members is key, especially in a distributed leadership model in which team members are expected to represent the project and be responsible for a well-defined geographic area.
- Holding each other accountable — We agreed on a few basic principles that are shared within the team and held ourselves accountable to them. This helps to create and reinforce a team culture, specifically about what we do and what we don’t do. One important example was the principle of being open to testing new ideas and learning from them for the sake of improvement. “Try not, learn not” was our quick reference. This principle helped us solve both simple problems, such as scheduling vehicles or the frequency of site visits, as well as more complex challenges, such as adapting the content and format for Learning Sessions or adapting the design of the scale-up to meet time and budgetary constraints.
- Stay true to your word — “Deliver on your promises” was a simple but important element in the project’s design and implementation. In the context of low-resource public sector settings, where implementation of planned activities is often a challenge, we strove to deliver what we planned and promised to the health facilities, districts, and regions. For example, the design of our initial Improvement Collaborative Networks required site visits on a monthly basis; we planned accordingly, and if we could not make it for an unforeseen reason, we would alert the QI teams ahead of time and make alternative plans. This reliability was appreciated by our key stakeholders and helped us also to hold them accountable to their promises, agreements, or planned activities.
Some of the above lessons have informed subsequent large-scale designs we have rolled out in places such as Ethiopia and Liberia. As we travel extensively across the Africa region, we are struck by the level of national ownership of the quality agenda through the development and implementation of national health care quality strategies, and the increasing recognition within the partner pool of the need for humble alignment with and support for building the capacity of health systems to achieve national aspirations.
In Durban, from February 19-21, 2018, we will be real about the daunting challenges of Africa’s health care systems at the first Africa Forum on Quality and Safety in Healthcare. But without doubt, we will also celebrate the inspirational efforts and contributions of many millions who have saved lives and improved the quality of life in Africa.