Measurement as a Stepping Stone for Change in RwandaCase Study #1 Measurement as a Stepping Stone for Change in Rwanda Institute for Healthcare Improvement (IHI). Read and critique the effort to Improve Case in Rural Rwanda. http://www.ihi.org/IHI/Programs/IHIOpenSchool/ImprovingCareinRuralRwandaPart1.htm?tab Id=0. Answer the questions in the case study. http://www.ihi.org/IHI/Programs/IH ...[Show More]
Measurement
as a Stepping Stone for Change in Rwanda
Case
Study #1 Measurement as a Stepping Stone for Change in Rwanda Institute for Healthcare
Improvement (IHI).
Read
and critique the effort to Improve Case in Rural Rwanda.
http://www.ihi.org/IHI/Programs/IHIOpenSchool/ImprovingCareinRuralRwandaPart1.htm?tab
Id=0. Answer
the questions in the case study. http://www.ihi.org/IHI/Programs/IHIOpenSchool/Improving_Care_in_Rural_Rwanda_Part_2.
htm Patrick Lee, MD, Partners in Health, Volunteer Clinical Mentor
Newton-Wellesley Hospital, Hospitalist Physician Harvard Medical School,
Clinical Instructor in Medicine
Part 1 of this narrative report tells the
story of Partners in Health’s (PIH's) recent quality improvement work in rural
Rwanda. Since Partners in Health’s founding over 25 years ago in rural Haiti,
the organization has worked to alleviate the underlying social and economic
conditions as well as the diseases that afflict the poor in developing
settings. PIH’s quality improvement work similarly emphasizes substantial
commitment to improving infrastructure, building capacity, and augmenting
available resources with the belief that, in resource-poor settings, these
components are necessary for both initiating and sustaining meaningful
improvements in quality of care.
Though related from the perspective of Dr.
Lee, the following narrative represents the concerted effort of many, including
Dr. Raymond Dusabe, Nurse Philbert Kanama, Nurse Caste Habiyakare, Kirehe
Program Manager Shema Jean René, the dedicated Rwandan staff of Kirehe
Hospital, PIH co-founder Dr. Paul Farmer, Director of PIH Rwanda Dr. Michael
Rich, PIH Rwanda Medical Director Dr. Henry Epino, PIH Medical Director Dr.
Joia Mukherjee, Meera Kotagal, and many others.
The Case
This report describes Partners in Health’s
quality improvement work at Kirehe Hospital — the newer of the two Ministry of
Health-Partners in Health (MOH-PIH) district hospitals in the rural Eastern
Province of Rwanda. This is a hilly, malaria-endemic area of nearly 500,000
people whose income averages less than 1 USD per day. Prior to PIH’s arrival in
2005, under-five mortality was about 23%, nearly half of all children suffered
from malnutrition and stunted growth, no one was being treated for HIV/AIDS or
tuberculosis (TB), and there were no doctors at all working in the district.
In the context of a partnership with the
Rwandan Ministry of Health to scale-up an effective and sustainable rural
health care model nationwide, PIH began working in the two poorest, most
underserved districts in the Eastern Province of Rwanda. With the hard work and
leadership of our talented Rwandan colleagues and mentorship from Paul Farmer,
Joia Mukherjee, Michael Rich, and others, PIH successfully implemented a
robust, community-based health care system adapted from its work on the central
plateau in rural Haiti.
In
18 months: hundreds of community health workers were trained and paid to
monitor patients and administer medications; nearly 2,000 patients were started
on antiretroviral therapy; TB, malaria, obstetrical, and comprehensive health
care services were established and strengthened; and a program was put in place
to meet the population’s urgent social needs, including nutrition, shelter,
school fees, and transport costs to and from the clinics.
