Original research••

Combining quality improvement and critical care training: Evaluating an ICU CPR training programme quality improvement initiative at the National Hospital in Tanzania

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Abstract

Background The United Republic of Tanzania has had a 41.4% mortality rate in the intensive care unit. In Tanzania, the Ministry of Health and Social Welfare has implemented quality improvement (QI), yet the Tanzanian health sector continues to face resource constraints, unsustainable projects and gaps in knowledge and skills, contributing to unacceptably high mortality rates for Tanzanian patients. This research aims to determine if a Critical Care Training Program incorporating QI concepts can improve technical competence and self-efficacy of providers in a critical care setting in Tanzania.

Methods A 2-day Critical Care Training Program was developed for providers. It included the following modules: vital signs directed therapy (VSDT), cardiopulmonary and brain resuscitation (CPBR), blood glucose monitoring, introduction to critical care concepts and the QI concept of change management. For analysis, data were collected from pretests and post-tests and reported in REDCap. Descriptive statistics and paired t-tests were performed (alpha=0.05).

Results A total of 77 nurses and three providers attended the training. The overall score changes among participants for CPBR and VSDT were significant (p<0.001). Six out of 10 questions in CPBR demonstrated significant improved change (p<0.001). All questions in the VSDT training showed significant improvement (p<0.001). Based on hospital guidelines, 63 (95.5%) passed the CPBR evaluation and 62 (95.2%) passed VSDT.

Conclusion A pre/post analysis demonstrated improvement in knowledge, skills and increased confidence towards emergencies. This study suggests a Critical Care Training Program significantly improves the knowledge among providers and that QI impacts culture of change. This research exemplifies a systematic approach to strengthening capacity of critical care delivery in limited resource settings, with implications for further innovation in other low- and middle-income countries.

What is already known on this topic

Quality improvement is pertinent in shaping healthcare delivery, yet many low- and middle-income countries struggle to implement care effectively. Standardisation of cardiopulmonary resuscitation/cardiopulmonary and brain resuscitation techniques is vital to saving lives and these skills promote efficacy among healthcare workers.

What this study adds

This study demonstrated a successful methodology to improve quality of care for patients in critical condition. It furthered the understanding of how to shift the dynamic of practice in a low-resource intensive care unit using change management as a practical and advantageous tool.

How this study might affect research, practice or policy

Quality improvement is a clear mechanism to underscore what aspects of care need to be improved and has highlighted how nurses are central to patient outcomes and must have the skills necessary to respond to emergencies.

Introduction

Adequate and standardised critical care skills are necessary when caring for critically ill patients. However, there are multiple constraints to making this a reality in many low- and middle-income countries (LMIC), including a lack of well-trained and motivated staff, insufficient and ineffective allocation of resources and lack of adequate assessments to measure quality parameters.1 Historically, the United Republic of Tanzania has had high mortality rates in the intensive care unit (ICU) settings2 3; ICU nurses at major hospitals across Tanzania have shown low levels of knowledge on evidence-based guidelines for ICU care.4 Thus, questions arise as to how to elevate the standard for providers to engender change.

Quality is a concept that has grown in popularity in healthcare since the 20th century.3 5 Quality care should be the goal for all stakeholders in healthcare. Yet, what is the optimal way to integrate quality with treating patients and how can the health sector turn these concepts into practice? Quality improvement (QI) has been part of the dialogue about patient care since the mid-1900s and was introduced in Tanzania in 2007.6 7

In Tanzania, the Ministry of Health and Social Welfare (MoHSW) (now called the Ministry of Health, Community Development, Gender, Elders and Children) has taken steps towards QI through the Tanzania Quality Improvement Framework. The framework’s aims are: (1) to encourage all health workers at all levels and other stakeholders in the sector to develop innovative approaches for QI and implement them; and (2) to outline what needs to be done to institutionalise quality of healthcare at various levels based on national interests and vision.7 Despite this commitment, the Tanzanian health sector continues to face familiar challenges of resource constraints, unsustainable projects and gaps in knowledge and skills.8 This has been apparent at the National Hospital in Dar es Salaam, where ICUs have far fewer than the international standard for number of beds, often lack adequate staffing and the admission of patients to the ICU is convoluted and inefficient.9 These conditions have contributed to high morbidity and mortality rates for critically ill patients.2

Human resources are an additional limitation contributing to substandard quality of care. Due to low in-country educational resources, providers may attend schooling in a different country and return with different understandings of how to perform care. Furthermore, in Tanzania, nurses may be educated in settings without ICUs. As such, training is not always consistent, leading to variable knowledge levels and approaches to delivering care. This is the case in Tanzania where there is a lack of standardisation across providers even within a ward.

