Photo by Natalie Pedigo | Unsplash
Proper implementation of quality improvement (QI) strategies can not only increase productivity and efficiency, but it can also improve quality and safety. This, however, requires a dedicated team to effectively carry out the changes.
To implement and sustain a quality strategy at the Kabale Regional Referral Hospital in Kabale, Uganda, we started by conducting a QI assessment. We observed waste of supplies, including expired drugs and other items, unnecessary time spent looking for items, frequent occurrences of hospital-acquired infections among members of the staff, and patient reports of waiting too long for services.
Following the assessment, we used a “fishbone” diagram and matrix tool to identify root causes of low quality. These included lack of understanding and misconceptions about routine work processes, insufficient knowledge about quality improvement — in our case, the 5S [Sort, Set in Order, Shine, Standardize, Sustain] approach to improving the work environment — poor coordination, and an absence of improvement team structure to support the work.
Based on these findings, we designed the following key interventions:
- Conduct trainings in 5S and other key quality improvement concepts.
- Develop action plans according to needs identified in the assessment.
- Assign key tasks and roles to specific people and form small teams to carry them out.
- Identify unnecessary supplies that did not contribute to the creation of value and were not necessary for the proper functioning of the process and relocate, remove, or discard accordingly.
- Organize necessary supplies according to workflow and label with care directions, drug directories, and standards developed or added as needed.
Challenges to Sustaining Involvement
In 2012, we started this work with the desire to be recognized as the best performing regional referral hospital (RRH) of the year, beginning with five showcase areas in the hospital using project funding from the Ministry of Health (MOH). Leadership and staff would often prepare for external reviews of the work, but the efforts vanished when the project ended.
There is a local expression — gavumenti etuyambe — which expresses the expectation that the government must always intervene and help. It was difficult for people to realize that they could identify their own challenges and their respective countermeasures. Many staff looked for help from somewhere, especially from leadership. Others expected this intervention to fail like a previous effort had.
Some staff were reluctant to allow access to supplies for fear of being shamed for unsatisfactory performance or even litigation or dismissal.
Engaging staff was key. When working with unit managers, we emphasized the importance of developing a work plan. As part of planning, we talked about efficiency and the Pareto concept or 80/20 rule. This is the idea that focusing on a small number of important causes of an issue (20 percent) can help us address most of the results (80 percent).
We also shared data among teams to promote positive competition. Most staff wanted to be recognized as being responsible for making the environment better. Also, some staff believed they were doing well. After assessing themselves with the standard checklist, however, they realized that their efforts fell short of the standards. This motivated them to change. Some of the staff that initially responded negatively to 5S ultimately demonstrated the best performance.
By 2018, more staff were trained in QI. This led to a paradigm shift from being driven by the project-specific funds and requirements to excitement about generating local solutions to local problems. At this time, all units participated at different levels despite limited funding. One’s level of seniority didn’t matter; rather, what mattered was one’s ability, commitment, and will to take up the role.
Teams focused on improvement formed among unit and ward staff, middle-level managers, and heads of units and hospital management. Staff took more ownership of what happened in the hospital whether good or bad. We believed we could create change even if resources were scarce. We continued to expand internal QI trainings.
Teams put these changes into practice. For example, to reduce wait times, action plans included defining patient flow and drawing patient flow charts; integrating multiple services at registration; orienting patients on arrival; and allocating staff to critical points of care.
As a result of these changes, improvements included:
- Brighter, more organized space — Teams created more free space after removing unnecessary items. They rearranged and labeled remaining items according to workflow. These changes also created room for more lighting in the wards.
- Shorter waits — Patient wait time fell dramatically. For example, the wait time at outpatient departments was unknown at the beginning. Once they had a baseline, teams reduced wait times to three hours and then to one hour.
- Improved safety practices — To conform with an Infection Prevention and Control standard to reduce infection spread, teams separated casual wear from work uniforms.
- Improved well-being — Feedback reflected better mental health among staff.
- Measurable improvement in quality of care — Using MOH standard assessment tools (Health Facility Quality of Care Assessment and 5S-Continuous Quality Improvement-Total Quality Management assessment), Kabale RRH has improved from a score of 42 percent at baseline to above 98 percent for more than eight consecutive quarters. (The MOH target is 80 percent.)
Data sharing and creating shared ownership in the work motivated staff to give their best. Small changes implemented within the available tools led to much bigger positive outcomes. Sustainable improvement is possible with limited resources.
Kamugisha Pidson, BScN-MUST, is a nursing officer at Kabale Regional Referral Hospital and National QI Facilitator at the Ministry of Health Uganda.
You may also be interested in:
IHI's Quality Improvement Essentials Toolkit
Why Compliance with Quality Measures Is Not Enough