Improving Care in Rural Rwanda
Improving Care in Rural Rwanda
Imagine you are a staff member at a hospital or clinic in a resource-poor setting. A team arrives and offers to help improve the quality of care. You are initially skeptical as prior quality improvement efforts have taken up considerable staff time and attention but have not resulted in sustained change.
There is no single, more reliable factor that a team leader can use when it comes to determining the team’s level of understanding of the underlying economic and sociopolitical context in the current situation in Kirehe than their performance. Naturally, a positive team and individual team member performance, one that exceeds all expectations, indicates that the team has a good understanding of the economic and sociopolitical context of the Kirehe healthcare community situation; and otherwise if the team’s performance is unsatisfactory. Basically, the team’s having an unsatisfactory performance only indicates that there improvements needed to be made
There are numerous, even hundreds, of specific ways how change (i.e. a positive change that is geared towards improvement) can be introduced in a hospital or clinic situated in a resource-poor community. In fact, even just a single highly effective intervention can make a huge impact with the way how the hospitals, clinics, and the members of the health promotion community do their job. This is what most nursing and allied health professionals must strive for. The first and often the biggest problem that nursing and allied health professionals have to deal with when it comes to introducing changes with regards to poor quality improvement effort outcomes is the lack of available resources in accomplishing their goals.
In some cases, the plans and the objectives and goals that the change management team (which is presumably composed of nurses, allied health professionals, and some prominent members of the community that they are trying to improve) have set are not based on smart principles (i.e. they are not specific, measurable, attainable, realistic, and time bound). Of the five characteristics of goals mentioned, goals and objectives set by the quality improvement teams often do not meet these two criteria: attainable and realistic. These are just examples of how complex the problem can be when it comes to addressing a quality improvement-related problem in a hospital or clinic situated in a resource-poor setting such as the Kirehe community in Rwanda that was discussed in the case analysis. The interplay of the factors and variables in Kirehe community’s hospital and clinic service quality improvement efforts classically describes the typical problems and hurdles that community health improvement organizations face.
Again, the biggest problems that they face, as identified in the case analysis were the lack of appropriate training (as evidenced by the trained community health members’ lack of attention to detail in e.g. vital signs, and medical record keeping, and etc.), the lack of resources, and the apparently poor implementation of policies and regulation when it comes to quality improvement. There were already quality improvement efforts and strategies that have been put in place. The problem is that they are either not enforced and reinforced or they worse; they are not being implemented at all.
One of the main problems that nursing and allied health professionals, especially the highly trained ones from the cities and non-rural areas would encounter when it comes to working with the apparently untrained and undisciplined community health workers from the resource-poor communities (i.e. they are community members being trained to conduct healthcare promotion activities) is the lack of confidence and low level of collaboration between the two sides. The two sides in most cases would be comprised of the nursing and allied health professionals who would train the community members and the nurses and healthcare workers of the hospitals and clinics in that community (in Kirehe’s case, the Ministry of Health (MOH) and Partners in Health (PIH) sponsored hospitals and clinics) on how they can improve the quality improvement, and the people who would be trained for quality improvement.
When it comes to improving the trust and confidence levels between the members of each group, one proposed strategic model discussed in an academic journal published in the Gerontological Society of America was the policy without technology model . According to the authors of that study, there are two conventional ways how medical and health care quality can be improved in both rural and urban settings and that is to either use an equipment and technology-centric approach, one that they described as the approach that would lead to the highest possible yields but often comes at a considerably greater cost compared to the second approach. The second approach, which is the one that they focused on, was the policy without technology approach.
According to their analysis, the policy without technology approach relies more on (as the name implies) policy changes and introduction of new regulations and systems of standardization both in terms of quality and hospital and clinic operations management and of course clinical practice when it comes to achieving a higher level of medical and health care quality. The main advantage of this approach is that it does not rely on the acquisition of costly technologies and equipment , which is why it can easily be considered as the approach that is most suitable to hospitals and clinics situated in resource-poor communities as in the case of Kirehe. By applying this approach in resource-poor communities, one of the biggest problems which is the lack of available plans of action as a result of insufficient resources can be easily eliminated and all the stakeholders and members of the team can focus more on confidence and collaboration building activities.
One of the best and most direct ways on how to improve and build confidence and collaboration among the members of a team, especially if it is in any way related to the medical and healthcare industry is to use case simulations in this case. By introducing and using case simulations, all of the team members’ ability to use their deductive and inductive reasoning improves; their clinical reasoning and decision making gets dramatically improved too . The important thing to remember about these skills is that they often get developed by being exposed to scenarios that require their use only. This means that they only get developed through experience. Unfortunately, experience calls for the commission of mistakes along the way, mistakes that could cause dramatic setbacks (be it in terms of resources, time, or efforts). Hospitals and clinics situated in resource-poor communities and settings cannot afford to suffer from such setbacks. And this is why they must rely on case simulations and the benefits of learning together; along such process, confidence and collaboration can be easily built among individual team members.
