Nana A.Y. Twum-Danso, MD, MPH, is the outgoing Executive Director for African Operations at the Institute for Healthcare Improvement (IHI). In this role for the past eight months, she oversaw the development of emerging quality improvement (QI) work in Africa while transitioning the leadership of Project Fives Alive! to her successor, Dr. Sodzi Sodzi-Tettey. Nana was recruited to IHI in February 2008 to become the Director of Project Fives Alive!, a partnership between IHI and the National Catholic Health Service of Ghana to accelerate the reduction of child mortality in Ghana through the application of QI methods nationwide. She served in that role until December 2011 when Sodzi took over from her. Before joining IHI, Nana held various leadership roles for six and a half years at the Task Force for Global Health in Atlanta, Georgia, in the fields of parasitic disease control, pharmacovigilance, and community-based health care delivery in sub-Saharan Africa and southeast Asia, working closely with governments, NGOs, WHO, and UNICEF to develop and implement national programs to eliminate or control debilitating parasitic infections on a large scale. She was also an adjunct faculty member in the Department of Family and Preventive Medicine at the Emory University School of Medicine in Atlanta for six years. Nana holds a bachelor's degree in biochemical sciences and a medical degree, both from Harvard University in Cambridge, Massachusetts. She also has a master's degree in public health with specialization in health policy and management from Emory University and is board-certified by the American College of Preventive Medicine. In April 2012 Nana will be joining the Maternal and Child Health Department of the Bill & Melinda Gates Foundation as a Senior Program Officer for Community Health Solutions.
Q: Can you describe your career path in health care and how you connected with IHI?
After medical school, I started training to be an emergency physician. Shortly after that I switched to public health, population health. I love clinical medicine and still miss it. But I feel more passionate about population health, especially in the African context, because I think the problems, the reasons people are dying needlessly in Africa are not rare or complex clinical conditions that need fine diagnostic skills to solve. The reasons are things like malaria, diarrhea, pneumonia — diseases that are simple clinical problems to solve, but from a public health perspective we haven’t yet succeeded. That’s really what drives me.
I had known about IHI for some time. In 2006 I heard Don Berwick [IHI’s former President and CEO] and Joe McCannon [former IHI Vice President] speak at a conference in Atlanta convened by my former organization, the Task Force for Global Health. They described IHI’s 100,000 Lives Campaign, which was underway at the time, and it was very compelling. IHI caught my imagination, but I didn’t know about its work in Africa. Then I heard about the Ghana opportunity [with Project Fives Alive!] and I was really intrigued. So I applied for the job, interviewed and the rest, as they say, is history. I ultimately joined IHI in February 2008 and moved to Ghana to be based in Accra, the capital.
Q: What has been the focus of your work at IHI?
I started as the Director of Project Fives Alive!, a collaboration between IHI, the National Catholic Health Service, and the Ghana Health Service. It’s a nationwide project funded by the Bill & Melinda Gates Foundation that works to assist Ghana in achieving Millennium Development Goal 4 — reducing mortality in children under five.
In many African countries, including Ghana, 40 percent of children under five die in the first month of life. Of those 40 percent, about half die on the first day — literally right after delivery. Within the first 24 hours, things go wrong and health professionals are not there to address the problem — either because the mother didn’t come to a health facility to deliver or she did, but the facility didn’t have the equipment or the skills or the protocols to monitor the mother’s labor carefully to ensure a safe delivery and appropriate care of the newborn.
We also know that child mortality is very much linked to the mother’s health, so a lot of our work focuses on prenatal care, medication during pregnancy, screening, counseling, health education, and also health clinic resources. So, indirectly we also support Millennium Development Goal 5 — maternal health.
We started on a small scale, teaching health care workers in three districts and one Catholic diocese how to use quality improvement (QI) methods to make improvements in their care. At the time QI was essentially new to Ghana so a lot of our initial work was encouraging, stimulating, catalyzing. Within about 18 months the health workers themselves could start looking at their own data, seeing results, and coming up with change ideas. We also developed a change package based on the most successful change ideas during the first wave.
In the second wave we scaled up, spreading the change package throughout the northern part of the country to a total of 38 districts serving roughly five million people. In parallel we started another Collaborative
in the south that’s focused on inpatient and emergency care in the National Catholic Health Service hospitals. The final phase, wave 4, which will cover the rest of the health facilities in the south, is planned for next year .
“The health staff involved are working really hard under very difficult conditions. It’s great to see them speaking the same QI language as we are, getting results, and using their own data.”
My hope is that what QI has done, and done in a sustainable way, is change the health care workers’ orientation to their work so they actually look at their data over time, notice when things are going well, when things are going badly, and then correct as needed. The health staff involved are working really hard under very difficult conditions. It’s great to see them speaking the same QI language as we are, getting results, and using their own data to say, “You know, I think we need to do things differently, because in the last three months, we noticed this has gone up and this has gone down…”
Project Fives Alive! was originally a five-year grant, but the Gates Foundation has recently awarded us a supplemental grant to do related work in Ghana, which allows us to extend the entire project to 2015. The Foundation wants us to piggyback the new work — which focuses on improving referral processes for maternal and newborn health — on the original work. This makes a lot of sense because once you have a collaborative network of people who come together for Learning Sessions, it’s easy to add a new focus onto that existing network.
So, it feels like a good time for me to be turning over the Ghana project to Dr. Sodzi Sodzi-Tettey, our new Director of Project Fives Alive!
Q: Can you describe your most recent role at IHI?
