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BUILDING LOCAL CAPACITY FOR DELIVERY

OF HIV SERVICES IN SOUTHERN AFRICA

PROJECT

NAMIBIA FINAL REPORT

2010-2013 QUALITY IMPROVEMENT AND

LEADERSHIP PROGRAM

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Building Local Capacity for Delivery of HIV Services in Southern Africa Project

Cooperative Agreement Number: LWA# GPO-A00-05-00024-00

Leadership, Management and Sustainability Program

Management Sciences for Health

Address: MSH HOUSE

Ditsela Place

1204 Park St. (Corner of Park & Duncan Streets)

Hatfield – Pretoria, Gauteng

South Africa

Tel No: +27 (0)12 364 0400

Fax No: +27 (0)12 364 0416/0462

Contact person: Donald Harbick, Project Director

Email: dharbick@msh.org

The views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

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TABLE OF CONTENTS

ACRONYMS ...................................................................................................................................................... 4 EXECUTIVE SUMMARY ..................................................................................................................................... 5 BACKGROUND ................................................................................................................................................. 9 PROGRAM DESCRIPTION ............................................................................................................................... 10 THE QIL PROGRAM ........................................................................................................................................ 11 SUMMARY OF KEY ACTIVITIES ....................................................................................................................... 15 PROGRAM IMPLEMENTATION CHALLENGES .................................................................................................. 16 KEY RESULTS AND NEXT STEPS ....................................................................................................................... 18 ANNEX A. SUCCESS STORIES .......................................................................................................................... 24

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ACRONYMS

BLC Building Local Capacity for Delivery of HIV Services in Southern Africa COHSASA Council for Health Service Accreditation of Southern Africa CoQIS COHSASA Quality Improvement System IHK Intermediate Hospital Katutura LDP Leadership Development Program MoHSS Ministry of Health and Social Services MSH Management Sciences for Health NSF National Strategic Framework PY Program Year Q Quarter QA Quality Assurance [Unit of the MoHSS] QI Quality Improvement QIL Quality Improvement and Leadership SMS Senior Medical Superintendent USAID US Agency for International Development WCH Windhoek Central Hospital

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EXECUTIVE SUMMARY

The Challenge HIV and AIDS are major development, health, and human rights challenges in Namibia. In its National Strategic Framework for HIV and AIDS (NSF) 2010/11–2015/16, the country identified the national priorities and targets to which all stakeholders are expected to contribute. The NSF planning process took into account the development dimensions of Namibia’s response to HIV and AIDS, including the need to align and harmonize the NSF with other national strategic policy frameworks, such as Vision 2030, the National Development Plan, the Poverty Reduction Strategy, and the Millennium Development Goals. Implementation of the NStmuF is at a critical juncture for the entire health sector as the Government is embarking on significant reforms that will increase its ability to manage, coordinate, and finance health services. The Initiative Between 2010 and 2013, with funding from USAID, the Building Local Capacity for Delivery of HIV Services in Southern Africa (BLC) and the Council for Health Service Accreditation of Southern Africa (COHSASA) collaborated to develop and deliver the Quality Improvement and Leadership (QIL) program to multidisciplinary teams of health personnel in Botswana. In 2012, BLC initiated the QIL program in Namibia at two national referral hospitals in the capital city of Windhoek: Intermediate Hospital Katutura (IHK) and Windhoek Central Hospital (WCH). The QIL program was introduced to address the need to improve the quality of services delivered at the two health facilities. Based on this initial experience and the lessons learned, the plan was to extend the QIL program to public health facilities in the rest of the country. Support from BLC to the Ministry of Health and Social Services (MoHSS) was planned for a period of four years, 2012 to 2015.

IHK and WCH baseline assessment scores of six elements

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The QIL program involves the development of leadership and management capacity of health workers at all levels combined with the use of data from COHSASA’s accreditation system to improve the quality of health services. QIL provides:

• Data to identify gaps: Evaluations of health facilities are regularly conducted using international accreditation standards established by COHSASA that are appropriate in the developing country context. The baseline and subsequent evaluations measure progress in quality improvements.

• Skills to address gaps: Working together in multidisciplinary teams, participants from the two health facilities, along with the Quality Assurance (QA) Unit of the MoHSS, learned the basic practices of leading and managing to: 1) address priority service delivery-related challenges and achieve results; 2) create a workgroup climate that supports staff motivation; 3) create and sustain teams that are committed to continuously improve health services; and 4) use data for decision making to ensure continuous quality improvement (QI).