There are numerous factors that might be used as a metric that can convince the leaders of the team, or the organizations (i.e. Ministry of Health and Partners in Health) that sponsor their programs and activities that there is already a good understanding of the hospital and or clinic’s underlying economic and sociopolitical context among the teams and those teams individual members already. One objective and highly reliable factor that one can rely on would be the results. In the case of the Kirehe hospital, the team leaders and the representatives of the organizations that sponsor the hospital’s programs, drives, and activities may use the performance of the members of that clinic or hospital to assess how in-depth their understanding of the current economic and sociopolitical situation or context it (i.e. the hospital) is in. Now, this can be likened to the act of judging based on actions of an individual or a team rather than judging based on what they are saying. It may also be similar to assessing performance and understanding of a context, scenario, or situation (i.e. a health and medical care-related one) based on how the teams and their individual team members walk the talk. This is a more reliable way of assessing things because it directly exposes all the underlying issues and checks the compliance of the teams to the goals and objectives that they set.
And if this is indeed going to be the metric that will be used to assess Kirehe Hospital and community’s understanding of the economic and sociopolitical context of the scenario they are currently in, it would appear, from an objective point of view, that they do not have a good grasp of such contexts at all. Some of the direct evidences that may be used to support this would be the fact that there are numerous gaps in the care that they provide, the staff morale has been consistently sitting at low levels, majority of the nurses are underperforming due to varying reasons, the medical and health care staff members show an inherent lack of attention to detail when it comes to providing services, and of course the never ending issue on resource inadequacy and the fact that they are doing nothing to turn around the situation.
Imagine again that you are the leader of the Quality Improvement Team in the previous scenario. Your team would like to improve quality of care across the board and sustain those gains. Whatever specific targets you choose to measure and focus on, your ultimate aim is to: raise staff morale, set a new higher standard of excellence, and empower staff members to see a problem and fix a problem in their daily work.
Before thinking about the most effective ways on how the involved teams and the individual team members of those teams can be assessed based on their local needs and on appropriate quality goals, it would be important to note what the ultimate goal of the organization is, because the goals that would be set based on the community’s local needs must be in line with what the organization aims to accomplish. In this case, there is no single, more reliable way to assess the local needs and set appropriate quality improvement goals than to observe the way how the community healthcare system works and from there, identify the major points of improvement.
These assessment and goal setting for quality improvement intervention call for a highly active approach when it comes to being the leader. This means that as the selected leader of the quality improvement team, time spent in the field, especially time spent with the people directly involved with the core roles and processes of the community healthcare system must be prioritized, because these are the aspects that would most likely require the highest level of attention and focus as far as quality improvement is concerned. It would certainly be easier to make decisions if the leader has a first hand or self-obtained knowledge of what the teams in the community and their respective members can do compared to when the leader has to rely on the inputs and observation of other people. This can instigate doubts on the reliability of the information and a lot of things can eventually go wrong from there. The more active and direct the observation and assessment is, the better. The same is true when it comes to setting appropriate quality goals. The goals that would be set must be based on what the leader has observed.
The most important allies in this case would be the individual team members because their performance and of course their compliance to the quality improvement interventions that would be selected are the ones that would directly affect the outcome of the quality improvement program. The healthcare community members would also be an important ally in this case because all the reliable forms of feedback would most likely be coming from them. The feedback in this case would serve as the leader’s barometer or tape measure because without it, it would be impossible to rule whether there were improvements made on the quality or otherwise.
Among all members of the team or group, the leader has the responsibility to take into considerations all the possible metrics that he can use as a baseline to determine where the group or the individual group member’s performance started at a certain period, and of course, to know how to use the same metrics when it comes to determining whether specific targets, goals, and objectives were met. The important thing to remember is that a consistent metric and evaluation and assessment strategy must be used in order to accurately and reliably determine whether there were significant changes in the performance of the team or group, be it in terms of staff morale, standards of excellence, empowerment, or attention to detail. This is also where the importance of setting smart goals (i.e. goals that are specific, measurably, attainable, realistic, and time-bound) comes in. Without a specific and measurable goal, for example, it would be next to impossible to improve a certain aspect of the team’s medical and health care delivery process.
When it comes to checking the vital signs and updating the charts of the patients being handled by the hospital or clinical team in Kirehe Hospital as a concrete example, the leader must ensure and specify and measure what and the kind of improvement that he expects to see after a certain time conducting an observation and assessment pattern of quality improvement. In the case, it was mentioned that only fifty percent or roughly half of the patients’ vital signs records get updated by the nurses and other members of the team.
