A national system for monitoring the performance of hospitals in Ethiopia.

Many countries struggle to develop and implement strategies to monitor hospitals nationally. The challenge is particularly acute in low-income countries where resources for measurement and reporting are scarce. We examined the experience of developing and implementing a national system for monitoring the performance of 130 government hospitals in Ethiopia. Using participatory observation, we found that the monitoring system resulted in more consistent hospital reporting of performance data to regional health bureaus and the federal government, increased transparency about hospital performance and the development of multiple quality-improvement projects. The development and implementation of the system, which required technical and political investment and support, would not have been possible without strong hospital-level management capacity. Thorough assessment of the health sector's readiness to change and desire to prioritize hospital quality can be helpful in the early stages of design and implementation. This assessment may include interviews with key informants, collection of data about health facilities and human resources and discussion with academic partners. Aligning partners and donors with the government's vision for quality improvement can enhance acceptability and political support. Such alignment can enable resources to be focused strategically towards one national effort - rather than be diluted across dozens of potentially competing projects. Initial stages benefit from having modest goals and the flexibility for continuous modification and improvement, through active engagement with all stakeholders.

De nombreux pays s'efforcent d'élaborer et de mettre en œuvre des stratégies pour contrôler les hôpitaux à l'échelle nationale. C'est un défi de taille, en particulier pour les pays à faible revenu, qui disposent de peu de ressources pour effectuer des mesures et des comptes-rendus. Nous avons analysé l'expérience qui a consisté à élaborer et mettre en œuvre un système national de contrôle des performances de 130 hôpitaux publics en Éthiopie. Des observations participatives ont révélé que ce système de contrôle a entraîné une communication plus systématique des données sur les performances aux bureaux régionaux de la santé et au gouvernement fédéral de la part des hôpitaux, a amélioré la transparence concernant les performances de ces derniers et a permis d'élaborer plusieurs projets d'amélioration de la qualité. L'élaboration et la mise en œuvre de ce système, qui ont nécessité des investissements et des soutiens techniques et politiques, n'auraient pas été possibles sans d'importantes capacités de gestion dans les hôpitaux. Il peut être utile, aux premiers stades de la conception et de la mise en œuvre, d'évaluer de manière approfondie l'ouverture au changement du secteur de la santé ainsi que son souhait de placer au premier plan la qualité des services hospitaliers. Cette évaluation peut s'appuyer sur des entretiens avec des informateurs clés, sur la collecte de données au sujet des établissements de santé et des ressources humaines, ou encore sur une discussion avec des partenaires universitaires. Le fait d'associer des partenaires et des donateurs à l'objectif d'amélioration de la qualité visé par le gouvernement peut permettre de renforcer son acceptabilité ainsi que le soutien politique en la matière. Cela peut permettre de faire converger les ressources de façon stratégique vers un même effort national, plutôt que de les éparpiller dans des dizaines de projets potentiellement concurrents. Au cours des premières phases, il est bénéfique d'avoir des objectifs modestes et de faire preuve de souplesse afin de permettre des modifications et une amélioration continues, par le biais d'un engagement actif auprès de l'ensemble des parties prenantes.

Muchos países tienen dificultades para desarrollar e implementar estrategias a nivel nacional para monitorizar los hospitales. El reto es especialmente complicado en países de ingresos bajos donde los recursos para la medición y la notificación son escasos. Se examinó la experiencia a la hora de desarrollar e implementar un sistema nacional para monitorizar el rendimiento de 130 hospitales del gobierno en Etiopía. Haciendo uso de una observación participativa, se observó que el sistema de monitorización se tradujo en una notificación de datos de rendimiento de los hospitales más coherente a las oficinas de salud regionales y al gobierno federal, así como un incremento en la transparencia sobre el rendimiento de los hospitales y el desarrollo de diferentes proyectos para la mejora de la calidad. El desarrollo y la implementación de dicho sistema, que requería de inversiones y soporte tanto técnico como en materia de inversión, no hubieran sido posibles sin una fuerte habilidad de gestión a nivel hospitalario. Una meticulosa valoración de la disposición del sector sanitario a cambiar y del deseo de este a priorizar la calidad hospitalaria podría ser de gran ayuda en las primeras fases del diseño y la implementación. Esta evaluación podría incluir entrevistas con informadores clave, una recopilación de datos sobre instalaciones sanitarias, recursos humanos y debates con asociados del mundo académico. Poner en consonancia la visión del gobierno sobre la mejora de la calidad con los asociados y contribuyentes puede hacer aumentar la aceptación y el apoyo político. Dicho alineamiento puede permitir una focalización estratégica de los recursos respecto a un solo esfuerzo nacional, antes que esparcirlo en docenas de proyectos potencialmente conflictivos. Las fases iniciales son las principales beneficiadas de tener objetivos modestos y flexibilidad para modificar y mejorar de forma continua, a través de un compromiso activo con todos los accionistas.

