Implementation of hospital governing boards: views from the field.

BACKGROUND: Decentralization through the establishment of hospital governing boards has been touted as an effective way to improve the quality and efficiency of hospitals in low-income countries. Although several studies have examined the process of decentralization, few have quantitatively assessed the implementation of hospital governing boards and their impact on hospital performance. Therefore, we sought to describe the functioning of governing boards and to determine the association between governing board functioning and hospital performance. METHODS: We conducted a cross-sectional study with governing board chairpersons to assess board (1) structure, (2) roles and responsibilities and (3) training and orientation practices. Using bivariate analysis and multivariable regression, we examined the association between governing board functioning and hospital performance. Hospital performance indicators: 1) percent of hospital management standards met, measured with the Ethiopian Hospital Reform Implementation Guidelines and 2) patient experience, measured with the Inpatient and Outpatient Assessment of Healthcare surveys. RESULTS: A total of 92 boards responded to the survey (96% response rate). The average percentage of EHRIG standards met was 58.1% (standard deviation (SD) 21.7 percentage points), and the mean overall patient experience score was 7.2 (SD 2.2). Hospitals with greater hospital management standards met had governing boards that paid members, reviewed performance in several domains quarterly or more frequently, developed new revenue sources, determined services to be outsourced, reviewed patient complaints, and had members with knowledge in business and financial management (all P-values < 0.05). Hospitals with more positive patient experience had governing boards that developed new revenue sources, determined services to be outsourced, and reviewed patient complaints (all P-values < 0.05). CONCLUSIONS: These cross-sectional data suggest that strengthening governing boards to perform essential responsibilities may result in improved hospital performance.

A brief questionnaire for assessing patient healthcare experiences in low-income settings.

OBJECTIVE: The aim of this study was to develop and to assess the validity and reliability of two brief questionnaires for assessing patient experiences with hospital and outpatient care in a low-income setting. DESIGN: Using literature review and data from focus groups (n = 14), we developed questionnaires to assess patient experiences with inpatient (I-PAHC) and with outpatient (O-PAHC) care in a low-income setting. Questionnaires were administered in person by trained interviewers. Construct validity was assessed with factor analysis; convergent validity was assessed by correlating summary scores for each scale with overall patient evaluations, and reliability was assessed with Cronbach's alpha coefficients. SETTING: Eight health facilities in Ethiopia. PARTICIPANTS: Patients >18 years old who had a hospital stay >1 day (n = 230), and patients who received outpatient care (n = 486). MAIN OUTCOME MEASURES: Patient evaluations of health care experiences. RESULTS: The factor analysis revealed 12 items that loaded on five factors for the I-PAHC questionnaire. The O-PAHC showed similar results with 13 items that loaded on four factors. Summary scores for nearly all factors were significantly associated (P-value < 0.05) with the patient's overall evaluation score. The measure of reliability, Cronbach's alpha coefficients, showed good to excellent internal consistency for all scales. CONCLUSIONS: The I-PAHC on O-PAHC questionnaires can be useful in assessing patients' evaluations of care delivery in low-income settings. The questionnaires are brief and can be integrated into health systems strengthening efforts with the support of leadership at the health facility and the country levels.

Implementing clinical guidelines in low-income settings: a review of literature.

The use of clinical guidelines has been shown to confer benefits for care delivery in high-income settings, but little is known about their implementation in low-income settings. We conducted a systematic literature review on the implementation of World Health Organisation (WHO) clinical guidelines for hospital care in low-income settings. We searched Medline, Global Health and Scopus for articles describing the implementation of clinical guidelines issued by the WHO for hospitals in low-income countries. Each article in the final sample was reviewed independently by two reviewers who harmonised their findings to identify key factors affecting the implementation process, which were grouped into thematic categories through negotiated consensus among project team members. Seventeen studies met the inclusion criteria. Factors affecting the guideline implementation process in low-income countries were (1) degree of support from facility management and Ministry of Health, (2) credibility and acceptability of clinical guidelines from the perspective of health care providers, (3) efforts to adapt clinical guidelines to local circumstances and (4) use of guides and checklists for implementation. These four factors consistently emerged in our review and should be considered when designing future strategies to implement clinical guidelines in low-income countries.

Educating leaders in hospital management: a pre-post study in Ethiopian hospitals.

Despite recent focus on health systems strengthening, few studies report large-scale efforts to improve hospital management capacity in low-income countries, a central component of improving health care delivery. We sought to assess the contributions of a systems-based approach, the Ethiopian Hospital Management Initiative (EHMI), which established hospital chief executive officers (CEOs) trained through a Masters of Healthcare and Hospital Administration (MHA) degree programme in Ethiopia. We conducted a pre-post study of 24 hospitals that are managed by CEOs in the MHA programme. We measured changes in hospital functioning based on adherence to a set of 86 hospital performance standards across 12 management domains published in the Standards for Hospital Management in Ethiopia. We found that adherence to hospital performance standards increased significantly during the one-year follow-up (27% compared with 51% of standards met at baseline and follow-up, respectively; P-value < 0.001); overall improvement was driven by improvement in seven of the 12 management domains. The EHMI is an example of health systems strengthening with focus on building hospital management capacity. Early evidence suggests that the establishment of hospital CEOs and MHA training to equip them with management skills may promote scalable improvements in health facility functioning.