Improving facility-based care: eliciting tacit knowledge to advance intervention design

The Meso-Level in Quality Improvement: Perspectives From a Maternal-Neonatal Health Partnership in South Africa

BACKGROUND

Sustained implementation of facility-level quality improvement (QI) processes, such as plan-do-study-act cycles, requires enabling meso-level environments and supportive macro-level policies and strategies. Although this is well recognised, there is little systematic empirical evidence on roles and capacities, especially at the immediate meso-level of the system, that sustain QI strategies at the frontline.

METHODS

In this paper we report on qualitative research to characterize the elements of a quality and outcome-oriented meso-level, focused on sub/district health systems (DHSs), conducted within a multi-level initiative to improve maternal-newborn health (MNH) in three provinces of South Africa. Drawing on the embedded experience and tacit knowledge of core project partners, obtained through in-depth interviews (39) and project documentation, we analysed thematically the roles, capacities and systems required at the meso-level for sustained QI, and experiences with strengthening the meso-level.

RESULTS

Meso-level QI roles identified included establishing and supporting QI systems and strengthening delivery networks. We propose three elements of system capacity as enabling these meso-level roles: (1) leadership stability and capacity, (2) the presence of formal mechanisms to coordinate service delivery processes at sub-district and district levels (including governance, referral and outreach systems), and (3) responsive district support systems (including quality oriented human resource, information, and emergency medical services [EMS] management), embedded within supportive relational eco-systems and appropriate decision-space. While respondents reported successes with system strengthening, overall, the meso-level was regarded as poorly oriented to and even disabling of quality at the frontline.

CONCLUSION

We argue for a more explicit orientation to quality and outcomes as an essential district and sub-district function (which we refer to as meso-level stewardship), requiring appropriate structures, processes, and capacities.

Receive, Sustain, and Flow: A simple heuristic for facilitating the identification and treatment of critically ill patients during their hospital journeys

Background

Hospital patients can become critically ill anywhere in a hospital but their survival is affected by problems of identification and adequate, timely, treatment. This is issue of particular concern in lower middle-income countries' (LMICs) hospitals where specialised units are scarce and severely under-resourced. "Cross-sectional" approaches to improving narrow, specific aspects of care will not attend to issues that affect patients' care across the length of their experience. A simpler approach to understanding key issues across the "hospital journey" could help to deliver life-saving treatments to those patients who need it, wherever they are in the facility.

Methods

We carried out 31 narrative interviews with frontline health workers in five Kenyan and five Tanzanian hospitals from November 2020 to December 2021 during the COVID-19 pandemic and analysed using a thematic analysis approach. We also followed 12 patient hospital journeys, through the course of treatment of very sick patients admitted to the hospitals we studied.

Results

Our research explores gaps in hospital systems that result in lapses in effective, continuous care across the hospital journeys of patients in Tanzania and Kenya. We organise these factors according to the Systems Engineering Initiative for Patient Safety (SEIPS) approach to patient safety, which we extend to explore how these issues affect patients across the course of care. We discern three repeating, recursive phases we term Receive, Sustain, and Flow. We use this heuristic to show how gaps and weaknesses in service provision affect critically ill patients' hospital journeys.

Conclusion

Receive, Sustain, and Flow offers a heuristic for hospital management to identify and ameliorate limitations in human and technical resources for the care of the critically ill.

Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic

Care for the critically ill patients is often considered synonymous with a hospital having an intensive care unit. However, a focus on Essential Emergency and Critical Care (EECC) may obviate the need for much intensive care. Severe COVID-19 presented a specific critical care challenge while also being an exemplar of critical illness in general. Our multidisciplinary team conducted research in Kenya and Tanzania on hospitals' ability to provide EECC as the COVID-19 pandemic unfolded. Important basic inputs were often lacking, especially sufficient numbers of skilled health workers. However, we learnt that higher scores on resource readiness scales were often misleading, as resources were often insufficient or not functional in all the clinical areas they are needed. By following patient journeys, through interviews and group discussions, we revealed gaps in timeliness, continuity and delivery of care. Generic challenges in transitions between departments were identified in the receipt of critically ill patients, the ability to sustain monitoring and treatment and preparation for any subsequent transition. While the global response to COVID-19 focused initially on providing technologies and training, first ventilators and later oxygen, organisational and procedural challenges seemed largely ignored. Yet, they may even be exacerbated by new technologies. Efforts to improve care for the critically ill patients, which is a complex process, must include a whole system and whole facility view spanning all areas of patients' care and their transitions and not be focused on a single location providing 'critical care'. We propose a five-part strategy to support the system changes needed.

"We just have to help": Community health workers' informal task-shifting and task-sharing practices for hypertension and diabetes care in Nigeria

Introduction

Nigeria's skilled health professional health workforce density is insufficient to achieve its national targets for non-communicable diseases (NCD) which include 25% reduction in the prevalence of diabetes and hypertension, particularly at the primary health care (PHC) level. This places a great demand on community health workers (CHWs) who constitute the majority of PHC workers. Traditionally, CHWs are mainly involved in infectious diseases programmes, and maternal and child health services. Their involvement with prevention and control of NCDs has been minimal. With government prioritization of PHC for combating the rising NCD burden, strengthening CHWs' skills and competencies for NCD care delivery is crucial.

Methods

We conducted a mixed methods study to explore the roles and practices of CHWs in the delivery of hypertension and diabetes care at PHC facilities in four states (two each in northern and southern regions) in Nigeria. We reviewed the National Standing Orders that guide CHWs' practices at the PHC facilities and administered a survey to 76 CHWs and conducted 13 focus groups (90 participants), and in-depth individual interviews with 13 CHWs and 7 other local and state government stakeholders.

Results

Overall, we found that despite capacity constraints, CHWs frequently delivered services beyond the scope of practice stipulated in the National Standing Orders. Such informal task-shifting practices were primarily motivated by a need to serve the community.

Discussion

While these practices may partially support health system functions and address unmet need, they may also lead to variable care quality and safety. Several factors could mitigate these adverse impacts and strengthen CHW roles in the health system. These include a stronger enabling policy environment to support NCD task-sharing, investment in continuous capacity building for CHWs, improved guidelines that can be implemented at the point of care, and improved coordination processes between PHC and higher-level facilities.