When I began working at Kirehe Hospital in
2007, I was asked by Henry Epino to focus on improving quality of care
throughout the system. For eight weeks, I served alongside the nurses and
doctors in the hospital and clinics as a clinical mentor, modeling the kind of
patient-centered, evidence-based care that I had been trained to practice and
that I believe is the fundamental right of every person. Each morning, I
engaged the staff in short chalk talks around issues relevant to our
hospitalized patients. We lived, ate, and relaxed together after the days’
work. All this time I listened.
I came to care deeply about Kirehe and
realized the strong ties between the hospital’s staff and the surrounding
community. Most of the staff lives within walking distance of the hospital.
They know their patients as neighbors and often friends. Many of them bear
traumas from the 1994 genocide. One of my personal heroines, Nurse M, became
the head of her family at age 12 when both her parents were murdered. She
supports six younger siblings and took in another AIDS orphan last year,
honoring his mother’s dying wish. I knew M first as a smart, dedicated nurse
with a radiant smile, and only later learned how profoundly she has cared for
her younger siblings and her community. She is not alone. Many of our staff and
members of the local community have suffered similar losses and have responded
with service and a quiet determination to go on, to make the future better than
the past.
In those first eight weeks, I also noticed
major gaps in care. Despite deep ties to the community, staff morale seemed
low. Many nurses were underperforming. I would pick up a patient chart and
often find that vital signs had not been done, or medications ordered by the
doctor had not been given properly, or lab tests had not been performed. Some
resources were missing, including several essential medicines and diagnostics
and adequate staff to allow sustainable patient-to-doctor and patient-to-nurse
ratios. The hospital, facilities, and staff had come a long way since the
beginning of the MOH-PIH partnership, but there were still gaps in care. Prior
quality improvement efforts, including exhortations to "do better"
and a report card/pay-for-performance intervention, had not resulted in lasting
change.
I knew we could do better. But how? We
needed to raise staff morale, set and achieve a new standard of excellence in
patient care, identify and supplement key missing resources, and maximize the
effectiveness of our existing staff and resource pool — and we had to do it
with the smallest possible footprint so that whatever gains we achieved could
be implemented and sustained without negatively impacting other programs.
Around the same time, I met Meera Kotagal,
a Harvard medical student who had prior experience working with the Institute
for Healthcare Improvement (IHI) and was volunteering for the year with
Partners in Health in Rwanda. Meera and I engaged in a series of conversations
about the existing gaps in care and the ways we might continue to improve the
system. Meera brought methodological rigor to the discussion based on her work
with IHI and introduced me to the Model for Improvement and Plan-Do-Study-Act
(PDSA) cycles (straightforward, effective techniques for focusing and measuring
change). We made a plan, got the nod from two of the hospital’s leaders, Shema
Jean René and Henry Epino, and forged ahead.
Our first task was to build broad consensus
and identify change goals. In a staff discussion, we agreed that our patients
and community deserved the highest standard of care — the same standard we
would want for our own families — and we reaffirmed our solidarity with the poor
community we serve. Vital signs and medication administration were chosen as
our first two targets in our simple quality improvement intervention. A
baseline evaluation revealed that a full set of vital signs were performed and
medications given as ordered only about 50% of the time.
We set our change goal at 95% compliance
for five consecutive days for both vital signs and medications. Achieving this
high standard would require effort on the part of every member of the nursing
staff over the course of five days. We hoped this might create a "last
man/woman" effect, enabling the better-performing members of the team to
motivate even the least enthusiastic nurses to bring their standard up.
Despite the previous six months’ status
quo, we quickly made remarkable gains. PIH’s comprehensive care model, emphasis
on building local capacity, and substantial resource and infrastructure inputs
at Kirehe provided a firm foundation for this early success. These inputs
included hiring new staff, providing incentive pay on top of base salaries,
supplementing missing essential medicines and diagnostics, implementing an
electronic medical record system to facilitate re-supply and patient tracking,
supplying electricity, fuel, vehicles, food, bedsheets, and so on. While these
inputs may eventually have raised vital signs and medications to 95% as has
occurred at other PIH sites in Rwanda, our QI intervention at Kirehe seemed to
accelerate this improvement. Something sparked in the kindling of existing
resources, the staff’s deep ties to the community, our emphasis on service and
solidarity, and the timely performance feedback. The status quo shifted.