The QIL program leads to the accreditation of health facilities as having met international standards of care. The systems-based approach focuses on technical, managerial, administrative, infrastructural, and support systems, ensuring that all systems improve simultaneously and consistently over time so that the health facilities meet and maintain quality standards and thereby improve the quality of health services delivered. Key Results and Next Steps BLC’s assistance for the implementation of the QIL program ended prematurely, in January 2014, because the US Agency for International Development (USAID)/Namibia changed the scope of work for the project’s activities in the country. As of that date, the following results had been achieved: 1. Leading and managing skills were acquired and applied by personnel, as demonstrated by the:

increased collaboration among some teams in various departments; conduct of routine self-evaluations to monitor progress and identify challenges; and the development of service element work plans.

2. The QIL program trained teams of health care managers and other professionals at the hospitals to address real workplace challenges in their facilities by applying leading and managing practices combined with the effective use of quality standards data for continuous quality improvement.

3. 20 facility staff were trained to use the web-based COHSASA Quality Improvement System (CoQIS), input their data, monitor their own facility performance, and manage QI activities.

In addition, BLC support has helped the MoHSS and the two hospitals achieve a number of milestones:

4. Enhanced staff capacity to:

- Understand the standards used in assessing the quality of services delivered and the interpretation of findings. Staff are now equipped to conduct periodic assessments to determine the status of and to monitor progress in the achievement of quality and comprehensive service delivery by facilities.

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- Understand the critical areas of service delivery (e.g., risk management, emergency services, infection prevention and control) that all departments need to support.

- Develop and implement comprehensive department-level QI plans, including those for HIV and AIDS. Integration of these plans into the MoHSS annual work plan for 2014–2015 is underway.

- Put in place comprehensive QI policy, with procedures and committees to oversee implementation and adherence and to guide the execution of activities.

- Carry out a comprehensive patient care audit for all services conducted by a multidisciplinary team. This was done for the first time. Such audits previously focused only on nursing services and were done by nursing staff.

- Review old and approve new standard operating procedures for social work, psychiatry, occupational therapy, and maternal/child health. In all departments, outdated procedures are still being reviewed and those that did not previously exist are being developed.

- For the first time, the health facilities are developing a comprehensive QI training plan. Previously, there was only a QI training plan for nursing staff. Consequently, the facilities had no training budget.

- Conducted risk management training to address challenges in both facilities, followed by the development of a plan and formation of a committee to oversee adherence to procedures.

5. While some progress was being made at IHK and WCH, it was not well documented and was

not being shared with stakeholders. In response, BLC collaborated with the QA Unit of the MoHSS to conduct a three-day communications training workshop for 17 coaches and health care staff providing customer care from both hospitals. Following the workshop, participants expressed motivation to share information on their work. They agreed to produce five kinds of QIL-related write-ups to disseminate to the public, government officials, hospital management, and other health workers. The products would include:

- Success stories documenting the positive health outcomes for patients. - Information pieces on available HIV and AIDS services and how communities can

access them. - Stories highlighting the often complex and challenging medical and social problems of

patients and the efforts of health workers to ensure good treatment outcomes. - Stories highlighting problems that require resources and/or interventions by hospital

management and MoHSS officials for the purpose of advocacy. - Stories describing outreach activities and the interactions that regularly occur between

hospital staff and the communities they serve. To support and keep each other accountable, participants in the BLC-organized communications training workshop selected a communications committee, whose purpose is to coordinate the production of the stories at each hospital according to an agreed-upon schedule. The committee consists of senior staff and other staff members with a special interest in writing and photography.

6. BLC supported the MoHSS QA Unit, IHK, and WCH to conduct a support visit to assess progress made in QI. During the one support visit conducted during the shortened period of BLC assistance, 10 service elements related to patient welfare were assessed. The 10 service elements were

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selected because of their potential impact on patient and staff safety, and because some elements had among the lowest baseline scores from the initial assessment conducted in February 2013. Five service elements improved at WCH and four improved at IHK. Infection prevention and control improved at both facilities, which is critical for both staff and patients, and especially patients with compromised immune systems.

