Getting Healthcare Quality Right – Part 2

By Ajibike Oyewumi. April 19, 2021.

CEO, Kalytera-Q Advisory Services/ Consultant, IFC Healthcare Quality.

In my previous blog I explained why quality is so important and what a culture of quality looks like in a healthcare organization. In this second blog I will look at four practical buildings blocks for building a culture of quality covering leadership, structure, people and training, and measurement medical organizations can undertake.

Leadership

Leaders articulate shared values, they establish goals, set priorities, model appropriate behaviour, and establish expectations for staff. Leaders should articulate quality and safety as an essential organizational goal and ensure the goal is translated into specific actions. This involves ensuring quality and safety are included in strategic plans, annual objectives, and in operating plans and budgets.

At Lagoon Hospitals, Lagos Nigeria where I started out my healthcare quality journey, I remember it was the Chairman of the Board at the time who had the Vision of the hospital delivering the best quality care at par with international standards.

Establishing a culture of quality can only happen with such visible leadership from all levels of hospital management, from the Board down to the middle managers. The Chairman of Lagoon Hospitals shared this vision first with management and then with all other staff. He communicated in a manner that got everyone onboard with the vision. He was often found engaging the frontline staff and the physicians on matters related to quality and patient safety. His commitment to ensuring quality was inspiring, and a role model for us younger leaders such that it became a part of our culture. It became ‘The Lagoon Way’.

 Structure

Leadership allocates resources through the structure of any organization. When I started my role in quality at Lagoon Hospitals, I was a one-woman team, although I was joined by another excellent doctor after a few months. The structure we put in place was that I reported on a day-to-day basis to the Medical Director, and then every month I reported to the Hospital Management Board, on which the Chairman sat. This was important as it signaled the importance of quality to the rest of the organization. We then pulled together teams from across the organization to cover the 14 (fourteen) Chapters of the Joint Commission International Standards. We did not know if this was the right way to do it or not, as there were no mentors we could turn to for advice. But after two years we changed to a structure of committees based on the themes that were important for our hospital. These included Quality Steering (which had oversight and coordination responsibilities), Infection Prevention and Control, Pharmacy and Therapeutics, Blood Transfusion, Occupational Health and Environmental Safety, and Medical Ethics committees.

We did this because we felt it was important to move away from the impression that quality was a stand-alone department. We felt that our work needed to be structured so that it was part of the whole organization, not separate from it. I was heartened to hear on our recent webinar that the CEO of the Nairobi Children’s Hospital explained that while there was one Director of Quality at his hospital, every head of department was responsible for quality within their own departments. This structure allows you to build quality early and quickly into every department. This gives it more chance of success. Just appointing a quality manager or other quality department staff is not enough to establish a culture and process of quality.

People and training

Once the structure is in place, it is vital to build quality capacity in each department. In essence, quality comes down to people and it starts with recruitment. The rest have to make sure all the people that they hire understand quality and why it is so important. I found that it was useful to emphasize quality in both job descriptions for open positions and KPIs for new joiners to make sure we had the right people. Staff should only be hired if they show a passion for the details that lie at the heart of quality.

The next stage is training, especially at the onboarding stage. This is key and cannot be over-emphasized. Hospitals needs to make sure that all staff have the right knowledge and skills from the very beginning, so they are immersed in the culture. Staff hired specifically into quality roles need to be trained across all areas of patient safety, accreditation and regulation, performance and process management, and data analytics. There also needs to be on going training on all new clinical guidelines and other operational issues, as well as quality-specific training on areas such as teamwork, communications and reacting to adverse events. While training needs to be on going and for everybody, not everyone should receive the same training. Think of it like dosing. You need to give staff the right dosage when it comes to training, to make sure they are correctly equipped to deliver quality services in their area.

Measurement

If hospital management is going to hold staff accountable for quality, then they need a robust quality measurement framework in place. This is a cyclical process of measuring, monitoring, and reporting progress towards strategic goals, which provides a structured, data-driven approach to identifying and prioritizing necessary quality projects. This goes for the hospital as whole, each department and individual surgeons and physicians. For instance, at our hospital, we measured the blood sugar levels of diabetic patients and measured what percentage of them were at levels that met evidence-based recommended levels. When we started to measure surgical infection rates, we looked at the data and on two separate occasions found that it was individual surgeons who needed to improve, rather than the surgery department as a whole. We worked with these surgeons to bring about the necessary changes.

One key strategy for measurement was to work with the senior staff to decide what was important to measure. And do this every year. It could be levels of control of blood pressure in the cardiologists’ patients. Or the time taken to discharge patients and what time of day is optimal for discharging them. Embedding measurement and monitoring is vital for accountability and for implementing a quality program.

Making quality a success is both an art and a science. Building a culture of quality goes hand in hand with the practical actions and quality processes that must flow through the organization. But if we are to achieve the SDGs in healthcare and reduce the huge number of adverse events, it is a journey we must all take.