It was specified that that specific aspect of their medical and healthcare delivery system was the one they wanted to improve and that they wanted to improve it from the current baseline level of fifty percent to around ninety five percent after the specified time frame. That can be a classic example of a specific and measurable goal. By setting that kind of goal, it would be easier for the group as a whole and the individual members to adjust their performance. Basically, the leader would just have to inspire and motivate the team members to adjust their performance, upwards in most cases, until they reach a point where they can say that they have already reached the specified and measurable goal they set.
Another thing would be to consider the use of the team members’ performance in various aspects (e.g. attention to detail, quality of patient care, types of service that a member can provide, among others) as a metric. The problems and issues the team is trying to address may also be used as a metric if the leader wants. Regardless what metric is to be used, they should all lead to an ending scenario where all the problems or issues the team is facing would have been solved already.
As the leader of a small group of people in the medical and healthcare setting, it is important to be result-oriented because any effort aimed at meeting the set goals and objectives probably cost the sponsoring organizations a significant volume of resources, resources that are profoundly scare in the communities that the team is trying to help and so it is important to ensure that positive results are achieved for every effort exerted.
I would frame the future quality improvement interventions based on the observations that I personally made. I would most likely focus on improving the key points and areas of improvement I managed to see when I was observing. I would also frame the intervention program in a way that would prevent me from committing the same mistakes that the previous QI teams committed.
Substantial resource inputs are essential to successful work improvement in resource-poor settings. At Kirehe, for example, nurses in the outpatient department were initially doing more than fifty patient consultations per day and had no time to talk with patients about their diagnoses. We had two major resource gaps here, not enough nurses, and not enough consultation rooms.
Resource inputs have always been identified as one of the most important requirements when it comes to launching any kind of program, especially one that pushes everyone to work harder and make their work contributions create a bigger impact, as in this case. In resource-poor settings frugality, and exceptional financial and resource management skills play a highly important role in almost any kind of improvement efforts.
Based on my own experience, I know for a fact that most community oriented medical and health care improvement activities would prove to be fruitless if not completely ineffective and also worthless without the availability of at least a sufficient amount of resources . Also, the interplay of resources and how exactly and efficiently they are managed are also important factors to consider . Naturally, leaders of community health improvement teams want to ensure that all resources and the things where they are spent are well accounted for and that they are being used in the best and most cost effective way possible because otherwise, they could easily lose the trust and support of their creditors and sponsors. Fortunately, in the case of Kirehe hospital and the surrounding community, it certainly seems that the support of its partners, specifically the Ministry of Health and Partners in Health is ironclad. However, that does not mean that the members of the quality improvement team would take their responsibilities for granted and simply do things based on the minimum or worse, below minimum standards set by their sponsors.
It is a part of the leader’s responsibility to ensure that every member of the team is striving hard to outperform their previous performance levels on a month on month and year on year basis. This is to ensure that for every time period, their performance and therefore the positive changes in the community and hospital and clinic that they stimulate would be progressive and not stagnant. Resource inputs play a critical role in promoting the quality of health and medical care in resource-poor settings . This is something that people must be aware of even during their grade school years—that it is simply impossible to make a change, let alone make a positive one (i.e. change), without any form of resource input. One can even use one of the most popular laws in science to back this claim that again is based on experience, up.
Remember how sir Isaac Newton, one of the most popular physicists, described the different laws of motion. One of the laws of motion suggests that for every action, there must and is an equal and opposite reaction. This can, in fact, be applied to the healthcare and medical field, especially when it comes to quality improvement. For leaders of teams that are underperforming, certain inputs must be placed in order for that team and of course its members to be motivated to change for the better. One of the most commonly required resources in making quality improvements is financial resources.
Money indeed makes the world go round and no matter how social workers and a vast majority of people may deny it, every program, be it healthcare related or not, requires money in order to be successfully executed. Manpower is another type of resource input that one can in fact consider as more important than financial resources because there are times were volunteer workers can contribute as lay people who can man the different posts and occupy certain responsibilities in a quality improvement project or program, for example. The good thing is that organizations and or teams that manage such projects or programs do not have to pay those volunteers a salary, although they can give a certain form of compensation as a form of goodwill or a token of appreciation for the services that they have decided to render without expecting any form of return; because after all, they are volunteers; they are not employees who are technically engaged in a legally enforceable contract with an employer.
In a resource-rich setting, instances where there is a lack of sufficient resource inputs may also occur . One instance may be in the case of Kirehe hospital. At some point during the initial phases of the quality improvement project, the resources allocated for the hospital’s programs were adequate. However, the members of the team (i.e. nurses and other members of the staff) were still underperforming. In that case, the problem was not related to the availability of the resource inputs but to the way how the people in charge of managing those resources actually mange them, that is, in an inefficient and ineffective way, as evidenced by the fact that they were underperforming.