7. Increased ownership of the QI initiatives was achieved, as indicated by the QA Unit being more involved in planning QI activities at the two facilities. Moreover, the QA Unit financed all training conducted in 2013.

8. QI coordinators were appointed at both facilities, and QI is a standing agenda item at monthly management meetings at the two facilities.

Although the two hospitals were not close to achieving accreditation at the time that BLC support ended, scores for some service elements at the facilities did improve from below or slightly above 20 points to above 30 points, out of a goal of 80 points required for accreditation. As of the writing of this report, the MoHSS is continuing to support the implementation of the QIL program through its Quality Assurance Unit, and is scaling up assistance to many facilities to improve the quality of services.

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BACKGROUND

Namibia’s Vision 20301 states that “Our future is about the people. Therefore, at the center of the visioning exercise is concern for the population in relation to their social (particularly health), economic and overall well-being. All the questions about the welfare and well-being of the people of this country at any point in time, even beyond 2030, are about our population and the conditions under which they live and commonly agreed living standard at a given point in time. The Vision will transform Namibia into a healthy and food-secure nation, in which all preventable, infectious and parasitic diseases (including HIV/AIDS) are under secure control; people enjoy high standards of living, a good quality life and have access to quality education, health and other vital services. All of these aspirations translate into a long life expectancy and sustainable population growth.’’ Improving the quality of health service delivery is therefore of paramount importance to Namibia if V2030 is to be achieved. In 2008/09, the MoHSS conducted a health systems review that identified the poor quality of health service delivery as a significant challenge in the country.2 In 2011, the MoHSS requested the USAID-funded BLC project to provide technical assistance. The objective was to help the MoHSS achieve its vision for Namibia: to provide integrated, affordable, accessible, quality health and social welfare services that are responsive to the needs of the Namibian population.

Launched in 2010 with funding from USAID, the BLC project implemented by Management Sciences for Health (MSH) strengthens government, parastatal, and civil society entities to effectively address the challenges of the HIV and AIDS epidemic. Throughout the Southern Africa region and with specific activities in six countries—Angola, Botswana, Lesotho, Namibia, South Africa, and Swaziland— BLC provides technical assistance in five areas: 1) leadership, management, and governance; 2) HIV prevention; 3) care and support for orphans and vulnerable children; 4) Global Fund grants management; and 5) health facility quality improvement.

With funding from the US President’s Emergency Plan for AIDS Relief/Namibia, BLC formed a partnership with the MoHSS and COHSASA, a South African nongovernmental organization that assists health care facilities in developing countries to deliver quality care to their clients through sustained improvement, using internationally recognized quality standards. COHSASA is accredited by the International Society for Quality in Health Care. Under this partnership, multidisciplinary teams of health workers were guided through a process to improve the quality of services at two public hospitals in the capital city of Windhoek over the course of the implementation period (2012 to 2015). The facilities were: Intermediate Hospital Katutura and Windhoek Central Hospital.

1 Namibia Vision 2030: Policy Framework for Long-term National Development. Available at: http://www.met.gov.na/Documents/Vision%202030.pdf 2 MoHSS. Health Systems Review Report 2008/2009.

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PROGRAM DESCRIPTION

Project Vision and Approved Work Plan The work plan BLC developed for its support to the MoHSS in Namibia has two intermediate results and two long-term results, as follows: Intermediate Result 1: Strengthen leadership, management, and governance capacity of BLC partners for the delivery of improved and sustainable services.

Long-term Result: The environment for sustained delivery of quality health services is enhanced.

Intermediate Result 5: Strengthened delivery of quality health services by health facilities in the region. Long-term result: Improvements in the delivery of health services by facilities are sustained. Expected results:

- Improved quality of health services delivered at facilities. - Increased number of individuals who can lead and manage health projects. - Improved leadership and management practices that will lead to improved performance

of the facilities, according to the international health services standards.

The main intervention conducted under the partnership with the MoHSS and COHSASA was the QIL program. QIL builds the leadership and management skills of facility-based health staff to improve the quality of service delivery in their hospitals and clinics. The program leads to the accreditation of health facilities as having met international standards of care. The QIL program was a combination of two existing, well-tested approaches: MSH’s Leadership Development Program (LDP) and COHSASA’s accreditation program called Quality Improvement (QI).