Our initial gains relied heavily on a surge
of staff effort. Lacking enough functioning blood pressure cuffs and thermometers,
for example, the nurses set up a creative relay system that allowed them to get
all the vital signs done before 9 AM. We were performing at goal, but not yet
in a sustainable way. Using basic quality improvement tools (including a series
of PDSA cycles), we were able to identify resource gaps and systemic problems,
then work to improve them.
We began to backfill. Or rather, the nurses
themselves began to backfill, addressing resource deficits and improving the
system’s organization and efficiency. They received full support in this effort
from Kirehe’s leadership, including Shema Jean René, Philbert Kanama, Henry
Epino, and others. Recognizing that half-an-hour after the morning meeting was
not enough time for the day nurse to perform vital signs and give out
medications before 9 AM, they transferred this task to the night nurse (a move
that had long been discussed but not yet implemented). This led to a wholesale
reorganization of the nursing staff from a nomadic rotation where nurses worked
several days in each ward then moved on, to one where nurses were assigned to a
ward and elected a chief who would be responsible for quality of care and
training of junior nurses.
Every Thursday, the all-staff meeting was
replaced by local "troubleshooting rounds" in each ward, where the
ward chief and nurses would review supplies, any problems from the previous
week, and solve problems directly if they could. Systemic problems identified
in these meetings would be discussed on a monthly basis with the head of nursing
and the hospital medical director. This is only a partial list. Change was
occurring organically throughout the system, driven by nurses who felt
motivated and empowered to “see a problem, fix a problem” — the defining
feature of a high-performing, self-correcting system.
We found that, by spotlighting keystone
patient care processes, we helped illuminate resource gaps and opportunities
for better use of existing resources all along the health care delivery chain.
For example, by counting a medication stock-out as a medication “not-given”
(since the patient did not receive it), we provided an incentive for the ward
nurses to strengthen our pharmacy supply chain by promptly requesting
medication re-supply and reminding their pharmacy colleagues to anticipate
stock-outs before they occurred. In my first month at Kirehe (about six months
after the hospital’s opening), we experienced a nearly two-week stock-out of
Lasix, an essential medication for the management of heart failure. This is
unfortunately not an uncommon occurrence in resource-poor settings such as
rural Rwanda. One patient, a kind 60-year-old man with smile lines around his
eyes, had been admitted for severe heart failure. We had stabilized his
condition but then the Lasix supply ran out. After several days, he asked to
return home. Since he lived nearby and we could go find him when the Lasix
arrived, there was little we could do but agree. We learned later that he had
died at home from heart failure. I keep the letter he wrote to me in perfect French
on the day he left the hospital in memory of him and as a powerful reminder of
why quality improvement matters.
I share this story not as a critique of the
early efforts at Kirehe, but rather in recognition of the difficult realities
of health systems in resource-poor settings, and the lifesaving potential of an
effective quality improvement program. We have not stocked out of Lasix for
over a year now at Kirehe. Though I wish we could have improved the system a
few months earlier, I am glad for all of the patients who have and will benefit
from our strengthened pharmacy system and a steady supply of essential
medicines.
Our Rwandan quality improvement team — Dr.
Raymond Dusabe, Nurse Philbert Kanama, and Nurse Caste Habiyakare — was the
driving force behind these remarkable improvements. Their fundamental
understanding of the methodology and their belief in its utility allowed them
to speak frankly and honestly with their colleagues about gaps in care and
solutions they had devised to improve the system. They inspired their
colleagues with their own outstanding service and solidarity with the community
while employing simple QI tools to track and respond to even small dips in
performance.
The Rwandan QI team was able to maintain a
very small footprint while spurring systemwide change because quality and
excellence had become an all-staff endeavor. Soon our social workers and
program director, who had frequent conversations with the local community,
reported that people they spoke to were talking about a “change at Kirehe.”