As healthcare systems in LMICs seek to improve healthcare delivery, many have adopted a QI approach.10 QI initiatives are useful to evaluate and change healthcare, as they have a specific framework, such as the Plan-Do-Study-Act (PDSA) to achieve continual improvement. The ‘Plan’ seeks to have a plan to change a current status quo. The ‘Do’ involves implementing the initiative. ‘Study’ allows for evaluation of the success and ‘Act’ creates the next cycle by forming the new status quo.11

Unfortunately, there is a paucity of research and published results of the impact of QI initiatives in LMIC settings, with most studies being US-centric or Euro-centric. A more dynamic understanding of how programmes using a QI framework implemented in a low-resource setting can transform delivery of care would be illuminating for scaling up programmes and assisting populations.

The current mortality rate alongside the relative newness of the ICU at the National Hospital necessitates an in-depth analysis of how a Critical Care Training Program can impact healthcare works in critical care settings. Thus, this study allows for empirical analysis of skills gained, especially since quality is setting specific, so it must be met in context. The first step is to equip providers with the necessary tools and education to meet the standard of care, deliver quality care and improve outcomes despite limited resources. The training employed in this research was designed based on local needs assessments. MoHSW has recommended a ‘cascading approach’ to training.7 This intervention used such an approach to reach a broader number of providers, since ICU nurses are considered a pillar of critical care units.12 13 As such, this research addresses QI at the National Hospital by focusing on critical care training to improve basic life support skills, and change management concepts to shift the culture and build capacity, all with the goal of increasing the quality of care that ICU patients receive.

In this study, our objective was to determine if a Critical Care Training Program incorporating QI concepts can improve the technical competence and self-efficacy of providers in a critical care setting in Tanzania.

Methods

Aims and study design

This quantitative pre/post study was conducted at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania, between June and July 2022. The study was designed to evaluate changes in knowledge, skills and confidence and will add to the existing literature surrounding critical care concepts and success in the methods of delivery. The aims were as follows:

Aim 1: Develop a Critical Care Training Program targeting critical care providers.

Aim 2: Quantify the level of knowledge change using pretests and post-tests.

Aim 3: Integrate change management concepts into critical care training.

Study setting

MNH is located in Dar es Salaam, Tanzania. It is the National Hospital and is situated on the same campus of Muhimbili University of Health and Allied Sciences (MUHAS), which has frequent overlap with the hospital, as MNH is a teaching hospital. The hospital comprises multiple wards, coordinated into ‘blocks’. There are 74 beds across the hospital designated for ICU use, comprising 4.93% of total beds. In the block studied, there were 10 beds in both the ICU and Surgical ICU (SICU) and six beds in the high dependency unit (HDU). The ICU treats patients with multiple organ failures or life-threatening injuries. The HDUs treat patients who need more focused care than general wards but not the degree of monitoring and expertise of an ICU.14 The HDU, as is standard, has a scope of practice to care for patients with one organ failure or acts as a step-down unit from the ICU. Within the ICU, patients are cared for using critical care technology, including mechanical ventilators, continuous monitoring, infusion pumps and central venous access. At the time of the study, there was a 37.1% mortality rate among surgical patients admitted to the ICU.15

Patient involvement

Patients were involved in the design of this research. In the design and practicality, staff recruited for participation was informed by patient outcomes and discussions with patients about their experience of quality care at the hospital.

QI methodology

In accordance with the effective QI methodology, a PDSA cycle was integral to forming the basis of this research.

Plan: What are our objectives? The QI team at the hospital recognised the need to improve the knowledge, skills and confidence of healthcare workers in critical care settings at the National Hospital.
Do: How will we achieve this goal? The QI team designed and implemented a 2-day Critical Care Training Program for healthcare workers, with more details below. In this phase, it is important to maintain the objective at the forefront of all actions that were implemented and ask ourselves if the sessions fulfilled the goal of the Plan phase. The entirety of this training was considered to be within one cycle of PDSA with the goal of setting up the next cycle.
Study: How do the outcomes compare to our objectives from the Plan? This can be achieved through the analysis of the pretests and post-tests as well as the survey data from participants. From there, it will also be imperative to evaluate success as compared with the larger setting of the hospital and QI.
Act: What are the next steps? Using this study and manuscript, future steps can be proposed to create a continual PDSA cycle that uplifts the core values of the hospital and larger QI to achieve good patient outcomes. Following data analysis, a presentation was given to the team as to the objective and subjective outcomes from participants to inform the next PDSA cycle.

