Understanding the barriers to setting up a healthcare quality improvement process in resource-limited settings: a situational analysis at the Medical Department of Kamuzu Central Hospital in Lilongwe, Malawi

Josephine Nana Afrakoma Agyeman-Duah; Antje Theurer; Charles Munthali; Noor Alide; Florian Neuhann

doi:10.1186/1472-6963-14-1

Table 2 Overview of themes on quality emerging from in-depth interviews by various stakeholders

From: Understanding the barriers to setting up a healthcare quality improvement process in resource-limited settings: a situational analysis at the Medical Department of Kamuzu Central Hospital in Lilongwe, Malawi

Respondent group	Strengths/existing quality model	Weaknesses/challenges hindering quality improvement in healthcare delivery	Areas for improvement
1. Affiliate respondents (n = 5)	- Existence of treatment protocols	- Staffing- related issues: shortage, underperformance and poor attitude	- Procure essential resources for patient care
	- Quality control and assurance measures are in place	- Scarcity of resources	- Use resources efficiently
	- Improved patient care practicies	- Patient care	- Enhance team work with supporting departments
	(Additional file 1: Appendix 1, Section 1.1)	- Lack of some patients taking responsibility for their own care	(Additional file 1: Appendix 1, Section 1.3)
		(Additional file 1: Appendix 1, Section 1.2)
2. Patient respondents (n = 4)	In-patients described their overall satisfaction of the care they receive as	- Poor amenities and services in the department	- Strengthen staff attitude and performance
	• 'very good’ (1 view)	- Weak adherence to treatment protocol	- Involve patients in their treatment and management
	• 'good’ (2 views)	- Patients not involved in their own care	- Improve amenities in the department
	• 'poor’ (1 view)	(Additional file 1: Appendix 1, Section 2.2)	(Additional file 1: Appendix 1, Section 2.3)
	(Additional file 1: Appendix 1, Section 2.1)
3. Staff respondents (n = 4)	- Staff attitude and performance is good	- Workload	- Provide supervision and training
	- Existence of treatment protocols	- Poor patient care	- Encourage patient-centred care
	- Availability of some logistics like the computer for e-learning	- Lack of adherence to treatment protocol by some staff	- Ensure accountability of and by staff
	(Additional file 1: Appendix 1, Section 3.1)	- Staff-related issues: inadequate training and supportive supervision, low incentives for work	- Encourage effective communication among staff
		(Additional file 1: Appendix 1, Section 3.2)
4. Management respondents	1. Effort to maintain quality	• The medical department is perceived to be the weakest department in KCH for quality of health care delivery(Additional file 1: Appendix 1, Section 4.1)	1. Civil society should be involved in sensitizing patients and holding health staffs accountable to patients
4.1 Current state of quality of healthcare	(Additional file 1: Appendix 1, Section 4.1)	• Inadequate human resource
		• Lack of some essential diagnostic tools
		• Limitation in the use of the few available diagnostic tools
4.2 Patient care and patient focus	1. Patients appreciate staffs when satisfied with service given	1. Patients complaint about wrong prescription or delayed treatment
		2. Weak patient involvement in their treatment plan
		3. Self referrals and weak patient referral system among referring facilities
4.3 Treatment protocols	• Treatment protocols are available and accessible to all staffs	1. Non-compliance due to personal preferences among prescribers; ignorance on the relevance of protocol use; lack of drugs to prescribe
	• There is a planned review of the current protocols
4.4 Change management	1. Emergency cases are attended to in the MSS ward before transferring to intensive care	3. No defined human resource plan to cater for staff who leave
	2. Team system for focused patient care and ward rounds
4.5 Management-related issues		• Shortage of staff
		• Lack of training and proper orientation for staff
		• Poor staff attitude (Additional file 1: Appendix 1, Section 4.5.1)
		• Weak accountability by staff (Additional file 1: Appendix 1, Section 4.5.2)
		• Weak leadership structures
		(Additional file 1: Appendix 1, Section 4.5.3)
		• KCH as a tertiary hospital wastes resources by attending to many primary level cases
		(Additional file 1: Appendix 1, Section 4.5.4)
		• Disintegrated data management system in the hospital
		• No strategic plan for the hospital (Additional file 1: Appendix 1, Section 4.5.5)

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