Patients noticed nurses working hard all night long, and using slow periods
during the day to teach basic lessons on health and hygiene. They expressed
their appreciation and growing trust that they were receiving the very best possible
care. Nurses in turn described “rediscovering their sense of professionalism”
and “renewing their commitment to health care and their community.” They
reported that they were working harder than before but feeling much more
satisfied with their jobs.
The Rwandan physician staff also made
several important changes to improve patient care. They instituted afternoon
rounds where they would follow up on any unstable patients as well as see any
new patients admitted during the day (who otherwise would be seen first by
nurses and not evaluated by a doctor until the following morning). The doctors
started giving direct pass-off to whichever colleague was on overnight call to
be sure key facts were communicated on the sickest patients. They installed a
light box in the staff room so x-rays could be shown and challenging patients
discussed during morning meetings.
The doctors also led a dramatic improvement
in the learning environment at the hospital. They instituted afternoon teaching
rounds that were initially led by either one of the visiting PIH clinical
mentors or myself. During these rounds we performed ultrasounds together at the
bedside, reviewed blood smears and urine sediments, and discussed the sickest
patients in order to optimize management. Over time, the Rwandan doctors began
to conduct these rounds on their own. Perhaps most impressively, the doctors organized
an inhouse lecture series. I returned to Kirehe Hospital in September 2008 to
find that, in place of our usual morning chalk talks, two nurses and a doctor
were collaborating to deliver PowerPoint presentations to the staff on core
clinical topics three days per week. This is an astounding feat in a rural
community with inconsistent running water and no access to the power grid,
where the majority of the population are poor farmers earning less than 1 USD
per day.
We were witnessing a remarkable change at
Kirehe. The staff was active and engaged, practicing excellence in their daily
work and solving problems locally. Meanwhile our Rwandan QI team gained
confidence with each success and stepped forward to lead and propose new
initiatives even as Meera and I moved back into more supportive roles.
We began spreading the model. Quality
improvement became an important theme of the first annual PIH Rwanda Physician
Retreat. At the retreat, our now-veteran Rwandan QI team shared their
philosophy on quality improvement: doctors, as system leaders, need to "be
the change" and exemplify the highest standards of care. They also led a
wonderfully nuanced workshop on the Model for Improvement. Our Rwandan team
trained nurses at two health centers in the Kirehe district and replicated both
the specific and global results of the QI intervention at Kirehe. At Kirehe, we
tapered from showing daily performance to random weekly spot-checks over the
course of three months and moved on to other QI goals, including laboratory
tests, universal HIV voluntary counseling and testing, partogram use, diabetic
nutrition, and patients being able to correctly name their diagnosis. One year
later, review of all of the Kirehe Hospital charts for September 2008 suggests
we have held our early gains, and still check vital signs, give medications,
and perform laboratory tests >95% of the time.
Using a wall chart, Lee and teammates
tracked the proper checking of vital signs each morning .as well as the proper
administration of medication. Part 1 of this narrative report recounted the
story of Partners in Health’s recent quality improvement work in rural Rwanda.
Part 2 discusses lessons learned from this experience, followed by several discussion
questions. In Part 1 of this case study, we saw how simple improvement tools,
when paired with substantial resource inputs and broad consensus, successfully
improved care at Kirehe District Hospital in rural Rwanda.
Questions
1. The authors found that ensuring a broad
consensus among health care staff was important. Why was this so?
2. Keeping a small footprint was important
in the process to generate buy-in and long-term sustainability. How might this
also impact staffing?
3. What impact did performance data have on
improving efficiencies?
4. In such a resource depleted area such as
Rwanda, physical changes were necessary as well as basic needs such as food and
electricity for the operations of the clinic by staff that in turn served
patients. Was this investment important? If so, why?
Published: 1 year ago
Published By: CPA Guru
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Category: | Case Study |
Published By: | CPA Guru |
Published On: | 1 year ago |
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Language: | English |
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