Quality improvement initiatives in county hospitals: a multiple case study of four hospitals in Uasin Gishu County
There is growing evidence showing that expanded access to healthcare services is in itself insufficient, and that quality and patient safety are vital components for achievement of good outcomes. Like other counties, Uasin Gishu County has made effort to encourage healthcare facilities to take up continuous quality improvement (QI) initiatives. While hospitals report implementing QI, no assessments have been done to inform the county policymakers. This study sought to fill that gap. Using four facilities as cases (Huruma, Turbo, Pioneer, and Uasin Gishu), the study employed a mixed-methods approach, including a questionnaire survey covering 180 participants (various roles and levels) and qualitative in depth interviews with facility in charges, heads of department or QI focal persons (champions). The study found that the Plan-Do-Study-Act (PDSA) model was the primary approach used across the County, building mainly from the vertical HIV care program. Most QI initiatives were externally driven under vertical programs such as reproductive health, tuberculosis and infection prevention programs. Barriers to QI implementation included staff and organizational-level challenges. Staff-related factors such as laxity, high turnover and low morale were elicited. Organization barriers included hierarchical culture, poor communication practices and inadequate QI leadership support from the County. Factors that facilitated QI implementation included relevance of the initiatives to the staffs, training in QI, monitoring of projects and rewarding staffs. While a narrow range of clinical outcomes were monitored objectively, most outcomes were estimated subjectively, making it difficult to gauge the effectiveness of the QI activities. The initiatives were also not sustained beyond the initial scope. The study recommends improving the QI approach by focusing strongly on internal gaps, improving the integration with existing structures, instituting on job training and addressing human resource challenges.