The current research reflects one iteration of a PDSA cycle within a larger framework. As mentioned above, QI is ongoing at the hospital site, so this is one test of change to be implemented using the PDSA cycle to henceforth dictate a new status quo and subsequent changes for a future PDSA cycle with the outcome of this research.

Training programme

A 2-day training programme was developed for critical care nurses and providers based on a needs assessment done at MNH. The 2-day Critical Care Training Program included the following modules: vital signs directed therapy (VSDT), cardiopulmonary and brain resuscitation (CPBR) knowledge, blood glucose monitoring, ‘Introduction to Critical Care Concepts’ and QI change management concepts. Each day of training began with a pretest for that day’s module topics. CPBR had a practical session to practise skills learnt with group scenarios. Each day had a post-test to evaluate knowledge gained. At the end of the training, participants were given an optional training evaluation to provide feedback.

Participants

Participants were selected from the block and comprised nurses and physicians and were considered leaders in some capacity in their role, with the goal of disseminating the information to the rest of their ward or block. Criteria for selection included working in a critical care setting.

Data collection and instruments

Prior to training, a self-administered written knowledge test was given to each participant on each day of the 2-day training. There were two tests administered, one assessed knowledge of the training dedicated to VSDT, and the other assessed the training dedicated to CPBR, blood glucose monitoring and ‘Introduction to Critical Care Concepts’. Each test was created to mirror the subsequent training. The CPBR test comprised 10 multiple-choice questions. The VSDT test consisted of seven fill-in-the-blank questions and three open-ended questions (see online supplemental tables 10 and 11).

On completion of the tests, the data were entered into REDCap electronic data capture tools.16 17 A REDCap form was created to automatically anonymise participants in the study. Throughout the training, groups completed practice-based skill requirements together as a prerequisite in order to move on to the next module of training. The data were subsequently analysed to examine outcomes and significance.

At the end of the 2-day training and after the post-test, a questionnaire was distributed to participants for their feedback and evaluation of the training, seen as a proxy for the QI programme at MNH. The questionnaire consisted of 26 scaled questions about their feelings towards the training, including the quality, delivery and relevance of each module, usefulness in practice for each module, length of time of each module and other logistics involved in the training (see online supplemental figures 1–9 and tables 1–8). The questionnaire also had four open-ended questions originally in English, but the author added Kiswahili to improve clarity of question stem for respondents. All test and questions were created in conjunction with the quality assurance unit at MNH.

Survey design

There were four cycles of training groups. The pretests and post-tests were revised between the second and third training groups using a formative process to boost and ensure clarity. After group 2 had been trained, questions and answers’ wording and unit standardisation were revised and reformatted to improve clarity, including adding Kiswahili (the main language of participants) to open-ended questions. In the CPBR test, there were 10 total questions and only one had a notable change to the stem to improve clarity, but weighting was not changed (see online supplemental table 9).

Analysis

Data quality was assessed and all variables were preliminarily examined using REDCap reporting software for statistics and charts function; for more in-depth analysis, RStudio (V.4.2.2) was used. Descriptive statistics were performed for all variables. Paired t-tests were performed to determine significance of changes between the pretest and post-test scores, alpha=0.05. The feedback form was analysed using thematic analysis, which phrases and comments were most frequent, and then amalgamated into charts using Excel.

Patient and public involvement

Patients nor the public were involved in this research. As such, the research question did not need to be developed or informed by their priorities, experiences or preferences. Patients and the public were not involved in the design and conduct of the study, the choice of outcome measures or the recruitment to the study. Patients nor the public were involved in choosing the methods or agreeing to plans for dissemination of the study results.

Results

Two-day trainings were conducted for four groups of critical care providers, comprising nurses and physicians. A total of 80 providers (3.7% physicians, 96.3% nurses) completed the training. 62 (77.5%) were female and 18 (22.5%) were male. The demographics of the individuals that completed a pretest and/or post-test for each training day based on the training group are shown in table 1.

Table 1

Demographic and descriptive data of training participants, descriptive statistics

There was a statistical change in score from pretest to post-test for each question in the CPBR and VSDT trainings (table 2). Table 2 demonstrates the test score before and after (average, SD and change) the CPBR and VSDT trainings. The overall score changes between pretest and post-test among participants for CPBR and VSDT were significant (p<0.001). Six out of 10 questions in CPBR demonstrated significant improved change (p<0.001). All questions in the VSDT training showed significant improvement (p<0.001). Graphical analysis allows for the ability to see a difference between the pretest and post-test scores and the score changes for CPBR and VSDT (figure 1a,b).