The LDP consists of a series of workshops designed to transform how personnel at all levels use leading and managing practices to produce organizational results. In health care facilities, staff members create and sustain teams that are committed to addressing real life challenges. These teams meet regularly to discuss challenges and apply the leading and managing strategies from LDP workshops to achieve results. People involved in the LDP become powerful agents for change in their facilities. The key stages of the LDP are: a first workshop followed by a coaching visit, a second workshop followed by a networking visit; and a final results-sharing workshop.

The QI program assists health care facilities to achieve sustained quality improvement through the collection, analysis, and use of data for decision making. Baseline surveys evaluate facilities’ compliance with a series of 44 internationally accredited standards. Once a facility’s scores are established, staff members work to improve each specific indicator. Self-evaluations are conducted every eight weeks to monitor progress, and data are inputted and

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analyzed using a web-based system. The QI program empowers facilities to systematically identify and address specific areas of improvement, leading to continuous quality improvement. The key stages in the QI program are: a standards training, a baseline survey, a series of eight self-evaluations, two to four sampled validation visits, an external survey, and eventual health facility accreditation.

THE QIL PROGRAM

The QIL program is a transformative leadership and patient-centered approach to improve quality of care. BLC conceived the program to address the challenges of weak and fragmented health systems and poor management of human resources for health, among other health system challenges in Botswana. Similar challenges exist in Namibia. QIL integrates the development of leadership and management skills with quality improvement in the delivery of health services. The quality improvement component assists health personnel to identify gaps in health care standards and address them through periodic assessments and on-going technical assistance. The QIL program is a two-year process that supports health facilities to ensure that health standard requirements are met and policies and standard operating procedures are in place and implemented. Through the leadership and management component, participants, organized into multidisciplinary teams, learn the basic practices of leading and managing to: 1) address organizational challenges and achieve results; 2) create a workgroup climate that supports staff motivation; 3) create and sustain teams that are committed to continuously improve health services; and 4) use data for decision making to ensure continuous quality improvement and, ultimately, international accreditation. To be accredited, health facilities must achieve an overall minimum score of 80 points based on an aggregate of the relevant service element scores. Once the 80 points are achieved, accreditation is granted for an initial two years, and may be extended for a further three years if the facility demonstrates continued compliance with standards and further improvements. If gaps exist, the facility may be awarded accreditation for fewer years, with an option for scheduling an earlier survey to ascertain any improvements. The QIL approach is based on the understanding that a country’s health system is complex; to run smoothly and fulfill its purpose (a healthy nation), many interdependent stakeholders must work together. The stakeholders are similar to cogs in a machine; each cog has a specific role and is essential for the system to function optimally. When one cog has broken or has worn teeth, it can slow or even stop the entire system. The QIL program facilitates the analysis of gaps in the health system (identifying worn or broken teeth) and provides skills to stakeholders to address the gaps. While gaps may be identified at the health facility level, to adequately address them frequently requires the cooperation and involvement of one or more stakeholders at other levels of the health system. For example, a health facility may have a gap in a specific department (such as emergency care) because the equipment is not working, requiring intervention from another government department, such as the Ministry of Works and Transport Services. The leadership and management skills provided by the QIL program are essential and promote collaboration at all levels, so that health facilities are able to function effectively, and quality of care improves. This process is depicted in the following diagram.

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The QIL program brings together the two key aspects needed to make a health system function: providing the information, or data, by identifying the “worn teeth” that need to be repaired, and providing the necessary skills to make the required repairs.

The key interventions in the QIL program are:

- Baseline surveys to assess each facility’s compliance with up to 44 international accreditation standards: 33 for hospitals and 11 for clinics. Nine of the critical service elements have cross-cutting impact on other elements: emergency care, health and safety, medical care, obstetric/maternity care, operating theater and anesthesia service, prevention and control of infections, resuscitation service, sterilizing and disinfecting unit, and surgical care.

- Training on relevant quality standards. - A series of leadership and management training workshops. - Coaching and mentoring of staff to systematically identify and address specific areas of

improvement. - Eight self-evaluations, two to four sampled validation surveys (depending upon a

facility’s progress), and an external survey, resulting in the accreditation of a health facility as having met internationally accepted standards.

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Training session on standards evaluation and interpretation for IHK staff

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Phases of the QIL Process

Phase 1: Start-up and baseline 1. A baseline survey determines a facility’s compliance with health standards. The survey

yields detailed information about each of the service elements, use of leadership and management practices, work climate, and the general quality of services.

