Influence of context on quality improvement priorities: a qualitative study of three facility types in Lagos State, Nigeria

Background Quality improvement (QI) collaboratives are increasingly popular. However, there is a need for an in-depth understanding of the influence of context on its implementation. We explored the influence of context on the change concepts considered by public primary (primary health centres), public secondary (public hospitals) and private (private facilities) collaboratives established to improve maternal and newborn health outcomes in Lagos State, Nigeria. Methods Between February 2019 and January 2020, we conducted a qualitative study using meeting reports, key informant interviews and participant observation. Data were analysed using the high-quality health system framework for assessing health system and user experience that distinguished three quality domains: quality impacts, processes of care and health system foundations. Results Nineteen change concepts and 158 change ideas were observed across 28 facility QI teams. Change concepts and ideas prioritised were influenced by government and non-governmental leaders but ultimately shaped by facility QI capacity, time allocated for QI activities and availability of local data. Of the three quality domains, process of care, including patient satisfaction, received the most attention across facility types. There was considerable variation in the change concepts considered across domains. For example, more public hospitals focused on complication management because of a relatively high prevalence of and capacity to manage maternal complications; primary health centres focused more on complication referrals, while private facilities prioritised revenue generation. Problems with availability of resources were particularly highlighted in primary health centres which had relatively less financial commitment from stakeholders. Conclusion Our findings provide insights into QI collaboratives’ mechanism of change in which external stakeholders, including government, drove QI priorities for action but the ultimate decisions depended on local realities of facilities. Our findings underscore the need for strong QI leadership and sufficient resources to enable facility QI teams to prioritise change concepts for greater health impact.


S/N Problem description Method of problem identification
Change ideas-change concepts Ensure checklist for tracking adherence is included as the 1st page of severe preeclampsia/ eclampsia patient case note-complication management (B2, B5, B7, B9, B10, B11, B12, B13, B17, B18). Sensitise doctors and nurses on the importance of using the checklist and adherence to protocol-complication management (B2, B5, B7, B9, B10, B11, B12, B13, B17, B18) Train/retrain doctors and nurses on the management of severe pre-eclampsia & eclampsia-complication management (B2, B13, B18). Develop and post pictorial protocol on the walls of the labour ward and share easily accessible protocol cards-complication management (B8, B12, B10); (C15) Appoint severe pre-eclampsia/ eclampsia champions who will ensure checklists are used-complication management (B18). Establish a triage protocol to facilitate prompt treatment and early referralcomplication management (B5) (C11) 2 Health workers were not adhering to the protocol for managing post-partum haemorrhage (PPH); there was a delay in commencing appropriate care for patients with PPH -From HSDF survey (B13) -Facility register (B11) Develop a checklist to monitor blood loss and signs of shock as per protocolcomplication management (B12, B13) Sensitise labour ward & postnatal ward doctors and nurses on the importance of adhering to PPH protocol-complication management (B11, B12, B13). Senior doctors' daily ward rounds for prompt identification and management of PPH cases-complication identification and management (B11). Consultant OBGYN should be informed of all newly admitted women in labourcomplication identification and management (B11). Train all clinical & non-clinical staff, including gatemen, on responding to emergencies such as PPH-complication identification (B11). Make close-user-group phone line avaialble to various service units e.g. laboratory, emergency room, wards etc. to facilitate within-facility communication-complication management (B11) 3 Increase in neonatal deaths from poor adherence to protocol on management of preterm babies; poor competence in neonatal resuscitation and delays in referral Use a checklist to ensure that all steps in neonatal resuscitation are followedcomplication management (B5). Educate health providers on the importance of early decisions and referralscomplication management (B5). 4 Partographs to identify labour complications are not properly filled.
Not documented Inform the apex nurse to sensitise the labour ward nurses on the importance of filling the partograph properly-complication identification (A1, A2, A3) Identify a health provider to train/retrain nurses on partograph use-complication identification (C20) 5 Late identification of births at risk of birth asphyxia 2. Quality impact-economic benefit: 6 problems identified, 12 change ideas tested Under this domain, the number of facilities documented to have identified problems and developed change concepts and ideas during the study period: -0 of 6 PHCs -0 of 14 public hospitals -2 of 8 private facilities (labelled C17, C20)