Table 2

T-tests of CPBR score change per question

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Figure 1

(a) Cardiopulmonary and brain resuscitation (CPBR) pretest and post-test data. Scores were evaluated before and after training as well as demonstrate the change in score points from pretest to post-test. (b) Vital signs directed therapy (VSDT) pretest and post-test data. Scores were evaluated before and after training as well as demonstrate the change in score points from pretest to post-test.

Analysis was completed to demonstrate the number of respondents who achieved each score level from 0% to 100% in the pre-CPBR and post-CPBR tests (table 3 and online supplemental figures 11 and 12). For CPBR, the MUHAS has a minimum passing score of 50%.18 Of those who completed the post-test, 63 (95.5%) passed the examination. In CPBR, the mean test score increased from 52.8% to 77.9% (p<0.001). The study also demonstrated the quantity of participants that had changes from the pretest to post-test for CPBR, where 31 (46.3%) respondents had a score increase of at least 3 points (30%) from pretest to post-test.

Table 3

Number of respondents who achieved each score level and amount of change for CPBR

Analysis was completed to demonstrate the number of respondents who achieved each score level from 0% to 100% in the pre-VSDT and post-VSDT tests and the number of participants who achieved each change from pretest to post-test (table 4 and online supplemental figures 13 and 14). Using the same passing standards from above, of those who completed the VSDT post-test, 62 (95.2%) passed. In VSDT, the mean test score increased from 49.7% to 70.7% (p<0.001). The VSDT test showed the number of participants who improved their score from pretest to post-test; 16 (23.9%) respondents had a score increase of at least 30% from pretest to post-test.

Table 4

Number of respondents who achieved each score level and amount of change for VSDT

The impact of modifying the question stem for question 8 (see online supplemental table 9) was examined by looking at the change in correct pretest and post-test answers split by the original and revised question 8 and, for reference, the change to question 7. Groups 1 and 2 achieved only 61.8% correct on post-test question 7 compared with 84.6% correct among groups 3 and 4. For question 8, groups 1 and 2 achieved 74.1% correct compared with 84.6% for groups 3 and 4.

Evaluation and feedback form results

Participants desired a varying level of training frequencies, with the majority seeking at least every 6 months’ frequency (table 5).

Table 5

Frequency of future trainings desired by respondents

In changes to the programme that trainees would like to see, the most given response was for more time for trainings (see online supplemental figure 1). Respondents indicated what types of future trainings they would like, and most respondents wanted technical or skills-based trainings, such as on ECG (see online supplemental figure 2a,b). The trainees also reported changes they will make in their practice going forward (see online supplemental figure 3a,b). The majority of respondents indicated a culture-based shift with the most frequent answer being about teaching others the concepts learnt. According to trainees, skills were the most useful aspect of the trainings to respondents with an overwhelming number of respondents marking cardiopulmonary resuscitation (CPR)/CPBR (see online supplemental figure 4a,b). Since trainees filled out evaluation forms, opinion-based responses informed trainee perspectives about the trainings (see online supplemental figure 5). In training feedback, trainees perceived that CPBR and teamwork were the most valuable aspects of training. 20 (24.4%) respondents thought the training too short. 15 (18.5%) trainees reported that they will teach colleagues what they learnt in the trainings. Referencing future trainings, trainees asked for training on additional medical concepts (11, 13.6%) and also additional training on leadership styles (2, 2.5%). Moreover, 16 (64.0%) respondents felt that they are very likely to change their practice after training. 17 (65.4%) respondents felt the Critical Care Training Program was very good overall. All participants who answered (26, 100%) felt satisfied or very satisfied with what they learnt from the programme.

Discussion

This study has demonstrated how a QI initiative and training can impact the skills, knowledge and confidence of nurses and providers at a large tertiary hospital. Specifically, ideas around technical competence, culture change and sustainability will be discussed as well as avenues for future research.

Technical competence

The results highlight the increase in technical competence and skills. 31 CPBR participants (46.3%) and 16 VSDT participants (23.9%) had a score increase of 3 points or 30%, respectively, demonstrating increases in understanding the skills learnt. In CPBR, participants demonstrated a significant increase in skills and knowledge across six of the questions. These topics included questions about chest compressions, opening airways after head/neck trauma, when to continue CPR and what heart rhythm indicates a shock is needed. The topics that did not show a significant change in score may need to be revisited for evaluating provider knowledge. The results from VSDT showed every single question to have a significant increase in score.

