Why It Matters
QI enabled frontline staff to build a tool that improved attendance at antenatal care appointments and changed the culture at the hospital and beyond.
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To Improve Care, Empower Frontline Staff to Create Solutions

By Birkety Mengistu | Tuesday, January 29, 2019

Dr. Getahun shares the collaborative participants’ experience spreading quality improvement work at an IHI workshop.

How do you help patients keep their appointments? Bitena Primary Hospital hoped to create a system to solve this challenge through change ideas, specific tests of new approaches that lead to improvement. The hospital is part of a collaborative aiming to reduce maternal and newborn mortality by 30 percent over five years. During a collaborative learning session, inspiration hit for a new, automated tool to address missed appointments for antenatal care (ANC).

Almost all of the facilities in the collaborative were trying to find ways to track patients who missed appointments, but the tools created were manual and cumbersome. Participants presented their quality improvement projects for the fourth ANC visit to the group. “Even though they were able to document improvement, the change ideas that they used were time and resource consuming,” said Dr. Getahun Geremew, a general practitioner at the hospital and head of the quality improvement (QI) unit. During a tea break, Dr. Getahun suggested a different solution to a colleague: an automated system that shows clients who missed their appointment.

Describing health care work, Dr. Getahun says, “It is a call… it is about saving lives and there is nothing more gratifying than seeing patients getting relief from their sickness.” He has worked at Bitena Primary Hospital, in the Southern Nations, Nationalities and Peoples’ Region, Ethiopia, for one year. Today, the hospital has 28 inpatient beds and nearly 100 deliveries each month, served by eight midwives, four integrated emergency surgical officers, and eight general practitioners. When he arrived, he was introduced to QI through his role as QI unit head. When he saw IHI’s work, he says, “The passion and commitment of the Institute for Healthcare Improvement’s senior project officers in bringing continuous QI…. motivated me.”

These officers share QI tools that enable frontline workers to come up with appropriate solutions using their skills and talents. Such locally designed systems can take into account the specific context and needs. They are also more likely to be owned and applied more often than tools and guidance that are forced on the organization from the outside. “The coaches’ training I got from IHI,” says Dr. Getahun, “increased my interest and capability to work on quality improvement.”

Through this interest and knowledge, Dr. Getahun created a different type of tracking tool for missed ANC appointments. Knowing that one of the main issues of previous tools was the manual format, he took a new approach by automating this system. With his computer skills, Dr. Getahun wrote a spreadsheet formula. He says, “With this system, if a mother misses her appointment, the… system would automatically show ‘appointment passed’ on the status bar. So, the midwife would then directly call either the mother or her husband if they happen to have a phone, or she may call the HEW [health extension worker] who would then go to track and remind the mother.” In addition, because the tool was no longer manual, the time and resource consumption of the project decreased.

The new tracking tool has created a positive change in addressing the problem of patients missing their appointments on a district level. Attendance at the ANC fourth visit throughout the district has now increased and sustained at a level above 80 percent (see Figure 1). Besides solving a challenge the hospital faced, this QI work has shaped a culture of quality throughout the hospital. Now, health workers say, “I have a change idea” during staff meetings, as the staff have internalized the concept of QI.

Figure 1: This control chart shows the rising percentage of clients at facilities in the Dunga Fango district collaborative, which Bitena Primary Hospital participated in, who attended the fourth ANC visit. NOTE: LS = learning session.

The support of IHI has transitioned to sustaining the gain, and the hospital is currently actively working to spread and scale-up QI while continuing to track progress internally. Steps have already been taken to build this regional spread of QI. As Dr. Getahun explains, “We mobilized [a] huge budget from another partner and gave the five-day basic QI training for [an] additional 70 health professionals in the region. This helped us spread QI beyond MNCH [Maternal, Newborn and Child Health] and our woreda [district]”. The vision of a tool to reduce missed ANC appointments started a movement of quality culture at Bitena Primary Hospital and beyond, showing how change ideas can spread QI and empower frontline health workers across communities.

Birkety Mengistu Jembere is IHI’s Maternal Newborn Health and Community Engagement Advisor in Ethiopia.


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