2. A Senior Alignment Meeting is held to provide an in-depth overview of the QIL program and to secure endorsement and commitment to the process.

Phase 2: Intervention design 3. Coaches and service element leads are identified and selected. Five coaches are

selected from the national and district levels to provide continuous coaching and mentoring to the facility-level service element teams, while the service element team leads provide leadership at the facility level.

Phase 3: Implementation 4. Coaches are trained on coaching and mentoring.

5. A five-day QIL inception workshop is held at each facility for the service element leads and one other participant from all the service elements. During the workshop, participants work in their service element teams and use the leading and managing practices to address their service element challenges and draft work plans.

6. The service element teams finalize and integrate their work plans into one facility work plan, which is incorporated into the MoHSS plan and budget.

7. Teams implement their service element work plans by applying leadership and management practices to achieve work plan objectives and targets.

8. BLC provides needs-based technical assistance, including coaching and mentoring to the coaches and service element leads to support teams in achieving their desired results.

Phase 4: Pre-accreditation evaluation 9. The service element teams conduct self-evaluation of service elements to assess their

compliance with the desired health standards and leadership and management practices.

10. The MoHSS conducts a mock validation of the service elements to determine a facility’s compliance with the desired health standards. The outcome of this validation informs the development of new sets of objectives that focus on the non-compliant service elements.

11. The teams review their work plans to address the non-compliant areas.

12. A team of surveyors from COHSASA, MoHSS and BLC conduct an actual validation on MoHSS recommendation.

13. An external survey is conducted by independent surveyors to determine a facility’s readiness for accreditation.

Phase 5: Accreditation 14. COHSASA awards the facility the accreditation certificate.

Phase 6: Post-accreditation evaluation 15. An impact evaluation of the quality of service provision is conducted in the facilities.

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SUMMARY OF KEY ACTIVITIES

In BLC’s Program Year (PY) 3 (August 2012 to September 2013), BLC and COHSASA delivered some components of the QIL program. Of the six phases of QIL and its 15 steps presented above, BLC supported the completion of three phases and eight steps. Sixty senior and middle management staff members from WCH and IHK were trained in how to evaluate and interpret the standards used in quality improvement. BLC also trained: 20 facility staff (one senior, thirteen middle, and six junior staff) who were medical doctors (three), a pharmacist, nurses (ten), and administrative support staff (six) on the use of the web-based data capturing system (CoQIS) to monitor the progress of the QIL program. Seventeen staff (14 middle; 3 junior) were equipped with skills to document and disseminate results, best practices, and lessons learned to partners and stakeholders. Finally, BLC trained 16 staff (one senior, 12 middle, three junior) from the two hospitals as coaches and mentors in quality improvement. Using the phases of the QIL process described on the previous page, the activities undertaken by the BLC, COHSASA, and MoHSS partnership to improve the quality of health services at the two hospitals are presented. Phase 1: Start-up and baseline 1. PY2 Quarter (Q) 4, a Senior Alignment Meeting for 26 people was held to provide an in-depth overview of the QIL program and to secure endorsement and commitment to the process.

In PY3 Q1, the then new Permanent Secretary of the MoHSS gave BLC a concurrence letter authorizing support to the two facilities and the Quality Assurance Unit.

2. In PY3 Q2, in collaboration with COHSASA, BLC conducted a baseline survey to determine the hospitals’ compliance with health standards. The survey yielded detailed information about each of the service elements, use of leadership and management practices, work climate, and the general quality of services.

Phase 2: Intervention design 3. In PY3 Q1, 17 coaches and 58 service element leads were identified and selected. Coaches provide continuous coaching and mentoring to the service element teams, while the service element team leads provide leadership at their facilities.

Phase 3: Implementation 4. In PY3 Q4, the 17 coaches were trained on coaching and mentoring.

5. In PY3 Q4, a five-day QIL inception workshop was held at each facility for the service element leads and one other participant from all the service elements (29 participants at IHK and 28 at WCH). During the workshop, participants worked in their service element teams and used the leading and managing practices to address their service element challenges and draft work plans.

6. 20 facility staff were trained to use the web-based COHSASA Quality Improvement System (CoQIS), input their data, monitor their own facility performance, and manage QI activities.

