Most of the time, we hear of quality improvement (QI) activities in established health facilities. The experience I am going to share here is that of a new hospital that started QI efforts on the second day of service.
My hospital, Hawela Tula Primary Hospital in Hawassa, Ethiopia, took part in QI training from the Regional Health Bureau and IHI one day after beginning to serve the public. As I participated, I reported to the hospital’s CEO and started challenging him and others about the importance of a QI unit.
At the beginning nobody, including facility leaders, was willing to listen. They thought a facility must have quality problems to do QI activities. I believe QI can help us identify quality problems from the beginning and start service delivery in line with the national standard; QI can also be used to prevent problems by sticking to standards and protocols.
I was assigned to the role of QI unit head and began my job by doing a baseline assessment, first using IHI’s Maternal, Newborn, and Child Health (MNCH) template and later the Ethiopian Hospital Services Transformation Guidelines, which include more areas of the hospital. I prepared an action plan on identified gaps and established a QI committee, representing coordinators of all case teams/units. We prepared a Term of Reference document that states what QI is, why it is needed in the hospital, who will be the members, the responsibility of the committee, and other rules, as well as an annual plan. Then, we prioritized the problems identified by the baseline assessment and launched QI projects accordingly.
Our first project was to increase the number of deliveries by skilled birth attendant (SBA) to 90 percent of our target of 50 deliveries per month (calculated based on the total population of the woreda [district] and expected deliveries at other health centers) over two months. Our change ideas included bringing women in labor to the hospital by ambulance and providing orientation for MNCH staff on the Compassionate, Respectful and Caring (CRC) initiative. CRC, implemented by the Ethiopian Federal Ministry of Health, aims to foster these aspects of health care delivery. Meeting weekly, we tested the change ideas and achieved our target over two months. In addition, we observed no maternal mortality over 10 months (507 deliveries). Coaching from IHI mentors was of great value in achieving this goal. We have sustained the improvement and surpassed our monthly goal for deliveries.
Our second project was to establish a neonatal intensive care unit (NICU) by preparing a proposal to get support from the Zonal Health Department, RHB, and nearby health facilities. With coaching from IHI, we started service with one medical doctor and two nurses. At the beginning no one had basic NICU training; now, three nurses and two general practitioners are trained.
We have admitted more than 90 neonates to date; more than 70 were discharged improved, while 18 neonates were referred to higher level hospitals (mostly due to lack of equipment to treat neonatal jaundice). There were two neonatal deaths, one at our facility and one at the referral facility.
We now have a strong QI unit with three standing officers: a nurse, a health officer, and a pharmacist. We have a QI team at each of 17 service areas and all of them have projects on problems identified in their respective case teams. 37 of 177 staff so far have completed basic QI training, and we have plans to train 80 more. In short, QI has already become a system in my hospital.
Some of the reasons for our success in making QI a system in my hospital include continuous coaching, mentoring and motivation from IHI mentors; a dedicated QI unit and officers; committed facility leader, and the quarterly learning sessions we hold.
The hospital is applying Ethiopian national health reform initiatives with continuous assessment, and all of the indicators are showing progressive improvement. We are also giving supportive supervision to six health centers in our catchment area and coaching them on QI with IHI and the Woreda Health Office, focusing on MNCH. I am also supporting a hospital in our region in starting a QI unit, applying national initiatives, and establishing a NICU. In addition, have also created a hospital webpage that we use to update our staff and partners about our successes and challenges. As a QI unit head, my vision is to make my hospital a “center of excellence” where staff from other facilities come to learn how QI can transform service provision.
The QI unit is now advising the leadership and board on hospital initiatives and QI activities, developing guidelines, preparing proposals for technical and financial support from partners, facilitating public and staff forums, coordinating blood donation programs, leading community service programs such as periodic free medical service at health post).
Dr. Degu Taye is the QI unit head and a general practitioner at Hawela Tula Primary Hospital.
Deliveries by SBA (skilled birth attendant) at Hawela Tula Primary Hospital, expressed as percent of the target of 50 deliveries per month.
Neonatal admissions at Hawela Tula Primary Hospital.