Stages of change: A qualitative study on the implementation of a perinatal audit programme in South Africa

Abstract

BackgroundAudit and feedback is an established strategy for improving maternal, neonatal and child health. The Perinatal Problem Identification Programme (PPIP), implemented in South African public hospitals in the late 1990s, measures perinatal mortality rates and identifies avoidable factors associated with each death. The aim of this study was to elucidate the processes involved in the implementation and sustainability of this programme.MethodsClinicians' experiences of the implementation and maintenance of PPIP were explored qualitatively in two workshop sessions. An analytical framework comprising six stages of change, divided into three phases, was used: pre-implementation (create awareness, commit to implementation); implementation (prepare to implement, implement) and institutionalisation (integrate into routine practice, sustain new practices).ResultsFour essential factors emerged as important for the successful implementation and sustainability of an audit system throughout the different stages of change: 1) drivers (agents of change) and team work, 2) clinical outreach visits and supervisory activities, 3) institutional perinatal review and feedback meetings, and 4) communication and networking between health system levels, health care facilities and different role-players.During the pre-implementation phase high perinatal mortality rates highlighted the problem and indicated the need to implement an audit programme (stage 1). Commitment to implementing the programme was achieved by obtaining buy-in from management, administration and health care practitioners (stage 2).Preparations in the implementation phase included the procurement and installation of software and training in its use (stage 3). Implementation began with the collection of data, followed by feedback at perinatal review meetings (stage 4).The institutionalisation phase was reached when the results of the audit were integrated into routine practice (stage 5) and when data collection had been sustained for a longer period (stage 6).ConclusionInsights into the factors necessary for the successful implementation and maintenance of an audit programme and the process of change involved may also be transferable to similar low- and middle-income public health settings where the reduction of the neonatal mortality rate is a key objective in reaching Millennium Development Goal 4. A tool for reflecting on the implementation and maintenance of an audit programme is also proposed.

Strengthening accountability for improved maternal and newborn health: A mapping of studies in Sub‐Saharan Africa

“…Facility-based maternal death and surveillance review (MDSR) including maternal death reviews (MDRs), audits, and confidential enquiry of maternal death (CEMD) (at national level) usually supported by health managers at district, region/province, and national level, aim to identify avoidable factors and opportunities for improvement through a confidential multidisciplinary team discussion with contributions from staff involved in the patient's care and a review of the patient documentation (Beyond the Numbers, WHO 2004). [25] Belizán et al 2011 [26] Project-based maternal death reviews and audits support a district or facility to conduct the process for a period of time with external support.…”

“…• Government leadership and ownership strengthens accountability within the health sector and assures sustainability [24][25][26]. • Engagement of district hospitals improves organization and quality of care [27].…”

The implementation of unit-based perinatal mortality audit in perinatal cooperation units in the northern region of the Netherlands

“…Grol et al found that none of the popular models for improvement of care are superior and that different models should be integrated to achieve change [20]. Knowledge of the field in which a new technology needs to be implemented and awareness of the stages of change necessary to implement and sustain the implementation of the new technology is therefore an essential factor in the whole process [8]. …”

“…Thirdly, similar to the findings of Belizaán et al, the presence of the members of the project team at all the introductory audit meetings and their non-judgmental participation in subsequent meetings was greatly appreciated by the local caregivers and increased the acceptance of holding a perinatal audit. It also emphasized the importance of a unit-based perinatal audit in all groups and stimulated continuation of the audit meetings [8]. …”

Sharing experiences to improve bereavement support and clinical care after stillbirth: report of the 7th annual meeting of the international stillbirth alliance

“…Understanding the causes of stillbirth allows services to develop to address specific populations' needs for preventing stillbirth. In many settings there have been substantial changes in perinatal and maternal mortality after the introduction of robust audits . Therefore, perinatal audit is essential at many different levels from individual maternity units up to national datasets.…”