For the past eight months I’ve been IHI’s Executive Director of African Operations, beginning to look across the entire portfolio of IHI’s work in Africa — Ghana, Malawi, and South Africa — and consider how we can improve or optimize our operations. I’ve also focused on working very closely with the country leaders for each project, because leadership and vision are so important to successful execution. In Ghana I’ve spent a lot of time with my replacement, Dr. Sodzi-Tettey, to make sure the vision he articulates to his team is clear and consistent, the design to match that vision is solid, and the work proceeds smoothly to execution.
The most important step is execution. When a project fails it’s often not because of poor design, it’s because people are not executing as planned or learning from what’s happened in the past. Are we doing what we said we’d do, and are we learning from what we’re doing so we can adjust and redesign if necessary? Because it’s easy to just do, but can we stop, look at the data, see how well we’re doing here or there, and redesign as needed?
Another goal of mine — something I’ve tried to lay the groundwork for in my time in this role — has been to work toward integrating and connecting the individual projects IHI has underway in Africa. There’s a lot of knowledge that’s generated by each project, but we haven’t had enough opportunities to share that knowledge. We do keep in touch through phone calls, email, meetings and major conferences, but the actual harnessing of knowledge and making sure the knowledge and experience gained by teams in one country can help teams in other countries design or execute their work better — that we need to do more of.
And it’s a challenge because the African projects are all distinct, with very different components and timelines. The Ghana work is one project with one funder; it’s very simple in many ways. The Malawi work is one project with multiple partners through an NGO called MaiKhanda, and one funder, the Health Foundation, for now. The aim is for MaiKhanda to be self-sufficient over time, which means we’ll be devoting more attention to expanding the funding base. Our South Africa portfolio involves almost a half dozen different projects — each one with different partners and funding.
Q: What do you see as the major challenges for IHI in this work?
I think probably the biggest challenge is working across cultures or systems and making sure that the projects we are supporting are really well aligned with what the people need or want. Because there are so many areas we can invest in across Africa — small projects here and there, medium-sized projects, larger ones. But I think to be really relevant you need to figure out what the people need most urgently and make sure that what you’re offering meets those needs.
The other main challenge I see for IHI is designing projects so they can go to scale. So many projects are designed as pilots and stay as pilots or demonstration projects, and I think what we need to do — for all of IHI’s projects, but especially in low- and middle-income countries — is make sure we design for scale. Because the need is so great — maternal health, child mortality, malaria, and so many other serious health needs.
What’s the point of doing an amazing project in one district when the country has 100 districts? Or the other way around, doing something fairly superficial in a bunch of districts that doesn’t really address the problem? Countries with relatively limited resources can’t afford to waste them on things that are only going to work in one area or for the short term. I think IHI has the capability to design really effective projects that can go to scale and be sustained. That’s the real challenge.
Q: What gets you most excited in your work?
I would say there are two major sources of excitement and also renewal for me. This work is hard, at least on the African continent. Almost all of our interactions are face-to-face, with a lot of slow, rural travel — you might be driving for four hours on difficult back roads to get to a site. But what gives me inspiration, what keeps me “on the road,” are two things.
One is the front-line providers themselves. They’re busy, they’re stressed, they don’t have enough resources, and all that. So, when we come in to teach them about quality improvement they might not really appreciate it or see how it can help them, initially. You know, we go in talking about root cause analysis; we do our process mapping with sticky notes. It seems a bit gimmicky at first. But then we start moving the “stickies” around and they start to see opportunities for improvement.
“What gives me inspiration are two things: the front-line providers themselves... and getting leaders truly engaged in this work.”
Over time, working with the same providers, we’ll see them become receptive to the tools and concepts, looking at their data, understanding their data, using it to do something different at their own local level; they’re seeing results that they themselves initiated — not us, we’re just facilitators. They initiated the changes; they saw them and captured them, and now they’re really pleased with themselves. And suddenly they’re thinking ahead, they want to do something else. So now we feel like, wow, they really get it.
That’s what makes it all worthwhile, when we stop and realize how we’ve transformed the way they think about problem-solving, the way they think about patient care. We can feel hopeful that they’ll continue doing quality improvement long after our involvement.
It’s so rewarding when it happens, but you have to be patient. It’s not a one-time interaction; it’s six months, 12 months, 18 months. But seeing progress, seeing things evolve, gives you reason to go back.
The second thing that keeps me excited is getting leaders truly engaged in this work. So many times, even when we’re able to get front-line providers engaged and excited and making changes, they don’t get enough support from their managers. So it’s huge when we can work with managers and leaders and see them becoming more receptive, really facilitating the work of the project — even beyond that, taking ownership. Hearing them say, “This is my hospital, this is my district. I care about the quality here as much as you — more than you do; you’re visitors. I’m the one who’s going to look at the data, sit with my front-line providers and say, 'Did you notice that last week this happened?'” And they’re going to get excited about their data and use it for action.
Leadership commitment is really powerful because it brings execution, especially sustainable execution. When leaders take control, take ownership and follow up regularly, then execution will happen reliably. (And if it doesn’t happen according to plan, you sit, you discuss, you redesign, you continue to execute.) When leaders really care and are focused on the quality indicators that the front-line providers are trying to improve; when they get excited about their data and use it to take action — that brings accountability, and with that comes strong support of front-line providers who can then continue the improvement work that saves lives.
Again this takes time. But when those two groups of people “get it,” when front-line staff and leaders start working with the QI concepts together, on their own without us, the facilitators — it’s great! That’s when you know for sure you have made a lasting impact.