S/N Problem description Method of problem identification
Change ideaschange concepts 1 Revenue generation affected by inefficient billing due to non-uniform price of services.
Not documented Create a uniform price list and post it in doctor's office, ward and pharmacy to prevent underbilling-revenue generation (C20, C17)

2
Inadequate stock taking at the pharmacy causing a disparity in dispensation and stock and consequently unexplainable revenue loss Routine data (C17) Develop and implement a drug auditing policy-revenue generation (C17).
Only drugs on prescription sheets should be dispensed-revenue generation (C17) Introduce stock-taking tools such as bin cards for monthly auditing of drug stockrevenue generation (C17) Access to pharmacy should be limited to pharmacy technicians-revenue generation (C17) 3 Patients were being admitted into the ward beyond their health insurance plan limit.
Not documented Put a code on each admission slip to reflect the appropriate ward per health insurance plan-revenue generation (C20). 4 Staff members admission into VIP ward limited available bed spaces for patients who require admission Not documented Develop and read out admission policy during clinical/staff meeting-revenue generation (C20). Mandate doctors to inform their HODs about their intention to admit a member of staff or staff relative-revenue generation (C20). HODs of department to review admission plan of staff--revenue generation (C20). Only one VIP ward should be assigned to staff members per time, and hierarchy should be considered-revenue generation (C20).

5
Inefficiencies due to staff shortage but the cost of employing new staff was too high.
Not documented Employ trained individuals on national assignment (NYSC) who have requisite knowledge and skills, but salary may be less-revenue generation (C20). 6 Ordering of multiple investigations despite patients' financial constraints and health insurance limits.
Not documented Senior doctors to review requested investigations and provide feedback to junior doctors on how to make judgement on the most important investigations-patient financial protection (C20).  Inappropriate umbilical cord care leading to increased risk of infection as some mothers lack understanding about the correct use of chlorhexidine gel Not documented Encourage and train mothers to use chlorhexidine gel for umbilical cord care-disease prevention and health promotion (C17) Include chlorhexidine gel as a delivery requirement -disease prevention and health promotion (C17) Solicit feedback from mothers on their experience with chlorhexidine through SMS, and WhatsApp platform -disease prevention and health promotion (C17) Liaise with apex nurse to facilitate training of nursing mothers on the use of chlorhexidine gel-disease prevention and health promotion (B8) 2 Some health workers do not understand the importance of disease prevention.

Not documented
Health talk on infection prevention and control including handwashing techniquedisease prevention and health promotion (A4, A2) Train staff on the proper use of colour-coded bins, safety boxes and proper disposal of medical waste-disease prevention and health promotion (A2) (C5) 3 Staff members had needle stick injuries while attending to Hepatitis B positive patient, thereby needing hepatitis B immunoglobulin.
Staff observation (B6) Deliver health talks to all staff on prevention of needle stick injuries and the need to get vaccinated-disease prevention and health promotion (B6) Screen staff for Hepatitis B-disease prevention and health promotion (B6) Procure and vaccinate Hepatitis B negative staff against the infection-disease prevention and health promotion (B6) 4 Increasing cases of hospital-acquired infection. Not documented Fumigate the ward at stipulated intervals-disease prevention and health promotion (B8) (C20, C5) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Purchase screening kit and ensure continued availability -disease prevention and health promotion (C17) Create awareness about hepatitis-disease prevention and health promotion (C17) Referral of patients that test positive for hepatitis and track completion of referraldisease prevention and health promotion (C17) Purchase screening kit and ensure availability-disease prevention and health promotion (C17) 6 HIV test not routinely done preventing early detection Not documented All patients presenting at the facility should be encouraged to undergo HIV counselling and testing -disease prevention and health promotion (C25) Treatment/care/support should be provided for patients that test positive for HIVdisease prevention and health promotion (C25) 7 Poor knowledge of common health conditions among patients; few platforms for health education of patients Not documented Encourage health providers to educate patients on prevention of common ailments; provide information on the diagnosis and treatment of ailment they are being managed for; play documentaries on common health topics during peak hours-disease prevention and health promotion (B9) (C11, C5) Post bills on notice boards and share pamphlets with health messages-disease prevention and health promotion (B7, B9) (C11)

