The hospitals have been enthusiastic about this process and the gains they have seen in the quality of care at their facilities. “We have made more progress in four months of the Hospital Management Improvement Initiative than we made in the previous five years with many other donors because this methodology is sound and appropriate for Afghanistan,” said Dr. Mohammed Ismael, the director of Ghazni Provincial Hospital.
One example of the process and results was the first area in which standards were developed—essential obstetric care. Physicians examined seven components of the quality of emergency obstetric care: handling of pregnancy complications; labor, delivery, and postpartum and newborn care; support services; infection prevention; health education given to families and mothers; human, physical, and material resources; and management systems in the obstetrics/gynecology department. After the standards were established, the first step was to find out where each hospital stood in meeting them. (For the combined results of that first baseline assessment for four hospitals, see Figure 1, p. 20.)
The changes in standards for emergency obstetric care at the hospitals from July 2004 to July 2005 have been impressive. The overall composite scores for emergency obstetric care for the four hospitals have improved from 31% at the baseline assessment to 47%. Here are the average improvements in the same four hospitals over one year:
The principal lesson learned through this hospital management improvement initiative is that combining clinical and management improvements can create innovation in a developing country. Improvements are made throughout a hospital—not just in one clinical area. Second, mentoring has proven essential as a follow-up to training. The training alone will not bring about significant positive changes. Only with on-site visitation is there the opportunity to integrate new knowledge with practical implementation issues that have proven troublesome to overcome. Third, setting standards is key to the sustainability of improvements. Training individuals in skills is helpful but is not sustainable if those trained staff depart. Using hospital teams and common standards throughout different hospitals leads to institutionalization of the process.
Staff motivation has also proven to be essential to sustainability. Staff have been motivated because they see that many positive changes are within their control; they do not have to wait for someone else to make an improvement before they can introduce positive change. An ethic of continuous quality improvement is achieved through staff who are proud of the changes they have introduced. The iterative nature of this process has been essential to quality improvement: The standards are continually revisited and revised as needed. At times, new standards for other areas are developed when the hospitals need them. Finally, providing resources to pay adequate salaries, renovate facilities, buy equipment and supplies, and provide essential medicines are all important elements of this success.
This method has proven successful in such a short time that the Minister of Public Health, Dr. Mohammad Amin Fatimie, has expressed his desire to extend it to many other hospitals in the country in an effort to improve the quality of hospital care throughout Afghani-stan. The U.S. Agency for International Development and MSH have agreed to support this request, and the program will expand in future years. TH
Dr. Hartman, is a family physician with subspecialty training in infectious diseases, epidemiology, and public health. He serves as the technical director and deputy chief of party of the REACH Project, based in Kabul. Dr. Newbrander is a health economist who has served in Afghanistan since 2002 as a senior advisor to the Ministry of Health. He is currently Health Financing and Hospital Management Advisor for the USAID-funded REACH Project.