7. The service element teams subsequently finalized and integrated their work plans into their respective facility work plans. When BLC support ended, these work plans had not yet been incorporated into the MoHSS plan and budget.

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8. By the end of BLC support, the service element teams had started to implement their work plans by applying leadership and management practices to achieve the plans’ objectives and targets.

9. BLC provided ongoing needs-based technical assistance, including support to the coaches and service element leads to help the teams achieve their desired results.

PROGRAM IMPLEMENTATION CHALLENGES

National level challenges: Despite several meetings between BLC staff and the Deputy Permanent Secretary, there was limited support from senior management of the MoHSS to allocate additional funds in the budget for substantive improvements at the health facilities. This included:

• Structural renovations • Upgrading of equipment • Sufficient staffing

Facility level challenges: As with the national level, there was limited support from the management of each hospital to motivate staff to actively participate in service delivery improvements in their departments. Specific challenges included:

• Staff’s resistance to change: Despite having QI coordinators tasked with ensuring effective implementation of the QIL process at the facilities, heads of departments never supported the coordinators to effectively undertake their role and responsibilities.

• Because of Internet connectivity challenges, the recording of progress in the CoQIS from the scheduled assessments conducted every eight weeks was difficult at times.

• Medical doctors provided limited support in areas that needed their involvement to make improvements, such as the development of departmental operating guidelines.

In response to these identified problems, BLC held several meetings with the Quality Assurance Unit of the MoHSS and the management of both hospitals to seek their support in addressing the challenges. However, by the end of BLC support, little had been done to resolve the challenges.

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Voices from the Field

“You can use the tool to assess any department other than where you work. We have got firsthand information on how to establish the quality of the services we currently offer to our clients.” - Lichisa from the Psychiatry Department of WCH

Hilma, the Head of Nursing Services at WCH said: “The training was an eye opener. We don’t have to be protective of our work and continue to deliver poor quality services. Let’s be open and identify the gaps so that we can address them for the answer lies with us.”

In closing the training, Katutura State Hospital Senior Medical Superintendent (SMS), Dr. George Judmann, stated: “The management of Katutura Hospital is committed to making certain that all the necessary support is given to all the staff members to learn and significantly participate in the process of improving the quality of health services delivered to the Namibian public.”

The SMS at WCH, Dr. Sarah Shalongo, reaffirmed that: “We all now realize that if we pull together, the work will be lighter. Fortunately, now we have the tools and skills to assess the quality of our services and identify the gaps that we should commit to address.”

“I have learnt about my responsibilities and roles of team members, their value to the team and how these complement each other. I now know how to log onto the COQIS, navigate it, and understood the scores. The Challenge Model simplified how to identify challenges; set a time frame; and develop an action plan.” - Ellie Ndugula, Senior Human Resources Practitioner, IHK

“It’s about that patient from the disadvantaged community who is looking at us for service that we should have in mind. What is my role to improve the community and give back to the community? We have learnt a lot and we are going back loaded with ideas and skills to improve.” - Sister Sitengu, Service element lead, Nursing Services, WCH

“QIL has helped us to plan for activities that are implementable and can be monitored and evaluated. The MoHSS planning template does not help us to plan appropriately.” - Dr. Amagulu, Acting Medical Superintendent, IHK

A few of the participants summarized the training as: “I can finally say that I am a coach, and finally understand the link between COHSASA, MSH, and BLC. This training has really cultivated and equipped me to be a more effective coach. I now know how to apply all these skills, and how to deal with challenges within my work environment. It was also good being challenged by the facilitators, because it helped us deal with them more effectively.”

Sister Manga Libita said: “With change, resistance usually comes, but the question is how do you break that wall of resistance. Here at the training we were taught how resistance can be overcome, and how to identify that you as an individual has changed, through information sharing. We were also taught that we should never give up, and I can honestly say that all our expectations have been met by the MSH/BLC Team.”

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KEY RESULTS AND NEXT STEPS

Key Results To be accredited as meeting internationally recognized health standards for proving quality services, a health facility requires an average score of 80 points across all service departments. The baseline assessments conducted at WCH and IHK yielded low average scores of below 30 points in most of the service departments.

