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

Background Knowledge regarding the best approaches to improving the quality of healthcare and their implementation is lacking in many resource-limited settings. The Medical Department of Kamuzu Central Hospital in Malawi set out to improve the quality of care provided to its patients and establish itself as a recognized centre in teaching, operations research and supervision of district hospitals. Efforts in the past to achieve these objectives were short-lived, and largely unsuccessful. Against this background, a situational analysis was performed to aid the Medical Department to define and prioritize its quality improvement activities. Methods A mix of quantitative and qualitative methods was applied using checklists for observed practice, review of registers, key informant interviews and structured patient interviews. The mixed methods comprised triangulation by including the perspectives of the clients, healthcare providers from within and outside the department, and the field researcher’s perspectives by means of document review and participatory observation. Results Human resource shortages, staff attitudes and shortage of equipment were identified as major constraints to patient care, and the running of the Medical Department. Processes, including documentation in registers and files and communication within and across cadres of staff were also found to be insufficient and thus undermining the effort of staff and management in establishing a sustained high quality culture. Depending on their past experience and knowledge, the stakeholder interviewees revealed different perspectives and expectations of quality healthcare and the intended quality improvement process. Conclusions Establishing a quality improvement process in resource-limited settings is an enormous task, considering the host of challenges that these facilities face. The steps towards changing the status quo for improved quality care require critical self-assessment, the willingness to change as well as determined commitment and contributions from clients, staff and management.

2J Agyeman-Duah et al., Understanding the Barriers to Setting up a Healthcare Quality Improvement Process in Resource-limited settings, November 2013 place measures of quality control which will make them better serve the Medical Department with accurate lab results.

Problematic Areas:
The three problematic areas that face the Medical Department according to the affiliate respondents include: staffing related issues, scarcity of resources and patient care.
Staffing was the commonest problem area raised several times by all respondents. The problem of staffing has to do with shortage of, under performance of and the attitude of some of the 'few' available staff. One respondent refers to the shortage of staff as '…a very big chronic problem…chronic shortage of staff because as you expand you expect more patients and if the number of providers remains the same it will pose pressure (on the staff)…'AFF01/29-06-10/58.
Describing staff performance in the Medical Department, one respondent made mention of shortage of staff as a probable cause of incompetence on the part of some medical officers who make poor diagnosis and wrong drug prescription for patients, '… somebody is just, is like copying, editing, then copying and pasting like what the other doctor prescribes…Yes, human resource, that is why I'm saying human resource because maybe they (staff) are not so many; at times there is only one clinician or doctor who is looking at all that queue (of patients) so maybe he is tired …that is why he is doing that copying and pasting…'AFF03/02-07-10/36.
The attitudes of staff which undermine the quality of care delivery was described by one respondent as due to 'lack of commitment from staff' (AFF04/07-10/50) and by the other as due to '…just negligence…'AFF03/02-07-10/36. Respondent AFF03/02-07-10/36 added that patients are sometimes the cause of the poor care they receive in the Medical Department; '…that is also another problem from the patient, because if the patients come here… I mean when somebody is so serious, they cannot even talk so even those clinicians/physician they fail knowing where to start (from)'

Recommended areas for improvement:
The affiliates recommended that for quality of healthcare to improve in the Medical Department, essential resources for patient care should be available; the 'scarce' resources available should be used effectively and team work with supporting departments like the laboratory and pharmacy should be enhanced.

PATIENT VIEWS
Respondents were from the 2A, 2B and 4B paying wards. Out of the five respondents, three were referred patients and two were self referred. The themes from the in-patient interviews have been categorized similarly to the affiliate views: existing quality models; problematic areas and recommendations.

Existing quality models:
The existing quality practices identified by in-patient respondents are expressions of their satisfaction of the services in the department. One patient respondent rated her overall satisfaction with the Medical Department as 'Very good'; two respondents said their overall satisfaction is 'Good', one however said it was 'Bad' and one other did not give any rating. One interviewee commented that: 'Patient care is there always … they care. The hospital is a bit better.' 2 IP02/30-06-10/28 2.2 Problematic areas: Areas identified include staff-patient relationship; amenities and services in the department and treatment protocols. Concerns were raised about poor communication between patients and care givers as well as patients not been involved in their own management. IP04/30-06-10/30: '… they just come and do what they want to do but they don't ask for my consent. A contrasting view from IP05/02-07-10/30 was '…yes, always (they ask for my consent). IP04/30-06-10/30 narrated, '… there is no one to explain what is going on..., There was a time I was given a drug and I was feeling itchy and I asked to know what drug I had taken but they told me I can't know the drug, only them (health workers) can know and they provide treatment of care and I couldn't proceed to ask more questions.' Interviewees also commented on the amenities and other non-medical services provided in the Medical Department which to them, do not define quality of care: '...food is provided here but I'm waiting for my wife to bring me food... because they don't bring it (the food) bed by bed.
They just call out to people to come for food but as it is, I can't walk for my food', IP02/30-06-10/28. One interviewee added; 'sometimes it (the ward) smells bad, sometimes, they just clean outside but not under the beds'IP04/30-06-10/30.
On the treatment protocols, I heard through informal conversations and through observations that, sometimes patients' preferences do not permit care givers to comply with the treatment protocols with reasons being the knowledge gap between patients and care providers about some medical procedures.

Recommendations:
In-patients mentioned the following areas which need to be improved to ensure better quality of care: staff attitude and performance; involving patients in their treatment and management and improving amenities in the department '… I think the nurses should be counselled. They should be patient because they deal with different kinds of people...',IP04/30-06-10/30. '... they just give the drugs and I take them I prefer that the health worker explains the relations of drugs', IP05/02-07-10/30. IP05/02-07-10/30: 'I get water to drink from the toilet taps and to me, it is not hygienic.
I will suggest they have taps in the rooms' (IP04/30-06-10/30).   Further on patient care, there is a missed opportunity for staff to learn from past experience to improve patient care in the Medical Department. For example, there is no mortality and morbidity meeting to review causes of death, negligence or any medical error. Again on deaths, there is no system to offer any recognized support to guardians when patients die and so most often in the Medical Department, the bereaved wail so loud that it could be very disturbing to other in-patients and staff.

Treatment protocols:
Management interviewees admitted that although the treatment protocols are useful for patient care, there is a problem of some staff not complying with the protocols. The reasons given were due to ignorance, lack of motivation and lack of the needed drugs to prescribe. MG05/05-07-10/32: I think there (are) some people who do not know their use and they are being used rarely and quite often not enough…sometimes I think (there is no) motivation to use the tools. However there is no defined system for monitoring or providing any supportive supervision for staff on the use of the protocols. MG05/05-07-10/32: 'I think it all depends on the team leader; like I try with my team to refer to the protocols, but basically there is no monitoring of staff adherence to the protocols',. For the review process of the treatment protocols, the interviewee mentioned that the protocols were introduced only last year but they will be reviewed soon. Interviewer: 'What are some of the strategic plans for the hospital?' MD01/29-06-10/45: The most strategic plan for this hospital since it was created will be developing one right now. We have requested yet…for a consultant to help us to develop the strategic plan.'

Change management
Again, data management is disintegrated and therefore there is the lack of a reliable data set for the hospital to use for its decision making: 'the data which is processed at (these different units)