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.

Exploring the lived experiences of parents caring for infants with gastroschisis in Rwanda: The untold story.

Pediatric surgery is a crucial pillar of health equity but is often not prioritized in the global health agenda, especially in low-and middle-income countries. Gastroschisis (GS) is a type of structural congenital anomaly that can be treated through surgical interventions. In Rwanda, neonatal surgical care is only available in one hospital. The experience of parents of children born with gastroschisis has not been previously studied in Rwanda. The objective of this study was to explore the lived experiences of parents of children diagnosed with GS in Rwanda. A qualitative study using a semi-structured interview guide was conducted. Parents who had children with gastroschisis and were discharged alive from the hospital in Rwanda were interviewed by trained data collectors, from May to July 2021. Data were transcribed, translated, and then coded using a structured code-book. Thematic analysis was conducted with the use of Dedoose software. Sixteen parents participated in the study. Five themes emerged from the data. They were: "GS diagnosis had a significant emotional impact on the parents", "Parents were content with the life-saving medical care provided for their children despite some dissatisfaction due to the delayed initiation of care and shortage of medications", "GS care was accompanied by financial challenges", "support systems were important coping mechanisms" and "the impact of GS care extended into the post-discharge period". Having a newborn with GS was an emotional journey. The lack of pre-knowledge about the condition created a shock to the parents. Parents found support from their faith and other parents with similar experiences. The experiences with the care received were mostly positive. The overall financial burden incurred from the medical treatment and indirect costs was high and extended beyond the hospital stay. Strengthening prenatal and hospital services, providing peer, spiritual and financial support could enhance the parents' experience.

Changing hospital organisational culture for improved patient outcomes: developing and implementing the leadership saves lives intervention.

BACKGROUND: Leadership Saves Lives (LSL) was a prospective, mixed methods intervention to promote positive change in organisational culture across 10 diverse hospitals in the USA and reduce mortality for patients with acute myocardial infarction (AMI). Despite the potential impact of complex interventions such as LSL, descriptions in the peer-reviewed literature often lack the detail required to allow adoption and adaptation of interventions or synthesis of evidence across studies. Accordingly, here we present the underlying design principles, overall approach to intervention design and core content of the intervention. METHODS OF INTERVENTION DEVELOPMENT: Hospitals were selected for participation from the membership of the Mayo Clinic Care Network using random sampling with a purposeful component. The intervention was designed based on the Assess, Innovate, Develop, Engage, Devolve model for diffusion of innovation, with attention to pressure testing of the intervention with user groups, creation of a think tank to develop a comprehensive assessment of the landscape, and early and continued engagement with strategically identified stakeholders in multiple arenas. RESULTS: We provide in-depth descriptions of the design and delivery of the three intervention components (three annual meetings of all hospitals, four rounds of in-hospital workshops and an online community), designed to equip a guiding coalition within each site to identify and address root causes of AMI mortality and improve organisational culture. CONCLUSIONS: This detailed practical description of the intervention may be useful for healthcare practitioners seeking to promote organisational culture change in their own contexts, researchers seeking to compare the results of the intervention with other leadership development and organisational culture change efforts, and healthcare professionals committed to understanding complex interventions across healthcare settings.

Addressing noncommunicable diseases among urban refugees in the Middle East and North Africa - a scoping review.

BACKGROUND: More than 5.5 million Syrian refugees have fled violence and settled in mostly urban environments in neighboring countries. The Middle East and North Africa (MENA) region accounts for 6% of the global population but 25% of the population are 'of concern' to the UN Refugee Agency. In addition to large amounts of forced migration, the region is also undergoing an epidemiologic transition towards a heavier burden of noncommunicable diseases (NCDs), which in 2018 accounted for 74% of all deaths in the region. To address NCD needs globally, a myriad of policies and interventions have been implemented in low-income stable country settings. However, little is known about which policies and interventions are currently being implemented or are best suited for refugee hosting countries across the Middle East and North Africa. METHODS: A scoping review of peer-reviewed literature was conducted to identify policies and interventions implemented in the Middle East and North Africa to address the needs of urban refugees with noncommunicable diseases. RESULTS: This scoping review identified 11 studies from Jordan, Lebanon, Iran, West Bank, Gaza and Syria. These studies addressed three foci of extant work, (1) innovative financing for expensive treatments, (2) improvements to access and quality of treatment and, (3) efforts to prevent new diagnoses and secondary complications. All interventions targeted refugee populations including Palestinians, Sudanese, Syrians, Afghans and Iraqis. DISCUSSION: The scoping review highlighted five key findings. First, very few studies focused on the prevention of noncommunicable diseases among displaced populations. Second, several interventions made use of health information technologies, including electronic medical records and mHealth applications for patients. Third, the vast majority of publications were solely focused on tackling NCDs through primary care efforts. Fourth, the literature was very sparse in regard to national policy development, and instead favored interventions by NGOs and UN agencies. Last, the perspectives of refugees were notably absent. CONCLUSION: Opportunities exist to prioritize prevention efforts, scale up eHealth interventions, expand access to secondary and tertiary services, address the scarcity of research on national policy, and incorporate the perspectives of affected persons in the broader discourse.

