Improving facility-based care: eliciting tacit knowledge to advance intervention design

Abstract

Attention has turned to improving the quality and safety of healthcare within health facilities to reduce avoidable mortality and morbidity. Interventions should be tested in health system environments that can support their adoption if successful. To be successful, interventions often require changes in multiple behaviours making their consequences unpredictable. Here, we focus on this challenge of change at the mesolevel or microlevel. Drawing on multiple insights from theory and our own empirical work, we highlight the importance of engaging managers, senior and frontline staff and potentially patients to explore foundational questions examining three core resource areas. These span the physical or material resources available, workforce capacity and capability and team and organisational relationships. Deficits in all these resource areas may need to be addressed to achieve success. We also argue that as inertia is built into the complex social and human systems characterising healthcare facilities that thought on how to mobilise five motive forces is needed to help achieve change. These span goal alignment and ownership, leadership for change, empowering key actors, promoting responsive planning and procurement and learning for transformation. Our aim is to bridge the theory—practice gap and offer an entry point for practical discussions to elicit the critical tacit and contextual knowledge needed to design interventions. We hope that this may improve the chances that interventions are successful and so contribute to better facility-based care and outcomes while contributing to the development of learning health systems.

The Meso-Level in Quality Improvement: Perspectives From a Maternal-Neonatal Health Partnership in South Africa

“…While the need for “whole system” perspectives 2 and multi-level action 10 , 14 on quality is now accepted, there is relatively little written specifically on meso-level system capacity. English et al, 34 in their analysis of the interaction between micro- and meso-level factors in QI in Kenya, provide insight into the general mechanisms of the meso-level. They refer to three local “resource systems”—material, skills and relational systems—and five “motive forces” of change (eg, leadership, goal alignment, responsive planning, empowerment, and learning).…”

“We just have to help”: Community health workers' informal task-shifting and task-sharing practices for hypertension and diabetes care in Nigeria

“…The insights and skills that CHWs might have developed in the course of overcoming challenges in their practice are often not recognized when new policies and initiatives are developed ( 58 ). English and colleagues highlight that the tacit and contextual knowledge held by those in practice must be harnessed for implementing successful interventions ( 59 ). The omission of frontline worker perspectives could undermine success of health system reforms ( 60 ).…”

Receive, Sustain, and Flow: A simple heuristic for facilitating the identification and treatment of critically ill patients during their hospital journeys

“…Tools such as SEIPS offer practical, universal approaches to safety that are likely to be effective for African hospitals but they lack the narrative, temporal power of hospital journeys [30,32]. Systems Engineering Initiative for Patient Safety 3 focuses very much on patients and has moved from the linear approach of Donabedian to a more cyclical approach that shows both a diagnostic cycle encapsulated in the work system and as outcomes feeding back into the work system [24].…”