8
Need to prevent unwanted pregnancies and abortions and improve uptake of services Not documented Conduct annual free/subsidised family planning outreaches to create awarenessdisease prevention and health promotion (C17)

9
Need to create awareness on cervical cancer to improve uptake of services Not documented Conduct annual free/subsidised cervical screening-disease prevention and health promotion (C17) 10 Continuity of care is not ensured. Patient tracking system needs strengthening. Health outcomes not consistently documented because of the nonavailability of referral register.
Not documented Assign officer to track completion of referral over the phoneservice uptake and continuity (A4). Inform the M&E Officer to make requisition for referral register or improvise with hardcover notebookdocumentation (A4). Send reminder text messages to ANC clients before the date of next ANC visit-service uptake and continuity (B7) (C16).
11 Increase in under-5 pentavalent vaccine drop out. Not documented Identify and track defaulters (that had pentavalent 1 vaccine but missed an appointment for either pentavalent 2 or 3 vaccines)service uptake and continuity (A2)

2
The patient spend time asking for direction to key service points as there are no signages.

Not documented
Develop signages to direct patients to key service pointsease of accessing care (A2).

3
Increased waiting time in laboratory due to only one investigation form was being used for haematology, microbiology & chemical pathology. Patients have to join long queues to photocopy and take a copy to each lab.
Not documented Notify printer to print separate forms for each lab unitwaiting time (B6).

4
Patients are unsure about the cost of investigation and have to look for additional funds when money is insufficient.

Not documented
Develop and paste laboratory investigation price listease of accessing care (B6).

5
Single phlebotomy point with patients needing to wait in long queues to have their blood sample taken.
Not documented Create multiple phlebotomy points with more than one phlebotomist at each pointwaiting time & ease of accessing care (A2).

6
Patients were often anxious/agitated because they did not understand that some test such as MCS take 3 days to culture.

Not documented
Communicate average duration of the investigation to each patient-ease of accessing care (B6).

7
Investigation results had to be typed before being released. Task shift certain roles to CHEWs such as checking vital signs, administering injection and dressing woundswaiting time (A4).

10
Patients go through a long process involving three visits before booking (register pregnancy) for ANC. The community members are not encouraged to attend the ANC clinics at the facility and may not come till delivery.

Facility register (B15)
Introduction of couples' clinic where couples are counselled on the importance of attending a recommended number of ANC clinics and husband is encouraged to donate blood voluntarily-ease of accessing care (B15) Health talks at out-patient clinics on the importance and process of registering pregnancy-ease of accessing care (B15) (C18)

11
Husband is expected to donate blood for ANC clients before registering pregnancy.

Facility register (B15)
Booking patients irrespective of whether they donated or not-ease of accessing care (B15).

12
Processes are expected to run sequentially such that one has to be completed before embarking on the next making it cumbersome Staff observation (B11) Allow the processes to run in parallel-ease of accessing care (B11).

13
Physicians were having to share a room for consultation, thereby compromising patient confidentiality & audiovisual privacy.
14 Need to improve patient involvement and participation in their health care delivery; strengthen the relationship with patients Patient complaint (C17) Develop a platform or leverage the QI committee to include one or more patients into the QI team or mini decision-making, e.g., patients-management forum-patients' dignity and staff-patient relationship (C17, C20 ).
Hospital to employ a customer service agent to identify and address patient needs and expectations-patients' dignity (C20) Train staff on patient rights and customer relations-patient dignity and staff-patient relationship (B3, B15) (C17, C18) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open Qual doi: 10.1136/bmjoq-2021-001532 :e001532.

