Discussion
HSM was initially developed in the aviation and logistics industry for efficient and effective use of resources.9–11 Implementation of this model helped the organisations to improve their productivity, which ultimately led to its adoption by various industries across the world.9 10 Conceptually, HSM is a natural fit for healthcare service delivery, especially, in resource-limited settings where it can help to augment the deficiencies in the peripheral facilities by linking them to a resource replete central hub facility. Use of this design for building QI skills is a novel innovation.
We tested the district level implementation model for scale up of QI using the hub and spoke mechanism for maternal and newborn care settings. This was adapted contextually for rural and urban districts across India. This was the first attempt at developing a model for upscaling QI at district level; it helped us to understand various factors that affect uptake of QI skills at different levels. It made us aware of the limitations of the model in implementation of QI at scale.
A key objective of this work was development and demonstration of a sustainable QI handholding/supportive supervision model. District and State Health officials, health facility staff and network mentors (from QI network) were the key participants in this process. The purpose of developing these linkages between the facilities in a district was to foster a culture of QI in the local health system. This is an important step in the direction of developing a health system that can deliver universal health coverage for all, as mentioned in the Lancet commission report on high-quality health systems.1 The report had highlighted that globally majority of initial attempts at QI are at facility level (micro-level). Such efforts are often not sustainable and may not lead to a system-wide improvement.
The meso-level efforts (eg, a QI network or collaborative), can be a catalyst for increasing uptake and spread of QI across facilities as demonstrated in multiple studies.12–15 However, interventions directed at meso-level are need to be operationalised more often in health systems.1 16 17 Sustenance of micro-level interventions without meso-level support is a serious bottleneck across all health systems.1 This finding from the commission is in conformity with our observations, as the ‘hub’ facilities in both rural and urban areas could not handhold ‘spoke’ facilities effectively for implementing QI skills. To sustain the improvements in the hub and spoke facilities, extensive mentoring support from the network QI mentors was required. This reiterates the fact that micro-level interventions require extensive meso-level support for medium term sustenance.
It was seen that the district and state level administrative buy-in/ownership was deficient. This was possibly due to lack of insight on benefits of implementation of QI at scale.18 This became one of the major bottlenecks in the effective implementation of the HSM. The major learning from this implementation exercise was that in absence of effective handholding and support at macro-level long-term sustenance of any micro-level and meso-level interlinked process is a formidable challenge.
Recognising these challenges, India has embarked on a mission to provide universal health coverage for all its citizens through Ayushman Bharat Scheme and the LaQshya initiative for improving quality of maternity care.19 The provisions of the aforementioned schemes have catalysed the process of onsite mentoring and handholding of medical colleges with an aim to develop them as regional resource centres for QI. This has been carried out with an objective of developing an operational HSM at the national level. Some of the QI team members and mentors from this implementation exercise are now part of the National Mentoring Group notified by the Ministry of Health & Family Welfare, Government of India. This process is fostering a QI culture in the health system with full support from macro-level and active involvement of micro-level and meso-level facilities. Development of national mentoring process is a conscious exercise to overcome challenges and build on the learnings of the HSM.
The main learnings from this exercise were: (1) this model helped in sensitisation of teams to the POCQI methodology and helped them to test and use the methodology in field conditions with ease; (2) for effective uptake and successful implementation of QI, initial intensive onsite mentoring is an essential requirement; and (3) absence of effective macro-level support is the major roadblock for effective implementation of any HSM.
Challenges experienced while operationalising the model are grouped for ease of understanding into micro-level meso-level and macro-level.
At micro-level: absence of an enabling environment at facility level created a culture that gave little incentive for health facility staff to learn QI skills. It was further compounded by a rigid hierarchical system and partial administrative support especially encountered in the urban hub facility. Maintaining motivation in physicians was a challenge. Both the rural and urban facilities lacked dedicated hospital QI personnel, especially at the urban-hub facility; this made healthcare providers visualise QI as extra work, which distracted them from their regular patient care. Non-provision of transportation for hub mentors to their allocated spoke facilities added to poor motivation to undertake mentoring visits. See figure 3 for fishbone diagram of factors that hindered mentoring visits by hub-mentors.
Meso-level: budgetary constraints for conducting intensive onsite mentoring led to visits being conducted by one out of the two network mentors. Delay in approvals for starting activities in urban setting led to inability of urban hub to become functional in sync with project timelines. Lack of sensitisation about QI methodology among the district and NHM officials led to deficient buy-in/ownership and consequent support. Lack of active participation from the district officials and state NHM officials on account of other competing priorities for district and state health officials.
Macro-level: lack of ownership and financial provisioning by the state administration for scaling up of this initiative across districts led to non-sustenance of the operational model. Irregular monitoring and evaluation of the QI work progress by the state and district officials led to lack of accountability for the process. The transfer of a senior official from health department led to significant delays in operationalising of the project.
Figure 3Fishbone diagram showing challenges faced by hub-based mentors in conducting mentoring visits to spoke facilities. QI, quality improvement.
Limitations of this work
There were a few limitations in our work. The work was conducted in two districts, which may not represent the health system of a country as diverse as India. The major bottlenecks encountered in the implementation process may not necessarily operate in other similar settings. It only offers possible pointers to future efforts on implementing QI programmes at scale. Active community participation was deficient in the implementation model. As multiple facilities worked on diverse improvement aims without using a collaborative approach, a system-wide improvement could not be demonstrated in the short span of 1 year. Moreover, the short duration of this work, sustenance of hub and spoke learnings beyond the project duration could not be determined.