I can use no other more reliable example than the previous quality improvement attempts that took place in Kirehe. Leaders of those intervention teams failed because they did a poor job of distributing and allocating the resources they were provided with to the aspects and key areas and points of improvement that needed the highest level of focus and attention from the QI team.
Imagine that you are a successful Quality Improvement Program Director
The importance of people skills, active involvement of the leader and members on the quality improvement effort were the two most important lessons I have learned from the events that happened in Kirehe. People skills are important because this was a project where one has to interact with a lot of people. Active involvement of the leader and team members on the entire quality improvement effort are also necessary because my experience has time and again proven that being passive when it comes to quality improvement yields nothing.
Basically, I am going to use a pre-selected set of metrics to be used in assessing the situation. Assessing the situation is going to be my first step in solving the problem because it would really be counterproductive to attempt to solve the situation without any form of background information regarding the case.
The possible solutions or options would basically be comprised of different proposals which can be funded. Naturally, the higher the level of funding, the more likely that a certain selected solution would yield the desired results; this is where the decision-making starts. The decision-making steps would be based on what the metrics would suggest. Suppose that the metrics suggest that the main cause of the poor quality in the system is the incompetency of the team members handling the operations; in that case, team member training and upgrades would most likely be the target of the fund.
The main advice for the quality improvement team in this case is to follow the same approach used before (minus the mistakes of course) because it is based on objectivity and on informed-decision making. This enables them to make the best decisions, the ones that carry that highest upside with the lowest level of risk exposure, available.
What can we learn from the experience at Kirehe? Consider four key lessons according to Dr. Lee.
I would make a decision on which proposal to fund based on which proposal offers the highest level of quality improvement. I would also most likely favor quality improvement proposals that focus on the improving the key areas and points of improvement I have identified during the observation and assessment phase.
There are, in fact, a lot of lessons that can be learned from the Kirehe community aside from the ones that Dr. Lee mentioned in the case analysis. However, since the answer to this question is limited to those that he mentioned, the ones chosen were based on the importance of: keeping a small footprint, making effective use of performance data, and addressing substantial resource and infrastructure gaps.
When it comes to keeping a small footprint, it may be safe to say that Dr. Lee was not just pertaining to the efforts being made by the teams, groups, and their members. He may have also pertained to the way how resources are being managed. Based on the way how I interpreted his analysis and how the case of Kirehe community was presented, I thought that he was highlighting the importance of being a frugal spender and being a good resource manager when it comes to attempting to improve medical and health care quality in a resource-poor setting. Kirehe is one of the resource-poor communities that the Ministry of Health and the Partners in Health, in a joint program, have decided to help. Dr. Lee knew that the volume of resource inputs available for the joint program and therefore for the utilization of the members of the team that would initiate and ensure the successful implementation of the quality improvement program would be limited and so it is important that the leaders, especially the members of the groups and teams, know how to keep a small footprint, when it comes to spending, and also when it comes to making mistakes . It is understandable for the teams and its members to encounter hindrances and even commit a few mistakes at least during the initial stages of the quality improvement program but they must at least try their best to mitigate the effects of those mistakes and to avoid committing them altogether.
What advice might you offer this new QI team as they get started?
The only advice I can give the new QI team as they get started with their own QI plan and intervention is to learn from the mistakes that the previous QI teams committed. This way, they would be able to be one step ahead when it comes to executing their plan; their outcome would most likely be more favorable and positive as well.
Knowing the different ways how to effectively and consistently evaluate the performance of the individual teams involved in the quality improvement program and of course the individual members of those tams is an important part of ensuring the success of the program because without this and other related processes, the joint effort of all the stakeholders of the program would be filled with unnecessary mistakes and unfortunate incidents. This is in fact the most unacceptable thing that can happen so it must be prevented at all costs. This is where the importance of performance data enters. Performance data must be collected prior to the start of the quality improvement initiative so that the leaders can establish a baseline from which they would compare the future performance data that they would be able to gather from their individual team members and other possible sources of such data. That way, they can objectively determine whether there are any significant improvements or regressions in the teams and the individual team members’ performance.
And lastly, when it comes to addressing substantial resource and addressing substantial infrastructure gaps, this was already discussed earlier. Basically, resources are important when it comes to stimulating any form of change. The higher the degree of change that a team or organization is trying to introduce, the more resource inputs such an effort would usually require. The same thing is true when it comes to infrastructure requirements. An organization would surely face an uphill battle if it is going to attempt to introduce a change such as a quality improvement program initiation in this case if there are identified gaps in infrastructure. The combination of resource and infrastructure gaps would surely hinder the success of such programs and so these gaps must be addressed first so that the entire process would go smoothly and as planned.
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