"What's happening in Syria even affects the rocks": a qualitative study of the Syrian refugee experience accessing noncommunicable disease services in Jordan.

BACKGROUND: Humanitarian actors and host-countries in the Middle East and North Africa region are challenged with meeting the health needs of Syrian refugees and adjusting the response to contemporary humanitarian conditions - urban-based refugees, stressed host-country health systems and high NCD prevalence. Although several studies have explored NCD prevalence, utilization of services and barriers to access, these analyses took place prior to dramatic shifts in Jordanian health policy and did not account for nuances in health seeking and utilization behaviors or operational barriers. Accordingly, we aimed to understand the depth and nuances of Syrian refugees' experiences accessing NCD services in urban and semi-urban settings in Jordan. METHODS: A qualitative study was conducted to explore the healthcare experiences of Syrian refugees in Jordan. The study team conducted 68 in-depth interviews with Syrian refugees in urban and semi-urban locations in central and northern Jordan. RESULTS: The findings indicated four themes key to understanding the healthcare experience: (1) emotional distress is a central concern and is frequently highlighted as the trigger for a non-communicable disease or its exacerbation; (2) service provision across all sectors - government, NGO, private - is complex, inadequate, expensive and fragmented, making engagement with the health sector physically and financially burdensome; (3) given financial constraints, participants make harmful decisions that further damage their health in order to reduce financial burdens, and (4) host-community members actively exhibit solidarity with their refugee neighbors and specifically do so during emergency health episodes. The findings from this study can be used to inform program design for forcibly displaced persons with NCDs and identify points of entry for effective interventions. CONCLUSIONS: Opportunities exist for humanitarian and host-country actors to provide more comprehensive NCD services and to improve the relevance and the quality of care provided to Syrian refugees in Jordan. Global and national funding will need to align with front-line realities and foster better coordination of services between host-country health systems, private actors and non-governmental organizations.

How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study.

BACKGROUND: Quality collaboratives are widely endorsed as a potentially effective method for translating and spreading best practices for acute myocardial infarction (AMI) care. Nevertheless, hospital success in improving performance through participation in collaboratives varies markedly. We sought to understand what distinguished hospitals that succeeded in shifting culture and reducing 30-day risk-standardised mortality rate (RSMR) after AMI through their participation in the Leadership Saves Lives (LSL) collaborative. PROCEDURES: We conducted a longitudinal, mixed methods intervention study of 10 hospitals over a 2-year period; data included surveys of 223 individuals (response rates 83%-94% depending on wave) and 393 in-depth interviews with clinical and management staff most engaged with the LSL intervention in the 10 hospitals. We measured change in culture and RSMR, and key aspects of working related to team membership, turnover, level of participation and approaches to conflict management. MAIN FINDINGS: The six hospitals that experienced substantial culture change and greater reductions in RSMR demonstrated distinctions in: (1) effective inclusion of staff from different disciplines and levels in the organisational hierarchy in the team guiding improvement efforts (referred to as the 'guiding coalition' in each hospital); (2) authentic participation in the work of the guiding coalition; and (3) distinct patterns of managing conflict. Guiding coalition size and turnover were not associated with success (p values>0.05). In the six hospitals that experienced substantial positive culture change, staff indicated that the LSL learnings were already being applied to other improvement efforts. PRINCIPAL CONCLUSIONS: Hospitals that were most successful in a national quality collaborative to shift hospital culture and reduce RSMR showed distinct patterns in membership diversity, authentic participation and capacity for conflict management.

Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study.

BACKGROUND: Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced. METHODS: This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services. RESULTS: We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011-2014 and 2012-2015. CONCLUSIONS: Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.

Use of a national collaborative to improve hospital quality in a low-income setting.

