“Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program
Abstract Background Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives’ varied impact...
| Main Authors: | , , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
BMC
2023-04-01
|
| Series: | BMC Health Services Research |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s12913-023-09341-7 |
| _version_ | 1797841174288924672 |
|---|---|
| author | F Procureur AS Estifanos DW Keraga AK Kiflie Alemayehu NW Hailemariam J Schellenberg H Magge Z Hill |
| author_facet | F Procureur AS Estifanos DW Keraga AK Kiflie Alemayehu NW Hailemariam J Schellenberg H Magge Z Hill |
| author_sort | F Procureur |
| collection | DOAJ |
| description | Abstract Background Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives’ varied impacts. Methods To understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives. Results The cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages. Conclusions The study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge. |
| first_indexed | 2024-04-09T16:26:48Z |
| format | Article |
| id | doaj.art-c6f1f7014fab41bdb65d8b666c8f5e73 |
| institution | Directory Open Access Journal |
| issn | 1472-6963 |
| language | English |
| last_indexed | 2024-04-09T16:26:48Z |
| publishDate | 2023-04-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Health Services Research |
| spelling | doaj.art-c6f1f7014fab41bdb65d8b666c8f5e732023-04-23T11:12:38ZengBMCBMC Health Services Research1472-69632023-04-0123111110.1186/s12913-023-09341-7“Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement programF Procureur0AS Estifanos1DW Keraga2AK Kiflie Alemayehu3NW Hailemariam4J Schellenberg5H Magge6Z Hill7Institute for Global Health, University College LondonDepartment of Reproductive, Family and Population Health, School of Public Health, Addis Ababa UniversityDepartment of Reproductive, Family and Population Health, School of Public Health, Addis Ababa UniversityInstitute for Healthcare ImprovementInstitute for Healthcare ImprovementDepartment of Disease Control, London School of Hygiene and Tropical MedicineInstitute for Healthcare ImprovementInstitute for Global Health, University College LondonAbstract Background Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives’ varied impacts. Methods To understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives. Results The cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages. Conclusions The study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge.https://doi.org/10.1186/s12913-023-09341-7Quality improvementQuality improvement collaborativesContextMechanismsImplementationLow-and middle-income countries |
| spellingShingle | F Procureur AS Estifanos DW Keraga AK Kiflie Alemayehu NW Hailemariam J Schellenberg H Magge Z Hill “Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program BMC Health Services Research Quality improvement Quality improvement collaboratives Context Mechanisms Implementation Low-and middle-income countries |
| title | “Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program |
| title_full | “Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program |
| title_fullStr | “Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program |
| title_full_unstemmed | “Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program |
| title_short | “Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program |
| title_sort | quality teaches you how to use water it doesn t provide a water pump a qualitative study of context and mechanisms of action in an ethiopian quality improvement program |
| topic | Quality improvement Quality improvement collaboratives Context Mechanisms Implementation Low-and middle-income countries |
| url | https://doi.org/10.1186/s12913-023-09341-7 |
| work_keys_str_mv | AT fprocureur qualityteachesyouhowtousewateritdoesntprovideawaterpumpaqualitativestudyofcontextandmechanismsofactioninanethiopianqualityimprovementprogram AT asestifanos qualityteachesyouhowtousewateritdoesntprovideawaterpumpaqualitativestudyofcontextandmechanismsofactioninanethiopianqualityimprovementprogram AT dwkeraga qualityteachesyouhowtousewateritdoesntprovideawaterpumpaqualitativestudyofcontextandmechanismsofactioninanethiopianqualityimprovementprogram AT akkifliealemayehu qualityteachesyouhowtousewateritdoesntprovideawaterpumpaqualitativestudyofcontextandmechanismsofactioninanethiopianqualityimprovementprogram AT nwhailemariam qualityteachesyouhowtousewateritdoesntprovideawaterpumpaqualitativestudyofcontextandmechanismsofactioninanethiopianqualityimprovementprogram AT jschellenberg qualityteachesyouhowtousewateritdoesntprovideawaterpumpaqualitativestudyofcontextandmechanismsofactioninanethiopianqualityimprovementprogram AT hmagge qualityteachesyouhowtousewateritdoesntprovideawaterpumpaqualitativestudyofcontextandmechanismsofactioninanethiopianqualityimprovementprogram AT zhill qualityteachesyouhowtousewateritdoesntprovideawaterpumpaqualitativestudyofcontextandmechanismsofactioninanethiopianqualityimprovementprogram |