This study identified profound deficiencies in the system functions of patient care, staffing and the management of the Medical Department of KCH. It illustrates that the staff are indeed aware of these problems and open for change. This, in itself, is a prerequisite for the next necessary steps that will include agreeing on achievable goals and defining and implementing “fixes” for quality improvement.
The observations of the selected group of interviewees concurred with the main themes and matched also the researcher’s observations and extractions from registers. Thus, the described results appear to be robust in triangulation.
Findings from this study have been related to the literature on similar studies, carried out to either confirm what is already known or to contrast what other studies may have reported in similar investigations.
Documentation
The study revealed important shortcomings in documentation in the OPD registers as reported in the results under heading 'registered diagnosis to the OPD II’. These data gaps presuppose that some staff do not appreciate the essence of keeping good registers and maintaining proper data management which is a tool to securing high quality of healthcare delivery.
The findings on improper data management suggest the need for a simplified checklist tool of diseases and conditions for clinicians and clerks to use in order to correctly describe the case load. Furthermore, much attention needs to be paid to the documentation of diagnosis at discharge, since this should provide more solid information on causes for admission and it is crucial for the continuum of care after discharge [15].
Patient flow, statistics and care
In a tertiary hospital, the WHO recommends that cases seen should require tertiary care [16]. In this survey, however, 64% of the 95 respondents to that question indicated that they are self-referrals to the KCH Medical Department (Figure 1). This observation may indicate poor functioning of the healthcare referral system or the lack of patient trust in the first and secondary levels of care [17]. The implications of a weak referral system on the quality of care constitutes a further strain on the limited resources - both human and material - and the inability of the Medical Department to fully concentrate on its mandate as a tertiary unit in focusing on tertiary care, teaching and research [16]. This also poses a conundrum: The department is being used by patients like a secondary level of care facility and currently the department can offer tertiary level of care only for a few conditions. This finding underlines the need to re-define the role of the department, including its relation to referring centres and hospitals. Furthermore, the defined function needs to be reflected in staffing and equipment.
Central hospitals have frequently been challenged to absorb numerous staff and resources compared to first- and second-line health providers, without delivering the respective quantity and quality of care. If left undefined, the problem will continue and create frustration with patients, staff and the wider health system [18].
The MSS in the Medical Department has been functioning as a triage unit, where critically ill patients are observed and discharged or admitted when necessary. The MSS has worked to reduce the burden on bed occupancy in the main wards [19] while improving on patient outcomes. The unit is thus functioning as a central and crucial point for delivery of quality care within the department: a practice in the Medical Department that is similar to the accident and emergency ward for triaging cases. The statistics on patient flow through the MSS, as recorded in the results, shows higher patient volumes at night than in the day, yet more staff were assigned to the MSS during the day shift than during the night shift. Improving the quality of care delivery, does not therefore always demand new resources, but often the more effective management of the few available resources [14]. Looking at data can assist the management to make informed decisions.
The number of patients followed during the participant/researcher observation was not of much interest to the patient flow patterns, rather the observation of patient flow was to give a broad overview of patient movement within the Medical Department. In contrast, the OPD registers have been used to establish the patient flow density and patterns of services assessed in the department.
Information obtained relating to the quality of patient-provider relationships was found to be encouraging, yet providers are to be encouraged to involve patients more in their own management, by allowing them to ask questions and explain their feelings and or fears about the care they receive.
Staffing-related issues
The human resource crisis in health is a huge challenge, not only in the KCH Medical Department but a shared problem throughout Malawi [20]. This challenge emanated as a common theme from the stakeholder interviews. In instances where there is a shortage of staff, the few available staff need to be efficiently managed to handle their workload without feeling demotivated by their work demands [6].
A match of the rate of patient flow to the staff capacity, as described in the Results section, (understaffing) would suggest that staff workload is not a problem as strongly indicated by the interviewees. However, it must be stressed that being a teaching hospital, the mandate of the medical team is not only limited to caring for patients, but also to teaching, research and outreach support to the sub districts. It follows that the views of the stakeholder interviewees about inadequate staffing may be a valid point in spite of the data of staff-to-patient ratios in the June 2010 OPD records.