IHK and WCH baseline assessment scores of six elements

The cluster, Clinical Areas, includes services in pediatrics, obstetrics/maternity, surgery, and medical care. The low scores at both facilities means that basic practices, such as infection control and maintenance of resuscitation equipment, are below standard, with a negative impact on patients’ health outcomes. In addition, non-compliance in fire and security areas risks the lives of both staff and patients. Structurally, both hospitals are poorly maintained: roofs are collapsing; walls are peeling; lifts are out of order; there is inadequate lighting in the corridors; and condemned equipment is left in the corridors. This was attributed to the poor standards of service from the Ministry of Works and Transport, which is responsible for the maintenance and security of buildings and equipment. With an average score near to and slightly above 50 points, Clinical Support Services scored the highest at both facilities because of the influence of laboratory services. Management of laboratory

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Critical areas are important to any health facility as they address the quality of services provided by staff and how patients rate it, how to avoid new infections, life threatening risks and measures taken in case of emergency for all round safety and health of patients and staff while at the facilities.

The 4 critical health service elements are:

• Infection prevention and control • Risk management • Emergency preparedness • Quality improvement

services is outsourced to the National Institute of Pathology, an internationally accredited agency. However, outsourcing does not automatically translate into quality service. For example, Hotel services, another area that is outsourced, received low scores at IHK and WCH for cleaning and catering services. Because the 4 critical criteria service elements (infection prevention and control, risk, emergency and quality improvement) represent the difference between life and death for patients, they carry more weight in terms of scores awarded for compliance. Addressing the critical criteria results in demonstrable quick-wins that help motivate and strengthen staff commitment to continuous quality improvement. In addition, compliance in the critical criteria in one service department has positive carry-over effects in related departments. From October 2013-September 2014, BLC and COHSASA supported the Quality Assurance Unit, IHK, and WCH to conduct a support visit to assess progress made in quality improvements. During the visit, 10 service elements related to patients were assessed. The ten were selected because of their potential impact on patient and staff safety, and because some of these service elements received among the lowest scores during the baseline assessments conducted in February 2013.

WCH progress assessment results

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• The five service elements that were the most improved at WCH were: infection prevention and control; resuscitation; human resource management; housekeeping; and risk management.

• IHK recorded improvements in four service elements: infection prevention and control; human resource management; administration and support services; and medical equipment.

Infection prevention and control is critical to QI because it impacts all the service elements in each hospital. Improved infection control protects both staff and patients. In particular, it protects patients with compromised immune systems from acquiring infections at the hospital, which is a major cause of illness and death among people living with HIV. The hospitals did not progress as quickly as expected to address the gaps identified during the baseline assessments. Challenges inhibiting progress described by facility staff included: lack of management support; limited involvement of medical doctors; poor understanding of individual roles in quality improvement; and inadequate use of the QIL guidelines provided by BLC and COHSASA.

IHK progress assessment results

In response to the results of progress assessment, the QIL support team used the visit to:

- Reinforce and clarify the interpretation of the QIL standards and the evidence required to show compliance in various areas.

- Review priorities according to the service element-specific work plans, and common areas for support.

- Make recommendations for further improvements in other service elements that were not assessed.

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IHK Baseline

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The BLC QIL support enhanced staff capacity to:

- Understand the standards used in assessing the quality of services delivered and the interpretation of findings. Staff are now equipped to conduct periodic assessments to determine the status of and to monitor progress in the achievement of quality and comprehensive service delivery by facilities.

- Understand the critical areas of service delivery (e.g., risk management, emergency services, infection prevention and control) that all departments need to support.

- Develop and implement comprehensive department-level QI plans, including those for HIV and AIDS. Integration of these plans into the MoHSS annual work plan for 2014–2015 is underway.

- Put in place comprehensive QI policy, with procedures and committees to oversee implementation and adherence and to guide the execution of activities.

- Carry out a comprehensive patient care audit for all services conducted by a multidisciplinary team which was done for the first time. Such audits previously focused only on nursing services and were done by nursing staff.

- Review old and approve new standard operating procedures for social work, psychiatry, occupational therapy, and maternal/child health. In all departments, outdated procedures are still being reviewed and those that did not previously exist are being developed.

- For the first time, the health facilities are developing a comprehensive QI training plan. Previously, there was only a QI training plan for nursing staff. Consequently, the facilities had no training budget.

- Conducted risk management training to address challenges in both facilities, followed by the development of a plan and formation of a committee to oversee adherence to procedures.

