Implementation experience during an eighteen month intervention to improve paediatric and newborn care in Kenyan district hospitals

Nzinga, Jacinta; Ntoburi, Stephen; Wagai, John; Mbindyo, Patrick; Mbaabu, Lairumbi; Migiro, Santau; Wamae, Annah; Irimu, Grace; English, Mike

doi:10.1186/1748-5908-4-45

Cited by 35 publications

(41 citation statements)

References 19 publications

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“…Their roles and experiences have been described elsewhere [29]. Here we concentrate on what aspects of their role seemed critical to promoting performance improvement amongst the wider set of clinicians and nurses responsible for care in their hospitals.…”

Section: Resultsmentioning

confidence: 99%

Explaining the effects of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals - interpretation based on retrospective examination of data from participant observation, quantitative and qualitative studies

et al. 2011

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BackgroundWe have reported the results of a cluster randomized trial of rural Kenyan hospitals evaluating the effects of an intervention to introduce care based on best-practice guidelines. In parallel work we described the context of the study, explored the process and perceptions of the intervention, and undertook a discrete study on health worker motivation because this was felt likely to be an important contributor to poor performance in Kenyan public sector hospitals. Here, we use data from these multiple studies and insights gained from being participants in and observers of the intervention process to provide our explanation of how intervention effects were achieved as part of an effort to better understand implementation in low-income hospital settings.MethodsInitial hypotheses were generated to explain the variation in intervention effects across place, time, and effect measure (indicator) based on our understanding of theory and informed by our implementation experience and participant observations. All data sources available for hospitals considered as cases for study were then examined to determine if hypotheses were supported, rejected, or required modification. Data included transcriptions of interviews and group discussions, field notes and that from the detailed longitudinal quantitative investigation. Potentially useful explanatory themes were identified, discussed by the implementing and research team, revised, and merged as part of an iterative process aimed at building more generic explanatory theory. At the end of this process, findings were mapped against a recently reported comprehensive framework for implementation research.ResultsA normative re-educative intervention approach evolved that sought to reset norms and values concerning good practice and promote 'grass-roots' participation to improve delivery of correct care. Maximal effects were achieved when this strategy and external support supervision helped create a soft-contract with senior managers clarifying roles and expectations around desired performance. This, combined with the support of facilitators acting as an expert resource and 'shop-floor' change agent, led to improvements in leadership, accountability, and resource allocation that enhanced workers' commitment and capacity and improved clinical microsystems. Provision of correct care was then particularly likely if tasks were simple and a good fit to existing professional routines. Our findings were in broad agreement with those defined as part of recent work articulating a comprehensive framework for implementation research.ConclusionsUsing data from multiple studies can provide valuable insight into how an intervention is working and what factors may explain variability in effects. Findings clearly suggest that major intervention strategies aimed at improving child and newborn survival in low-income settings should go well beyond the fixed inputs (training, guidelines, and job aides) that are typical of many major programmes. Strategies required to deliver good care in lo...

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Section: Resultsmentioning

confidence: 99%

Explaining the effects of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals - interpretation based on retrospective examination of data from participant observation, quantitative and qualitative studies

et al. 2011

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“…[16] Multifaceted interventions using AF have been demonstrated to improve care in low-resource settings. [1,19] Inadequate data quality and limited understanding of when feedback is effective are likely to be key barriers to using eHealth for performance feedback. As innovations in the analysis of clinical data are introduced [20] and with increased understanding of when clinical AF is effective for changing behavior, [21] these barriers may begin to be overcome.…”

Section: Introductionmentioning

confidence: 99%

Emerging ICT implementation issues in aged care

Kapadia

Ariani

Jun-hua

et al. 2015

International Journal of Medical Informatics

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“…[16] Multifaceted interventions using AF have been demonstrated to improve care in low-resource settings. [1,19]…”

Section: Introductionmentioning

confidence: 99%

Barriers to using eHealth data for clinical performance feedback in Malawi: A case study

Landis-Lewis

Manjomo

Gadabu

et al. 2015

International Journal of Medical Informatics

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Introduction Sub-optimal performance of healthcare providers in low-income countries is a critical and persistent global problem. The use of electronic health information technology (eHealth) in these settings is creating large-scale opportunities to automate performance measurement and provision of feedback to individual healthcare providers, to support clinical learning and behavior change. An electronic medical record system (EMR) deployed in 66 antiretroviral therapy clinics in Malawi collects data that supervisors use to provide quarterly, clinic-level performance feedback. Understanding barriers to provision of eHealth-based performance feedback for individual healthcare providers in this setting could present a relatively low-cost opportunity to significantly improve the quality of care. Objective The aims of this study were to identify and describe barriers to using EMR data for individualized audit and feedback for healthcare providers in Malawi and to consider how to design technology to overcome these barriers. Methods We conducted a qualitative study using interviews, observations, and informant feedback in eight public hospitals in Malawi where an EMR is used. We interviewed 32 healthcare providers and conducted seven hours of observation of system use. Results We identified four key barriers to the use of EMR data for clinical performance feedback: provider rotations, disruptions to care processes, user acceptance of eHealth, and performance indicator lifespan. Each of these factors varied across sites and affected the quality of EMR data that could be used for the purpose of generating performance feedback for individual healthcare providers. Conclusion Using routinely collected eHealth data to generate individualized performance feedback shows potential at large-scale for improving clinical performance in low-resource settings. However, technology used for this purpose must accommodate ongoing changes in barriers to eHealth data use. Understanding the clinical setting as a complex adaptive system (CAS) may enable designers of technology to effectively model change processes to mitigate these barriers.

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Implementation experience during an eighteen month intervention to improve paediatric and newborn care in Kenyan district hospitals

Cited by 35 publications

References 19 publications

Explaining the effects of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals - interpretation based on retrospective examination of data from participant observation, quantitative and qualitative studies

Explaining the effects of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals - interpretation based on retrospective examination of data from participant observation, quantitative and qualitative studies

Emerging ICT implementation issues in aged care

Barriers to using eHealth data for clinical performance feedback in Malawi: A case study

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