Overcoming Obstacles to Clinical Quality of Care

Jim Rice

Former LMG Project Director
This is the first of a four-part series that will address four essential areas for health systems strengthening.

Staff from the Kapchorwa, Uganda STAR-E maternity facility.Photo: Rui Pires

Following a recent training for executive hospital leaders from Nigeria Hospitals, LMG Project director Dr. James A. Rice, participated in a day of discussions about the hospital of the future and strategies Nigerian hospitals and other low- and middle- income countries will want to consider for their future vitality and sustainability.

Four random groups of executives were invited to quickly identify important obstacles to:

  • Improve clinical quality
  • Enhance patient satisfaction
  • Increase efficiency (reduce costs)
  • Enhance stakeholder engagement

The following ten obstacles should be used by health leaders and hospital executives for discussions with their physician, nurses, staff and governing body about how best to implement sensible actions that could remove, reduce or work around each of the obstacles to improved clinical quality.

Obstacles to Improve Clinical Quality:

  1. Lack clear indicators and measure of world class quality, and we lack disciplined clinical care protocols for each medical specialty, procedure, or type of admission
  2. Lack patients who are ready, willing and able to demand quality from us
  3. Staff lack education and training about clinical care standards, and they have inadequate staff education and training about factors that lead to poor quality and actions to enhance quality
  4. Lack culture and work place environment that is enabling of good and continuously improving clinical quality because too many managers have leadership style that is authoritarian and dictatorial, and/or our physicians and governing body do not demand excellent quality.
  5. Lack properly designed facilities, technologies and purpose built care delivery systems
  6. Work environment lacks psychological safety to take risks for care innovations, and we have too much of a “blame culture” rather than a celebrate excellence culture
  7. Staff are unhappy and frustrated from bureaucracy, low pay, low praise from managers so are unwilling to improve
  8. Lack enough human resources to improve quality
  9. Managers do not know how to create climate for quality, and there is no accountability, consequences, or penalties if we fail to deliver quality
  10. Lack data and information to monitor quality trends by service/department

The key for health leaders to succeed in addressing a defined list of obstacles to health system strengthening is to take the list and get your team to discuss them, refine them, and then add to them. Then prioritize the list down to the top 3 to 5 and assign a small team to do something about each one. Develop practical actions that can yield positive results by reducing, removing or working around each of the top obstacles. These first set of actions will embolden hospital leaders and managers staff to try the next 3 to 5 obstacles on the list.

Three specific strategies that will help address these obstacles:

  1. Ask staff to conduct a three step review of the quality in each service/department by:
    1. Define in their own words the 2-3 most important ways to tell if a service is of excellent clinical quality;
    2. Ask them to candidly assess their service against these standards;
    3. Ask them how they could improve against these standards in the coming 3 months.
  2. Invite a team of physicians, nurses and allied health workers to take one department and define ideal clinical care standards for it for the coming year based on ideas from other hospitals or countries (see sources below). Provide time to develop the standards and recognize and reward them for implementing changes to meet or exceed these standards;
  3. Invest in training programs on clinical quality process improvement and team work.

Sources for ideas about clinical process improvement and standards can be found here:

Institute for Healthcare Improvement web portal is here: http://www.ihi.org/Pages/default.aspx

UK care standards may be found here: http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp