What I’ve Learned: Reflections on a Quality Improvement Journey
(Dr. Pahwa meets with the QI team at Ganesh Das Hospital in Shillong, Meghalaya. Photo credit: Ganesh Das Hospital staff.)
ASSIST has been working in India since 2013 to enhance improvement capability in the Indian health system by building the capacity of individuals and institutions to conduct improvements across the “RMNCH+A” continuum. ASSIST is ending its work in India this month, and tomorrow we celebrate what we have achieved during our final meeting “Looking to the Future: Lessons Learned from the USAID ASSIST Project” in Delhi.
I joined the USAID ASSIST Project/URC in December 2013 as a District Improvement Coordinator, a role in which we were expected to support the district in improving the quality of healthcare services. Before joining URC, for me “quality” was just ensuring that standards were met – for example, making sure everything is available with respect to equipment, material, and medicines, and ensuring that medical practitioners are properly trained— but working on the ASSIST Project taught me an altogether different perspective of quality improvement (QI). Previously, in my experience, the question of “why” the health workers are not able to do something was hardly explored or focused upon. But QI methodology confirms that it’s not always human error or lack of knowledge or training that’s causing problems; in fact, it’s often issues with the health care system and processes which are causing hindrances in getting the desired results.
We initially started focusing on improving simple interventions in very few facilities and there I learned how true Pareto principle is: 80% of the problems we faced were actually solved by 20% of the simplest change ideas. They were those change ideas which were easily applied by simple logical thinking of facility health workers. It was just the systematic approach which facilities were lacking and QI helped in bridging those gaps.
The real challenge came when health workers started working on the remaining 20% of the problem, and that’s when I learned how complex a health system is, how each level of the system is struggling and trying hard to achieve their individual goals and have forgotten the overall mission. How the new guidelines are being circulated from state to district to facilities on daily basis, but no one is actually oriented and aware about the difference between the new and old guidelines, leaving frontline workers juggling between which directions to follow. There, I learned that how QI can help individuals and facilities, as well as the different departments within facilities, to remain interconnected and be aligned with overall goals and objectives.
Another thing I learned is that there is very often a disconnect between where data is being collected and where it’s being used for decision-making. The data collated and presented in monthly reports on the basis of which state, district officials are planning the next steps is very much different from the point where the data is originating. I learned how working on improving a single process can help in identifying these issues and helped the facilities to learn how to start utilizing their own data to bring improvement in their indicators of interest and not to wait till monthly meetings.
It was a systematic approach that facilities lacked and QI helped in bridging those gaps.
As we all know, communication plays a major role in getting the things done appropriately and at right time. While working at the community, facility, district and state level, I learnt that the planners (district and state offices) are meeting and communicating very frequently to discuss why things are not working, how to make the services more accessible, what the data is suggesting etcetera while the actual implementers (community health centres and facilities) barely meet to discuss even their basic problems or issues. Quality improvement provides the structures for implementer to meet and analyse problems in care, and empowers them to take action to address the issues they observe. I learned that QI not only helps in solving technical issues, but also helps in developing the culture of learning and sharing to bridge the communication gaps.
When joined URC I believed that issues like training, procurement, data, communication, and process improvement are separate and should be dealt with using different strategies. But here I learned that all of these issues are interrelated and QI methodology – with its focus on problem analysis and process change – can help in bringing improvement in all these areas and at all the levels of health care system.