Quality Healthcare : A Business of management and frontline staff

Seven years ago, the leadership of the National Catholic Health Service (NCHS) envisioned a future where no child under five would die needlessly. They envisioned a future where the science of quality improvement was deeply integrated into routine care and also found application in other areas outside the maternal and child health space.

Today, Project Fives Alive!, the project that was born out of that vision that I am privileged to lead, has achieved success across the whole country as a partnership among the National Catholic Health Service, Institute for Healthcare Improvement and the Ghana Health Service.

Working in over 135 district and regional hospitals across seven regions, we have just recorded a 31 per cent reduction in facility-based under five deaths, and a 35 percent reduction in children dying from malaria. This has been achieved through hundreds of quality improvement teams formed by various managers to develop, test and implement innovative local solutions that come from the frontline staff themselves. These quality improvement teams used their own ideas to solve challenges such as delays in seeking care, delays in prompt delivery of care and poor adherence to standard treatment protocols.

Quality improvement methods Within the Catholic Health Service, quality improvement methods have also been deployed system-wide to reduce health insurance claims losses to less than five per cent of submitted claims. More recently, the leadership has put a group of nursing and midwifery schools together in a learning network with the explicit aim of improving pass rates in the licensure examinations.

I wish to use this opportunity to paint a picture of the future- but this picture will need health leaders to create a sense of urgency for change, build a guiding coalition of those willing to help and invest in the necessary skills for improving the system. All this will create a supporting environment for transformation.

In 2011, I was privileged to visit Cincinnati Children’s Hospital in the United States with a small team of officers. Our aim was to learn from their systems transformation agenda. We learnt that improving clinical outcomes –mortality and morbidity—was the primary responsibility of the board and management and not solely the frontline staff. We watched as the elderly chairman of the hospital’s board recounted data going back over five years of mortality trends.

We listened as the chief executive of the hospital recounted a situation where the management had held a very senior surgeon to account for failing to adhere to surgical safety protocols.

As a first step, the once unthinkable had been done – his surgery was cancelled! We watched how everyone, and I mean, everyone in the hospital, from management through staff, had either gone through deliberate training in Improvement Science or was scheduled to be trained. Teams of professionals in the frontline of care all had little improvement projects that they were working on in one part of the hospital or the other.

Driving transformational agenda We learnt a number of lessons that day; that to provide effective and lasting leadership for quality, management must own and drive the transformational agenda. This it can do by honestly confronting the failures of our current health care systems and co-creating a vision of what a desirable future could look like.

The second lesson I learnt from Cincinnati that day pertains to the use of data for local action. Here in Ghana, I have heard of management meetings where the discussion has not been about how to reduce the number of deaths, improve care processes or work more collaboratively with patients and their relations in their care.

Rather, some of these meetings have been rich with discussions about land acquisition, purchase of new vehicles and construction plans. While these welfare issues are certainly important, the total disconnect between management priorities and measurable improvements in the care of our patients has been painful to watch sometimes.

A lot of our managers do not have a first-hand experience about who is dying and who is living and the specific circumstances of the care. Even fewer visit the District Health Information Management System themselves to ascertain their facility performance on various indicators. Quality improvement emphasises looking critically at our data over time, month by month. On the contrary, some of our managers only have contact with their facility’s performance during annual regional performance review when biostatisticians are called upon to write reports.

In many cases, therefore, the data is being collected purely for purposes of reporting and not for local reflection and action. If we are to design systems for continuous quality improvement, this culture must change.

As managers here, do we know how long it takes a woman to have a caesarian section in our hospitals? Do we have a sense of post-surgical wound infections in our facilities? Do we know if stillbirths are increasing or decreasing over the last six months and what we specifically did to achieve those results?

Combination of methods My third lesson was that to improve required a specific combination of methods, tools and skills that needed to be taught widely and deeply. After managers have facilitated the building of wide and deep capacity among themselves and the frontline staff, we can define specific improvement projects and begin to hold each other accountable at all levels. Fortunately, there are a lot of rich resources –human and material –that currently exist in the country to spur this effort.

Project Fives Alive! has developed a curriculum for the training of improvement coaches and we have trained over 350 such coaches in the health system to date at National, Regional and district levels.

Finally, I wish to reflect on the first law of improvement –that every system is perfectly designed to get the results it gets. In other words, if the systems that we superintend are delivering unreliable care with bad outcomes, the first step is not to blame that poor frontline staff, but to improve the inherent processes in that system and the outcome will automatically change. As true as this is, I have also come to a related conclusion after some years of practice in quality improvement.

My personal conclusion is that if we have to hold someone accountable for poor results at all cost, then it has to be the leader of the system, and not just some frontline worker who is simply adhering to a laid-down design.

So as leaders here, we should hold ourselves fully responsible for whatever outcomes our hospitals, clinics, national health services are providing and accountable for providing the frontline staff with the tools to improve care in their own settings.

Today we have a choice to make –to acknowledge the performance of our systems as reflected in our own local data and empower change, or to continue with business as usual and complain about the end product.

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