15
Patients complained about poor staff attitude.

16
Poor level of cleanliness within the facility.
Water-logged toilets that were not regularly cleaned. Poor patient satisfaction due to poor state of the ward and environment. Untidy service areas because some housekeeping staff were not performing assigned duties. Patient wards were not conducive for habitation because of mosquitoes Patient satisfaction survey (B15, B17) Patient complaint (C20) Get management buy-in and advocate to them to address plumbing issues-clean and conducive environment (B15) Develop cleaning roster and supervisors should monitor compliance of cleaners-clean and conducive environment (B15) (C11). Constitute a committee to look into cleanliness of hospital environment -clean and conducive environment (B17) Renovate wards and clinics-clean and conducive environment (B17) (C17, C20) Caution erring housekeeping staff-clean and conducive environment (C20) A copy of housekeeper's job allocation and phone numbers should be pasted at each nursing station to know erring housekeepers-clean and conducive environment (C20). Train cleaners -clean and conducive environment (B8) Install electronic insect killer in the wards/periodic use of insectides in the ward -clean and conducive environment (C20) 17 Patients complained about the quality of food served. Plausible reasons included inadequate training of cools, no functional diet committee, non-availability of some equipment, lack of variety of meals, patients on special diets not enlightened

Patient complaint (B8) Staff observation (B8)
Train all cook-quality meals (B8) Place catering officers on weekend calls -quality meals (B6) Mandate catering officers to fill an attendance sheet to track compliance with weekend calls-quality meals (B6). Refurbish the kitchen and its call room-quality meals (B6).
Constitute a diet committee-quality meals (B6) Provide the requisite kitchen equipment, ingredients and utensils-quality meals (B6, B8). Develop and post a food menu that reflects variety-quality meals (B8) Enlighten patients on special diets (e.g., diabetics) that their meal may taste differentquality meals (B6). Assign someone to taste the food before it is served-quality meals (B8) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Not documented Institute monetary awards to best junior and senior staff that have been supportive of QI activities as well as compliance with standards of practice in the facility-staff welfare (C25).

2
Shortage of doctors in the facility as doctors often reject posting to the facility because of its remote location and poor state of the roads leading to the area.

Not documented
Renovate staff quarters to accommodate newly posted doctors to forestall the need to travel to workstaff welfare (B12).

3
To ensure continued commitment of QI team members.

Not documented
Giving of incentive to all QI members-staff welfare (B18)

4
Complaints that staff should have rights Not documented Staff rights should be written alongside patient rights-staff welfare (C20).
Develop a platform such as suggestion box where staff members can provide suggestions or complain -staff welfare (C20). 5 Lack of cordial relationship among staff with frequent disagreement between staff members.
Not documented Create a WhatsApp group for staff members to interact-staff welfare (C15).

6
Staff lateness was contributing to delay in attending to patients Not documented Provide staff attendance registers in all units to track staff punctuality-staff discipline (A2) (C15).
Institute staff disciplinary committee to review staff conduct and make recommendations-staff discipline (C20) Not documented Inventory taking should be done by a staff with requisite skills in stock taking-availability of commodities (C20).
Prompt reordering of drugs to prevent stockout -availability of commodities (C20).

4
The need for good Ambu bag as the available does not fit well with the oxygen connector.
Not documented Get a good Ambu bag and a connector to attach it to oxygen supply -availability of equipment (C15).
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open Qual doi: 10.1136/bmjoq-2021-001532 :e001532.

5
The need to promptly identify faulty equipment and repair accordingly as it was contributing to waiting time Not documented Send a memo to inform staff to document faulty equipment in their respective departmentsavailability of equipment (C20) Employ a facility manager to facilitate fixing/replacement of faulty equipment identified in the various departments-availability of equipment (C20) Meet with head of engineering to repair faulty equipment and install the new machineavailability of equipment (B6). 6 Inadequate number of vital sign equipment often means that nurses have to take turns to use the available equipment, consequently increasing waiting time Not documented Purchase more BP apparatus, weighing scale and thermometers -availability of equipment (A1)

7
Non-availability of wash hand basin with taps, no disposable hand towels to dry hands after washing to prevent the spread of infection Not documented Purchase more Veronica buckets with stands and bowls for handwashing -availability of equipment (A2) 8 Non-availability of running water during a power cut when the water pumping machine cannot be powered Not documented Purchase a storage tank to store pumped water such that water is available for longeravailability of utility (A3)

9
Inadequate power supply affecting service delivery Not documented Purchase a generator to power service units -availability of utility (A5) Purchase and use machines that don't rely on electricity-availability of equipment (A2).

10
Inadequate power supply making it difficult to power laboratory equipment.
Not documented Connect all lab equipment to facility generator-availability of utility (A5).
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open Qual doi: 10.1136/bmjoq-2021-001532 :e001532.