Roles of Management in Quality Improvement

1. Role of Management in Quality
Improvement

2. Presentation Outline
• Quality Improvement (QI) principles and the QM policy
• General QI implementation challenges
• Lessons learnt
• Discussions
oThe role of management in quality improvement
oNext steps

3. Defining Quality Improvement (QI)
• Quality improvement is defined as
“Systematic, data-guided activities designed to bring about
immediate improvement in health care delivery in particular
settings”.
 Quality improvement (QI) is the framework we use to
systematically improve the ways care is delivered to patients.

4. Quality Improvement Principles
Focus
on
System
Focus
on
Client
Focus
on
Team
Focus
on
Data
• Successful institutionalization
of quality improvement
requires incorporation of the 4
QI principles.

5. 1. Client-centred Care
• Client centered care puts individuals, families, and
the needs of people and communities, not only
diseases, at the center of health systems.
• The MoH therefore seeks to ensure that the highest
standards of care are implemented and reinforced at
all levels in close collaboration with the community
and civil society through;
o Enhancing communication and feedback
mechanisms to improve quality of care.
o Reinforcing use of providers/patients/service’
charters.
o Ensuring application of human rights approach to
patient/client care.
o Involving community and civil society in planning
and monitoring of service delivery.
o Strengthen reporting of health facility
ombudsman report in the DHIS2.
Focus on Client
1. Client centered
care
2. Client safety

6. The challenge
• Complaint and feedback mechanism non-functional/non-
established.
oHealth facility ombudsman
oSuggestion boxes
oExit interviews
• Health facility ombudsman not supported with working tools.
• Service charters not available and facility users not informed.
• Civil society not involved in planning and monitoring health
service delivery.
• Health facility ombudsman reporting – a major challenge.

7. 2. Client Safety
• Patient Safety is a health care discipline that emerged with the evolving
complexity in health care systems and the resulting rise of patient harm in
health care facilities.
• It aims to prevent and reduce risks, errors and harm that occur to patients
during provision of health care.
• Patient safety is fundamental to delivering quality essential health services.
• A cornerstone of the discipline is continuous improvement based on
learning from errors and adverse events.
• To ensure successful implementation of patient safety strategies; clear
policies, leadership capacity, data to drive safety improvements, skilled
health care professionals and effective involvement of patients in their
care, are all needed.
• To achieve client safety, the QM policy has highlighted what should be
done under three priority areas.

8. Priority Areas for Client Safety
a. Safeguard clients and
patients against unqualified
health workers and harmful
products
• Ensure recruited health staff
are appropriately trained,
registered and regulated.
• Regulate the use and
maintenance of electronic
technologies for client
management.
• Establish systems to monitor
and manage drug resistance.
• Prevent harmful traditional
practices.
b. Ensure that client safety
standards and guidelines are
adhered to at all times
including those related to the
safe use of injections, safe
use of invasive devices and
blood transfusions
• Define and implement client
safety standards.
• Promote safe and conducive
environment for staff and
clients.
• Ensure that health
infrastructure is in line with
standards to promote user
safety.
• Establish systems to prevent
and ethically manage medical
errors and adverse events.
c. Ensure that quality
Infection Prevention and
Control (IPC) practices
including Hospital Acquired
Infection (HAI) surveillance
are in place at each health
facility
• Strengthen availability of IPC
supplies including personal
protective equipment at all
levels;
• Enforce adherence to infection
prevention and control
practices including medical
waste management;
• Establish Hospital Acquired
Infection (HAI) surveillance
systems.

9. The Challenge
• Antimicrobial resistance on the rise.
• IPC guidelines not available in departments.
• Staff not up to date with IPC and patient safety guidelines.
• Hospital Acquired Infection (HAI) surveillance systems not in place.
• Health providers not up to date with adverse event form and adverse
event reporting process.
• Risky infrastructure and equipment.
• Inadequate IPC supplies.
• Clinical audits not a routine – deaths, near misses, patient case
files

10. • Ensure that structures and coordination mechanisms for implementation of
the Quality Management (QM) policy are in place and functional at all
levels of the health system at all times.
o Establish/strengthen QM structures at all levels in the health sector.
o Facilitate capacity building of staff in the QM policy and the QM
divisions (standards and norms, Quality assurance and QI).
o Strengthen staff participation in QM and promote team work at all
levels.
o Institute a framework for enhanced application of quality management
processes at all levels.
o Strengthen quality management in disaster preparedness and response
at all levels.
o Enhance coordination of the activities of all implementing partners and
other key players in the health sector in line with national quality
management priorities.

