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BMJ Quality Improvement report
Implementing a quality improvement initiative for the management of chronic obstructive pulmonary disease in rural Nepal
  1. Stephen Mehanni1,2,3,
  2. Dhiraj Jha1,4,
  3. Anirudh Kumar1,5,
  4. Nandini Choudhury1,
  5. Binod Dangal1,
  6. Grace Deukmedjian1,2,6,
  7. Santosh Kumar Dhungana1,
  8. Bikash Gauchan1,2,
  9. Tula Krishna Gupta1,
  10. Scott Halliday1,7,
  11. S P Kalaunee1,8,
  12. Ramesh Mahar1,
  13. Sanjaya Poudel1,
  14. Anant Raut1,
  15. Ryan Schwarz1,9,10,11,
  16. Dipendra Raman Singh12,
  17. Aradhana Thapa1,
  18. Roshan Thapa1,
  19. Lena Wong1,2,13,
  20. Duncan Maru1,5,14,15,16,
  21. Dan Schwarz1,9,10,17,18
  1. 1 Possible, Kathmandu, Nepal
  2. 2 Health Equity Action Leadership Initiative, University of California San Francisco, San Francisco, California, USA
  3. 3 Gallup Indian Medical Center, Gallup, New Mexico, USA
  4. 4 Department of Health Services, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
  5. 5 Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  6. 6 Department of Pediatrics, Natividad Medical Center, Salinas, California, USA
  7. 7 Henry M. Jackson School of International Studies, University of Washington, Seattle, Washington, USA
  8. 8 College of Business and Leadership, Eastern University, St. Davids, Pennsylvania, USA
  9. 9 Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  10. 10 Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
  11. 11 Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  12. 12 Public Health Monitoring and Evaluation Division, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
  13. 13 Tuba City Indian Medical Center, Tuba City, Arizona, USA
  14. 14 Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  15. 15 Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  16. 16 Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  17. 17 Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  18. 18 Ariadne Labs, Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Dan Schwarz; dan{at}possiblehealth.org

Abstract

Background Chronic obstructive pulmonary disease accounts for a significant portion of the world’s morbidity and mortality, and disproportionately affects low/middle-income countries. Chronic obstructive pulmonary disease management in low-resource settings is suboptimal with diagnostics, medications and high-quality, evidence-based care largely unavailable or unaffordable for most people. In early 2016, we aimed to improve the quality of chronic obstructive pulmonary disease management at Bayalpata Hospital in rural Achham, Nepal. Given that quality improvement infrastructure is limited in our setting, we also aimed to model the use of an electronic health record system for quality improvement, and to build local quality improvement capacity.

Design Using international chronic obstructive pulmonary disease guidelines, the quality improvement team designed a locally adapted chronic obstructive pulmonary disease protocol which was subsequently converted into an electronic health record template. Over several Plan-Do-Study-Act cycles, the team rolled out a multifaceted intervention including educational sessions, reminders, as well as audits and feedback.

Results The rate of oral corticosteroid prescriptions for acute exacerbations of chronic obstructive pulmonary disease increased from 14% at baseline to >60% by month 7, with the mean monthly rate maintained above this level for the remainder of the initiative. The process measure of chronic obstructive pulmonary disease template completion rate increased from 44% at baseline to >60% by month 2 and remained between 50% and 70% for the remainder of the initiative.

Conclusion This case study demonstrates the feasibility of robust quality improvement programmes in rural settings and the essential role of capacity building in ensuring sustainability. It also highlights how individual quality improvement initiatives can catalyse systems-level improvements, which in turn create a stronger foundation for continuous quality improvement and healthcare system strengthening.

  • chronic disease management
  • continuous quality improvement
  • evidence-based medicine
  • decision support, computerised
  • PDSA

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2018-000408

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    Footnotes

    • SM and DJ contributed equally.

    • DM and DS contributed equally.

    • Contributors SM, DJ, BD, GD, SKD, BG, TKG, SK, RS, AT, RT, LW, DM and DS conceived and designed the study. NC, RM, SP and AR performed the relevant data quality and extraction processes. SM, DJ, GD, RT and LW analysed the data. SM, AK and DM wrote the first draft of the manuscript. AK, SH, SM, LW and DS edited and revised the manuscript draft. All authors contributed to programme implementation and iteration, contributed to the writing of the manuscript, and reviewed and approved the final manuscript draft.

    • Funding DM received support for this work from the Office of the Director, National Institutes of Health under an Early Independence Award, number DP5OD019894. The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Dental and Craniofacial Research provided support for this award.

    • Disclaimer The funders played no role in research design, data collection, data analysis, manuscript write-up or decision to publish. Any opinions, findings, conclusions or recommendations expressed in this article are those of the authors alone and do not necessarily reflect the views of the US National Institutes of Health.

    • Competing interests SM, AK, GD, RS, LW, DM and DS work in partnership with and DJ, NC, BD, SKD, BG, TKG, SH, SK, RM, SP, AR and AT are employed by a non-profit healthcare company (Possible) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic and private foundation sources. At the time of initiative implementation, RT was employed by Possible. SM, GD, BG and LW are academic fellows affiliated to a bidirectional fellowship programme (Health, Equity, Action, Leadership Initiative Fellows) that is affiliated with a public medical school (University of California San Francisco). DJ and DRS are employed by the Government of Nepal. AK is an academic fellow at and DM is a faculty member at a private medical school (Icahn School of Medicine at Mount Sinai). GD is employed part time at a public medical centre (Natividad Medical Center). SH is employed part time at a public university (University of Washington). SK is a graduate student at a private university (Eastern University). RS and DS are faculty members at an academic medical centre (Brigham and Women’s Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. RS and DS are faculty members at a private university (Harvard Medical School). RS is employed at an academic medical centre (Massachusetts General Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. LW is employed by a medical centre (Tuba City Regional Health Care) that is managed using public sector funding through the Indian Health Services. DM is a non-voting member on Possible’s board of directors but receives no compensation. DS is employed at an academic medical centre (Beth Israel Deaconess Medical Center) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. DS is employed at an academic research centre (Ariadne Labs) that is jointly supported by an academic medical centre (Brigham and Women’s Hospital) and a private university (Harvard TH Chan School of Public Health) via public sector research funding and private philanthropy. All authors have read and understood BMJ Open Quality’s policy on competing interests and declare that we have no competing financial interests. The authors do, however, believe strongly that healthcare is a public good, not a private commodity.

    • Ethics approval This study protocol was approved by the Nepal Health Research Council, registration number 472/2017.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Deidentified data will be made available at the Healthcare System Design Group’s, Possible’s Implementation Research Team website (http://hsdg.partners.org/). Data may also be requested by emailing: research@possiblehealth.org.

    • Patient consent for publication Not required.