95.5% of CPBR participants and 95.2% of VSDT participants met MUHAS standards. Another standard is the American Heart Association standard, which sets 84% as a passing score. With these standards, 25 (37.9%) of CPBR and 17 (25.4%) of VSDT passed. Previous studies have reported a limited accurate knowledge of CPBR.19 Thus, this training has bolstered accurate basic life support skills. Additionally, this training focused on the brain resuscitation component of CPR; a new component introduced in critical care. This increased technical competence impacted the lives of patients due to the new-found life-saving skills that were not previously present in critical care settings of the hospital. This demonstrates objective impact of the training programme, with skills gained for immediate use in critical care settings and confirmed with passing scores from the post-tests.

Several of our participants noted that they hoped the knowledge they gained could be used to create change in their units. A review after implementing QI for 7 years across three African countries found creations of ‘QI champions’ due to a shift in culture and a feeling of collaborative ownership.20 This is echoed in our participants.

Culture change

The participants highlighted that while they found skills the most useful aspect of trainings and that they desire more technical trainings, the participants reported that they will make cultural changes, with teaching others and providing quality care the most popular answers, as seen from the survey data, which quantifies these responses (see online supplemental figures 2–4). All participants noted that they were likely or very likely to change their practice, establishing the desire to propagate knowledge and improve care delivered. Such outcomes promote quality and how to direct change across a wider subset of providers. For further detail of the culture change respondents felt they would make, see online supplemental figures 3a,b and 5. Moreover, the participants noted their satisfaction with the training programme, with 34.6% noting the training to be good and 65.4% to be very good overall (see online supplemental figure 5 and tables 4 and 8). Another word cloud was coded for the most common words used among open-ended evaluation feedbacks (see online supplemental figure 10). The data support the validity that this training had impact; nurses felt more willing and able to respond to emergencies and had the self-efficacy to not wait for a more senior counterpart, reducing the time to start life-saving skill implementation.

Change management can direct the culture of an organisation, which complements the concepts of reorganising processes and individuals’ responsibilities.21 It has been documented that long-term programme success is contingent on team members’ investment and the resources that exist to further training.22 Moreover, individuals must trust their trainers and the change agents in order to optimally achieve change.23 Indeed, by training providers and including them in the process, feelings of ownership can be achieved, further spurring innovative engagement.24 25

A Ghanaian cross-sectional study across two hospitals revealed that while the priorities were to garner communication as a cohesive team and adaptability, the biggest barrier was inadequate training that inhibited empowerment.26 In Iran, change management was employed to encourage quality techniques amidst learning. This training found increased cooperation, teamwork and more involvement from employees.23 In Tanzania, the MoHSW has promoted the concept of Training of Trainers and the importance of developing every individual provider’s sense of responsibility towards the culture of care.7

This research demonstrates need for an emphasis on the role that culture and change management plays in gaining technical competence that leads to programme success. As there currently exist weekly touch-base learning sessions on a smaller level, there have been plans for continuation of skills, where training concepts can be reprised in a more intimate environment. Ensuring these skills are regularly rehearsed and practised on a weekly basis will help prevent loss of knowledge/skills and promote sustainability for the future incoming cohorts of nurses. Nonetheless, larger future initiatives should focus on engaging multiple levels of providers and imbuing them with tools for a level of autonomy and change management. This will encourage feeling empowered to attend to their duties and may go above and beyond in their care for patients, thereby improving quality of care delivered.

Need for continual trainings/future direction

QI by its definition is an ongoing process.27 28 As such, this aspect of QI is significant and must be recognised. Most trainees desired trainings at least every 6 months. Such input from participants is informative of the desire for more skills to improve quality of self and of care for the patients. It must be noted that while respondents most frequently requested a 6-month interval in this research, future research should be conducted to determine the appropriate and most effective interval to maintain knowledge, skills and momentum of culture change.