BACKGROUND: Quality improvement collaboratives are a widely used mechanism to improve hospital performance in high-income settings, but we lack evidence about their effectiveness in low-income settings. METHODS: We conducted cross-sectional and longitudinal analysis of data from the Ethiopian Hospital Alliance for Quality, a national collaborative sponsored by Ethiopia's Federal Ministry of Health. We identified hospital strategies associated with more positive patient satisfaction using linear regression and assessed changes in patient experience over a 3-year period (2012-2014) using matched t-tests. RESULTS: A total of 68 hospitals (response rate 68/120, 56.7%) were included in cross-sectional analysis. Four practices were significantly associated with more positive patient satisfaction (p<0.05): posting a record of cleaning activity in toilets and in patient wards, distributing leaflets in the local language with each prescription, and sharing ideas about patient experience across the hospital. Among hospitals that had complete data for longitudinal analysis (44/68, 65%), we found a 10% improvement in a 10-point measure of patient satisfaction (7.7 vs 8.4, p<0.01) from the start to the end of the study period. CONCLUSIONS: Quality improvement collaboratives can be useful at scale in low-income settings in sub-Saharan Africa, particularly for hospitals that adopt strategies associated with patient satisfaction.

Implementation of the WHO Surgical Safety Checklist in an Ethiopian Referral Hospital.

BACKGROUND: The WHO Surgical Safety Checklist has a growing evidence base to support its role in improving perioperative safety, although its impact is likely to be directly related to the effectiveness of its implementation. There remains a paucity of documented experience from low-resource settings on Checklist implementation approaches. We report an implementation strategy in a public referral hospital in Addis Ababa, Ethiopia, based on consultation, local leadership, formal introduction, and supported supervision with subsequent audit and feedback. METHODS: Planning, implementation and assessment took place from December 2011 to December 2012. The planning phase, from December 2011 until April 2012, involved a multidisciplinary consultative approach using local leaders, volunteer clinicians, and staff from non-governmental organisations, to draw up a locally agreed and appropriate Checklist. Implementation in April 2012 involved formal teaching and discussion, simulation sessions and role play, with supportive supervision following implementation. Assessment was performed using completed Checklist analysis and staff satisfaction questionnaires at one month and further Checklist analysis combined with semi-structured interviews in December 2012. RESULTS AND DISCUSSION: Checklist compliance rates were 83% for general anaesthetics at one month after implementation, with an overall compliance rate of 65% at eight months. There was a decrease in Checklist compliance over the period of the study to less than 20% by the end of the study period. The 'Sign out' section was reported as being the most difficult section of the Checklist to complete, and was missed completely in 21% of cases. The most commonly missed single item was the team introduction at the start of each case. However, we report high staff satisfaction with the Checklist and enthusiasm for its continued use. CONCLUSION: We report a detailed implementation strategy for introducing the WHO Surgical Safety Checklist to a low-resource setting. We show that this approach can lead to high completion rates and high staff satisfaction, albeit with a drop in completion rates over time. We argue that maximal benefit of the Surgical Safety Checklist is likely to be when it engenders a conversation around patient safety within a department, and when there is local ownership of this process.

Development of a brief instrument for assessing healthcare employee satisfaction in a low-income setting.

BACKGROUND: Ethiopia is one of 57 countries identified by the World Health Report 2006 as having a severely limited number of health care professionals. In recognition of this shortage, the Ethiopian Federal Ministry of Health, through the Ethiopian Hospital Management Initiative, prioritized the need to improve retention of health care workers. Accordingly, we sought to develop the Satisfaction of Employees in Health Care (SEHC) survey for use in hospitals and health centers throughout Ethiopia. METHODS: Literature reviews and cognitive interviews were used to generate a staff satisfaction survey for use in the Ethiopian healthcare setting. We pretested the survey in each of the six hospitals and four health centers across Ethiopia (98% response rate). We assessed content validity and convergent validity using factor analysis and examined reliability using the Cronbach alpha coefficients to assess internal consistency. The final survey was comprised of 18 questions about specific aspects of an individual's work and two overall staff satisfaction questions. RESULTS: We found support for content validity, as data from the 18 responses factored into three factors, which we characterized as 1) relationship with management and supervisors, 2) job content, and 3) relationships with coworkers. Summary scores for two factors (relationship with management and supervisors and job content) were significantly associated (P-value, <0.001) with the two overall satisfaction items. Cronbach's alpha coefficients showed good to excellent internal consistency (Cronbach alpha coefficients >0.70) for the items in the three summary scores. CONCLUSIONS: The introduction of consistent and reliable measures of staff satisfaction is crucial to understand and improve employee retention rates, which threaten the successful achievement of the Millennium Development Goals in low-income countries. The use of the SEHC survey in Ethiopian healthcare facilities has ample leadership support, which is essential for addressing problems that reduce staff satisfaction and exacerbate excessive workforce shortages.