11. The Challenge
• Low awareness of QM policy including the QM directorate.
• Knowledge deficit in QI.
• Low application of QI even after trainings.
• Weak QM structures.
• Low reporting of QM activities.
• Low support to QI teams from management.
• Low motivation to do QI among staff.
• QI not yet a routine – implementation partner driven.

12. • Ensure that capacity in generation and use of accurate strategic
information for evidence-based decision making is strengthened for
quality of care at all levels.
o Facilitate the generation of quality data.
o Strengthen data collection, analysis, interpretation, display and
use at all levels of the health system.
o Facilitate documentation and learning from quality
improvement efforts.
o Strengthen operational research and monitoring and evaluation
at all levels of the health system.
o Strengthen utilization of generated data to improve quality of
care.
o Strengthen integration and reporting of quality care indicators
with HMIS.
o Promote the culture of knowledge sharing at all levels of the
health system.

13. The Challenge
• Data quality gaps highly prevalent – data sources, reports and DHIS2.
• Data use and display not common.
• DQAs and data reviews program based and mostly partner driven.
• QI initiatives not well documented – learning within and beyond district difficult.
• Knowledge deficit on use of registers, reports, DHIS2 and data quality issues.
• Facility and district learning sessions not common.

14. 1. In-puts
a. People
• Strengthen HR performance
management and appraisal
systems.
• Strengthen mechanisms for
motivating and disciplining
staff.
• Sensitize staff on Malawi
Public Sector Regulations
(MPSR) and enforce its
implementation.
• Sensitize staff on their job
description.

15. b. Support Systems
Ensure that equipment, medicines and
supplies are available, acceptable,
equitably accessible, economical and
safe at all times.
• Strengthen physical assets management
at all levels.
• Standardize and coordinate acquisition,
procurement/donation, distribution,
maintenance and replacement of medical
equipment and supplies.
• Manage equipment, medicines and
supplies loss at all levels of the health
system.
• Ensure adherence to need-based
minimal standards of equipment,
medicines and supplies for facilities.
• Strengthen procurement and supply
chain management at all levels.
Ensure regular supportive supervision
and a functional transport and referral
system at all levels.
• Strengthen the referral system
and safe patient transport
including timely
communication.
• Reinforce integrated supportive
supervision by qualified
personnel.

16. 2. Process
Ensure that clinical guidelines, SOPs
and standards are available and
adhered to at all facilities at all times.
• Create awareness among all cadres of
HRH on the available clinical guidelines
and SOPs.
• Institute a systematic QI approach to
ensure adherence to the clinical
guidelines and SOPs at all levels.
• Set norms and standards to improve
quality of health care and monitor
compliance.
• Strengthen recognition system and
establish and maintain centers of
excellence.
Ensure regular evaluation of the
overall health service delivery
outcomes
• Establish and implement
routine/periodic opportunities
to evaluate key outcome
indicators – fatality, change in
behavior, disease incidences,
change in health status and so
on.
• Facilitate routine evaluation of
client satisfaction.
3. Outputs

17. The Challenge
People
• Staff not aware of the
MPSR – unprofessionalism
on the rise.
• Others not conversant with
their job description.
• Weak disciplinary
mechanisms especially in
peripheral facilities.
• Staff recognition not
common.
• Line managers/incharges
not aware of key quality
checks, leadership and
managerial functions.
Process
• Some key SOPs not available
and head of
program/department have no
catalogue of required SOPs.
• Incompliance to SOPs is
prevalent.
• CPD opportunities can be
further improved.
Outcomes
• Means of evaluating outcomes
not institutionalized.
• Client satisfaction not
periodically and routinely
evaluated.
Support system
• Preventive maintenance not
prevalent.
• Faulty/unused
equipments/supplies filling up
spaces – no active board off.
• Delay to refer still common.
• Some facilities are rarely
supervised.

18. Lessons Learnt
• QI – improves client outcomes – reduces pressure on the health system –
reduces expenditure – improves client and staff satisfaction.
• Management support is key in driving the QM – QI agenda.
• Involvement of the client, civil society and community is key in facilitating
stewardship, transparency and accountability.
• Strong and well informed immediate leadership (in-charges/line managers)
is crucial.
• Staff routine relationship building strategies are fundamental.
• Periodic managerial evaluation of basic quality checks is of paramount
importance.

19. What should be the next steps in driving the QI agenda?
• Facility level
• District level
• National level