While all the above results were achieved at IHK and WCH, the process and outcomes were not being well documented or shared with stakeholders. In response, BLC collaborated with the QA Unit of the MoHSS to conduct a three-day communications training workshop for 17 coaches and customer care staff from both hospitals. Following the workshop, participants expressed motivation to share information on their work. They agreed to produce five kinds of QIL-related write-ups to disseminate to the public, government officials, hospital management, and other health workers. The products would include:

- Success stories documenting the positive health outcomes for patients. - Information pieces on available HIV and AIDS services and how communities can

access them. - Stories highlighting the often complex and challenging medical and social problems of

patients and the efforts of health workers to ensure good treatment outcomes. - Stories highlighting problems that require resources and/or interventions by hospital

management and MoHSS officials for the purpose of advocacy. - Stories describing outreach activities and the interactions that regularly occur between

hospital staff and the communities they serve. To support and keep each other accountable, participants in the BLC-organized communications training workshop selected a communications committee, whose purpose is to coordinate the

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production of the stories at each hospital according to an agreed-upon schedule. The committee consists of senior staff and other staff members with a special interest in writing and photography.

Program Implementation Challenges Implementation of the QIL program in Namibia encountered several challenges. They included:

• The launch of the program was delayed because of changes in senior management at the MoHSS. It took the new Permanent Secretary four months to authorize BLC to start implementing the program, which began implementation in September 2012.

• Management at the two hospitals did not fully mobilize staff and engage them to understand the QIL program. QIL was therefore viewed by some staff as extra work that was not part of their daily tasks.

• The frequent turnover of personnel involved in the QIL program at the facilities hampered progress at some points during implementation.

• Inadequate internet connectivity made recording of the progress of improvements in the QIL program’s web-based system difficult at times.

• Implementation of the QIL program was affected by the limited involvement of management and medical personnel in the two facilities.

• BLC’s direct involvement in the QIL program ended based on instructions from USAID in PY4Q2. However, the national Quality Assurance Unit informed BLC that the MoHSS will fund the two health facilities to continue to implement the QIL program, a clear indication of the Ministry’s ownership of the quality improvement process in the country.

Next Steps As noted earlier in this report, BLC assistance in the implementation of the QIL program ended earlier than planned, in January 2014. BLC communicated with the MoHSS in writing about the change in USAID’s focus and, consequently, the change in BLC’s scope of work. In this letter, BLC highlighted the achievements made as well as the challenges faced during the course of its support. Since this time, the QA Unit has informed BLC that the MoHSS will fund the two health facilities to continue to implement the QIL program, a clear indication of the Ministry’s ownership of the QIL program. In order to use existing knowledge and experience, the QA Manager, Sr. Christine Gordon, informed BLC that the Unit will continue to collaborate closely with BLC in the implementation of the QIL program. Using training materials and the knowledge and skills acquired with BLC support, the QA Unit is coaching and mentoring the QI coordinators responsible for the health facilities in Namibia at: one national referral hospital, three intermediate hospitals, 30 district hospitals, 47 health centers, 295 clinics, and 9 nine sick bays. Coaching is one of the interventions used to improve the quality of services delivered to receive international accreditation. The objectives of the training are:

• To support the QI coordinators to gain an understanding of coaching and mentoring principles and how to apply them to support the department leads in implementing strategies for quality improvement.

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• To be able to coach others and to learn the importance of team work and collaboration. • To enhance their problem solving skills and enable them to improve their interpersonal

communication, two of the areas identified by the WCH and IHK experiences that hinder quality improvement.

• To learn how to communicate effectively and give timely feedback to their team members, supervisors, and supervisees.

• To introduce the participants to the leadership and management tools and practices, their application for personal and professional growth and for the improvement in the quality of services at the facilities.

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ANNEX A. SUCCESS STORIES

Namibia success stories Title Link

Success Story Shares BLC achievements in particular project areas with the focus on an individual, organization or event

A snapshot of positive changes at Katutura Hospital in Namibia – July 2013

Link: http://www.hivsharespace.net/node/3761

QIL helps Intermediate Hospital Katutura solve problems—one problem at a time – Nov 2013

Link: http://www.hivsharespace.net/resource/success-story-qil-helps-intermediate-hospital-katutura-solve-problems-one-problem-time