Creating a pathway for public hospital accreditation in Rwanda: progress, challenges and lessons learned.

QUALITY PROBLEM: Weaknesses in the quality of care delivered at hospitals translates into patient safety challenges and causes unnecessary harm. Low-and-middle-income countries disproportionately shoulder the burden of poor quality of hospital care. INITIAL ASSESSMENT: In the early 2000s, Rwanda implemented a performance-based financing (PBF) system to improve quality and increase the quantity of care delivered at its public hospitals. PBF evaluations identified quality gaps that prompted a movement to pursue an accreditation process for public hospitals. CHOICE OF SOLUTION: Since it was prohibitively costly to implement an accreditation program overseen by an external entity to all of Rwanda's public hospitals, the Ministry of Health developed a set of standards for a national 3-Level accreditation program. IMPLEMENTATION: In 2012, Rwanda launched the first phase of the national accreditation system at five public hospitals. The program was then expected to expand across the remainder of the public hospitals throughout the country. EVALUATION: Out of Rwanda's 43 public hospitals, a total of 24 hospitals have achieved Level 1 status of the accreditation process and 4 have achieved Level 2 status of the accreditation process. LESSONS LEARNED: Linking the program to the country's existing PBF program increased compliance and motivation for participation, especially for those who were unfamiliar with accreditation principles. Furthermore, identifying dedicated quality improvement officers at each hospital has been important for improving engagement in the program. Lastly, to improve upon this process, there are ongoing efforts to develop a non-governmental accreditation entity to oversee this process for Rwanda's health system moving forward.

Twinning Partnership Network: A Learning and Experience-Sharing Network Among Health Professionals in Rwanda to Improve Health Services.

We describe the development, implementation, and evaluation of a novel twinning approach: the Twinning Partnership Network (TPN). Twinning is a well-known approach to peer learning that has been used in a variety of settings to build organizational capacity. Although twinning takes many forms, the heart of the approach is that institutions with shared characteristics collaborate via sharing information and experiences to achieve a specific goal. We adapted a twinning partnership strategy developed by the World Health Organization to create a network of like-minded health institutions. The key innovation of the TPN is the network, which ensures that an institution always has a high-performing peer with whom to partner on a specific topic area of interest. We identified 10 hospitals and 30 districts in Rwanda to participate in the TPN. These districts and hospitals participated in a kickoff workshop in which they identified capacity gaps, clarified goals, and selected twinning partners. After the workshop, districts and hospitals participated in exchange visits, coaching visits, and virtual and in-person learning events. We found that districts and hospitals that selected specific areas and worked on them throughout the duration of the TPN with their peers improved their performance significantly when compared with those that selected and worked on other areas. Accreditation scores improved by 5.6% more in hospitals selecting accreditation than those that did not. Districts that selected improving community-based health insurance coverage improved by 4.8% more than districts that did not select this topic area. We hypothesize that these results are due to senior management's interest and motivation to improve in these specific areas, the motivation gained by learning from high-performing peers with similar resources, and context-specific knowledge sharing from peer hospitals and districts.