At the hospital, the level of CPR knowledge had been demonstrated to be poor in all cadres.19 Yet, nurses spend the most time of all providers in critical care units and are integral to patient success.12 Thus, it was imperative for nurse training and improving confidence in responding to emergencies, especially as a systematic review reported significantly fewer ICU beds in LMICs compared with high-income countries for the same denominator of individuals.29

This is especially imperative when considering the sustainability of such initiatives. These initial results have begun to inform the exact frequency of continual trainings. Nonetheless, these concepts have begun to be incorporated in the weekly touch-base sessions that are pre-existing on the wards. These skills can be continually reflected on to ensure there is not a hospital-wide loss of knowledge. It would be therefore pertinent to follow-up with a longitudinal quantification of knowledge and mortality rates in a subsequent study. Moreover, while informal trainings that involve rehearsal of skills are common in many settings, and as aforementioned currently exist at the hospital, there is a need for institutionalised continual training framework. By designing and executing a recurring training programme, this could keep skills sharp and allow for providers to feel ownership.

Extrapolations to broader Tanzanian QI

Quality is the cornerstone in creating initiatives in Tanzania, codified in the Vision 2025 to create programmes that promote care and improve quality of life.7 Nonetheless, Kaihula et al in 2018 demonstrated that while quality standards exist at MNH, there is a wide deficit in CPR/CPBR skills.19 This study highlighted that while providers were conducting CPR routinely, it was not being done accurately and needed improvement. During that study, only 25% and 50% passed MUHAS standards and only 4% and 9% of providers passed American Heart Association (AHA) standards for CPR.19 Other studies have measured quality and have found similar lacking results in adequate knowledge of critical care concepts.30 31 In comparison, this research concentrated on critical care providers and subsequently demonstrated higher passing rates after a focused, context-specific training. One reason could be due to the focus on QI concepts including a needs assessment that determined training aspects as well as encouraging participants to be change agents and expand the impact of their training by using their skills to teach others and change the culture on their units.

Thus, this Critical Care Training Program has shown that training rooted in QI affects providers with the potential to change the culture of care. Such research is necessary, as it is powerful in being able to direct changes and create a sustainable framework for continuous improvement. Studies have demonstrated the importance of QI and its role in shaping health-based interventions, but there is a paucity in quantifying interventions that incorporate change management.5

Limitations

There are a number of limitations to be considered in the context of this research. Limitations to this study may be in the generalisability to other settings, in the language, in statistical analysis and a post-study mortality rate. This research was conducted in a resource-limited setting with a newer ICU. While English is the language of the hospital, people predominantly speak Kiswahili in Tanzania and presented a challenge for certain aspects of this research. The trainings were led by local staff leadership of the hospital to reduce any miscommunication of skills; however, the pretests and post-tests were conducted in English per the leadership’s direction. Therefore, while theoretically all the staff who underwent training speak English, there could be variability in the amount of written comprehension. This challenge was attempted to be rectified by revising the language of the pre/post-test (as discussed earlier). Moreover, it is possible that there could have been error in the code used for analysis. Nonetheless, any error was attempted to be reduced using statistical methods and having multiple people review the code. Last, one challenge of this study design was that a post-study mortality rate was not part of the study design, as this study was focused on skills gained. If another study were conducted, it would be informative to have these mortality rate statistics.

The purpose of this study was to examine skills gained directly following training, therefore, further research could examine how sustainable this knowledge is with continual trainings. Moreover, it may allow for dissemination for others to learn proper skills. This could also increase trust in trainers and allow planning for appropriate future training resource allocation.

Conclusion

This study demonstrates that technical skill and knowledge-based trainings connected to QI concepts including change management can contribute to participants wanting to create a positive culture change in their workplace. In the face of limited resources, including limited human resources, this momentum and culture can help improve the quality of patient care, but must be a continuous process supported by leadership. With the outcome of this research, next steps can be taken for a new PDSA cycle at the hospital to create a continual improvement of critical care changes and patient care and further evaluate mortality rates. Further research should evaluate the impact of including QI concepts into healthcare worker trainings and determining optimal training intervals.

Contributors: SS conducted and collected the data, led the reporting through interpreting and performing the statistical analysis on the data as well as wrote the manuscript, submitted the study and is the guarantor. SN, JJ and FK planned the study and assisted with the design of the research. TM, TS, OB, AL and NA planned the study and assisted with the design of the research and the acquisition of data. SH and BM assisted with the design of the research and were the major contributors in writing the manuscript. All authors read and approved the final manuscript.
Funding: This study supported student travel with funding from the Emory Global Health Institute.
Competing interests: None declared.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review: Not commissioned; externally peer reviewed.
Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication:

Ethics approval:

This project was determined to be IRB exempt since it evaluated a training and QI programme, and all data were deidentified prior to analysis. It was approved by the MNH Quality Assurance Unit and the Emory Global Health Institute and Emory University Institutional Review Board (IRB00002551) and determined exempt.

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Abstract
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