Hunting the beast with five “i”s – institutionalization
To me, the word institutionalization rolls off the tongue the same way that fingernails roll off a chalkboard. It’s a word so long that I get annoyed with typing it when I’m well less than halfway through. So, here I’ll call it “inst.” It’s my blog – and I’m no masochist.
As much as I don’t like the word, inst is the holy grail of our improvement work in the ASSIST Project. But when we escape our bubble of the health care improvement world, it’s likely people won’t know what we’re talking about when we use the word. Don’t believe me? Try inserting it into your next cocktail party conversation and see how things go. Understanding inst gets to the nub of why USAID has spent millions over decades trying to make it happen all around the low- and middle-income world. Here’s a metaphor that helps me get it.
Let’s say ASSIST (or its predecessors HCI, QAP I, II and III, and PRICOR I and II) was asked to put out a fire in the maternity unit of a hospital. We come in with our fire extinguishers and hoses and ask all hospital staff we see to fill water buckets and remove gas bottles and patients from the burning rooms. Hopefully, we succeed and there’s no more fire. Of course, we want the absence of fire to be sustained, so we ask the staff to watch the embers and have water buckets and fire extinguishers ready, just in case. But if we did nothing else, we wouldn’t be helping the hospital in the long run.
So, we show the hospital how to install smoke detectors and a sprinkler system and install fire hoses and extinguishers throughout the whole facility. And we help them train staff to fight fires and evacuate and make sure they have regular drills when we’re gone to ensure the system continues to work. We also work with the district fire department too. So if another fire starts later – not in the maternity ward but in, say, the surgical unit – it will be put out, just as we helped put out the maternity ward fire, and the whole hospital won’t burn down.
Now let’s define those prosaic but confusing terms that scare your potential cocktail party friends away. “Sustaining the gain” is keeping the original fire in the maternity unit completely out. Institutionalization is the system of sprinklers and hoses and smoke detector AND the trained staff who can use them AND the district fire department that’s ready for action. To see if inst exists, we look for those sprinklers and hoses and detectors and make sure they work. We ask the staff if they know which is the business end a fire extinguisher, etc. We also visit the fire department to make sure they are completely ready. We can tell if the inst has worked by asking about the fires in the whole hospital since we left. That’s proof of “sustaining the ability to improve.” We don’t just look in the maternity unit to make sure it’s not burning.
Of course, ASSIST only fights metaphorical fires. But we are often asked to decrease stubbornly high rates of maternal and infant mortality. If we work with front-line clinicians and those who support them – facility managers, district health officers and Ministry of Health officials – we may succeed in improving birth outcomes, which is our first aim. And we would want to see those better birth outcome rates continue (sustaining the gains) or improve. But our larger goal is having clinicians, managers and MOH officials embrace improvement methods and put systems, procedures, organizational structures and budgets in place so they not only sustain good maternal and neonatal health results, but also work on other problems outside pregnancy and childbirth – institutionalization: our five-“i”ed beast.
This is what USAID wants us to do. It’s the international development ideal – a little investment to solve a small problem that leads to building a durable, autonomous solution to a much larger problem.