Assuming the OPD data reported in this study is a true reflection of patient density at the Medical Department, then this observation may imply an inefficiency and underutilization, or misallocation or even absenteeism of the staff strength in the unit [21]. On the other hand, if there was considerable underreporting of patients in the registers, then this may be a sign of serious data gaps and thus call for some data quality checks in the Medical Department. Again, if the patient load and the interviewee assertions about staff shortage are anything to go by, then in the attempt to ensure quality improvement in care delivery of the Medical Department, increasing the staff capacity and reducing staff turnover needs to be addressed promptly, and no longer as merely a known but 'neglected’ issue [5]. To address the staffing needs, the leadership of the Medical Department has to provide data to inform management decisions: for example, about patient needs and how to meet the needs with the staff available [22, 23]. This argument aligns with Øvretveit’s recommendation of designing a standard for management quality which will guide service efficiency [24].
Communication in healthcare is very crucial for the efficient management of patients. With the observed gaps in both verbal and written communication among staff, the Medical Department could adopt the SBAR (Situation-Background-Assessment-Recommendation) model to enhance communication among staff and to improve patient safety [25].
Leadership
This study equally confirms Øvretveit’s observation [24] that managers sometimes feel they have little control over health workers. In the Medical Department and KCH at large, management mentioned that it is struggling with little or no accountability from staff, low or lack of commitment and low staff motivation (Additional file 1: Appendix 1, Sections 4.5.1, 4.5.2). Staff and management interviewees attributed the lack of accountability from staff to weak leadership structures (Additional file 1: Appendix 1, 4.5.3) at the departmental level and the centralization of authority over the health workforce at the national level. Therefore, neither the hospital management nor the heads of departments have control over their staff or are able to hold them accountable for their actions, omissions or absenteeism (Additional file 1: Appendix 1, 4.5.2.). According to Kotagal [26] leadership is one of the cornerstones of sustainable quality improvement, as continuous weak leadership structures may further compromise the quality of care delivery.
Stakeholder view
The quality of healthcare is defined and influenced by people’s experiences, perceptions and expectations [27]. While patients may be more concerned about non-medical procedures like provision of food or cleanliness (Additional file 1: Appendix 2), staff may focus on how to apply evidence-based care to patients. Both perspectives are needed to complement each other for effective quality of care interventions in the Medical Department.
According to the definition of Peach [28] the high rate of patient satisfaction in this survey would imply that a high quality of care exists in the Medical Department (refer to Results, Section 4.1). However, relying on indicators like satisfaction alone does not prove that good quality of care exists [29]. It might also mean that patients do not know what to expect. It is, therefore, more helpful if service clients are asked to discuss different components of healthcare and base their judgement on the different aspects rather than to give a broad and general description of such a multifaceted entity like a hospital or a complex interaction like healthcare delivery. It is noteworthy that the interviewed patients do not openly complain about the limited capacity for diagnosis and treatment at the department, as the staff respondents did.
This attitude can partially be explained by social desirability [30], i.e. whether patients do not know about better treatment options or whether they know and simply accept the status quo.
Although the study employed adequate measures to ensure that respondents could speak freely and sincerely during and after the interviews without being victimized by staff, it may be possible that some respondents were apprehensive about getting poorer care if they were forthcoming about any shortcomings in their own care at the Medical Department [31].
Among the providers, quality of care was considered to be good in a hospital if the staff is satisfied with the work they do and patients appreciate the care they receive. Required here is a conducive environment where resources are available, staff work output is recognized through salary or incentives, and an end result of improved health for their patients (Additional file 1: Appendix 2). From the responses, however, the Medical Department is under-resourced to fully execute its duties [2] as a tertiary hospital (Additional file 1: Appendix 1, 1.2).