BackgroundAudit and feedback is an established strategy for improving maternal, neonatal and child health. The Perinatal Problem Identification Programme (PPIP), implemented in South African public hospitals in the late 1990s, measures perinatal mortality rates and identifies avoidable factors associated with each death. The aim of this study was to elucidate the processes involved in the implementation and sustainability of this programme.MethodsClinicians' experiences of the implementation and maintenance of PPIP were explored qualitatively in two workshop sessions. An analytical framework comprising six stages of change, divided into three phases, was used: pre-implementation (create awareness, commit to implementation); implementation (prepare to implement, implement) and institutionalisation (integrate into routine practice, sustain new practices).ResultsFour essential factors emerged as important for the successful implementation and sustainability of an audit system throughout the different stages of change: 1) drivers (agents of change) and team work, 2) clinical outreach visits and supervisory activities, 3) institutional perinatal review and feedback meetings, and 4) communication and networking between health system levels, health care facilities and different role-players.During the pre-implementation phase high perinatal mortality rates highlighted the problem and indicated the need to implement an audit programme (stage 1). Commitment to implementing the programme was achieved by obtaining buy-in from management, administration and health care practitioners (stage 2).Preparations in the implementation phase included the procurement and installation of software and training in its use (stage 3). Implementation began with the collection of data, followed by feedback at perinatal review meetings (stage 4).The institutionalisation phase was reached when the results of the audit were integrated into routine practice (stage 5) and when data collection had been sustained for a longer period (stage 6).ConclusionInsights into the factors necessary for the successful implementation and maintenance of an audit programme and the process of change involved may also be transferable to similar low- and middle-income public health settings where the reduction of the neonatal mortality rate is a key objective in reaching Millennium Development Goal 4. A tool for reflecting on the implementation and maintenance of an audit programme is also proposed.
Setting KwaZulu-Natal, South Africa a predominantly rural province with high burdens of TB, MDR-TB and HIV infection. Objective To determine the most effective model of care by comparing MDR-TB treatment outcomes at community-based sites with traditional care at a central, specialised hospital. Design A non-randomised observational prospective cohort study comparing community-based and centralised care. Patients at community-based sites were closer to home, had easier access to care and home-based care was available from treatment initiation. Results Four community-based sites treated 736 patients, while 813 were treated at the centralised hospital (a total of 1549 patients). Overall, 75% were HIV co-infected (community: 76% vs. hospitalised: 73%, p=0.45) and 86% received antiretroviral therapy (community: 91% vs. hospitalised: 82%, p=0.22). In multivariate analysis MDR-TB patients were more likely to have a successful treatment outcome if they were treated at a community-based site (adjusted OR=1.43, p=0.01). However, there was heterogeneity in outcomes at the four community-based sites, with Site 1 demonstrating that home-based care was associated with increased treatment success of 72% compared with success of between 52 - 60% at the other three sites. Conclusion Community-based care for patients with MDR-TB was more effective than care in a central, specialised hospital. Home-based care further increased treatment success.
BackgroundThe importance of clinical leadership in ensuring high quality patient care is emphasized in health systems worldwide. Of particular concern are the high costs to health systems related to clinical litigation settlements. To avoid further cost, healthcare systems particularly in High-Income Countries invest significantly in interventions to develop clinical leadership among frontline healthcare workers at the point of care. In Low-Income Countries however, clinical leadership development is not well established. This review of the literature was conducted towards identifying a model to inform clinical leadership development interventions among frontline healthcare providers, particularly for improved maternal and newborn care.MethodsA structural literature review method was used, articles published between 2004 and 2017 were identified from search engines (Google Scholar and EBSCOhost). Additionally, electronic databases (CINHAL, PubMed, Medline, Academic Search Complete, Health Source: Consumer, Health Source: Nursing/Academic, Science Direct and Ovid®), electronic journals, and reference lists of retrieved published articles were also searched.ResultsEmploying pre-selected criteria, 1675 citations were identified. After screening 50 potentially relevant full-text papers for eligibility, 24 papers were excluded because they did not report on developing and evaluating clinical leadership interventions for frontline healthcare providers, 2 papers did not have full text available. Twenty-four papers met the inclusion criteria for review. Interventions for clinical leadership development involved the development of clinical skills, leadership competencies, teamwork, the environment of care and patient care. Work-based learning with experiential teaching techniques is reported as the most effective, to ensure the clinical leadership development of frontline healthcare providers.ConclusionsAll studies reviewed arose in High-Income settings, demonstrating the need for studies on frontline clinical leadership development in Low-and Middle-Income settings. Clinical leadership development is an on-going process and must target both novice and veteran frontline health care providers. The content of clinical leadership development interventions must encompass a holistic conceptualization of clinical leadership, and should use work-based learning, and team-based approaches, to improve clinical leadership competencies of frontline healthcare providers, and overall service delivery.
Setting In KwaZulu-Natal, South Africa, a TB and HIV endemic setting, prolonged hospitalisation for the treatment of the growing number of MDR-TB patients is not possible or effective. Objective We compared early treatment outcomes in patients with MDR-TB, with and without HIV co infection, at a central, urban, referral hospital with four decentralised rural sites. Design This is an operational, prospective cohort study of patients between 1 July 2008 to 30 November 2009, where culture conversion, time-to-culture-conversion, survival and predictors of these outcomes were analysed. Results Of the 860 patients with MDR-TB, 419 were at the decentralised sites and 441 at the central hospital. Overall, 71% were HIV co-infected. In the 17 month study period, there was a higher proportion of culture conversion at the decentralised sites compared with the centralised hospital (54% vs. 24%; P<0.001; Odds Ratio 3.76, 95% CI 2.81 – 5.03). The median time to treatment initiation was significantly shorter at the decentralised sites compared with the centralised hospital (72 vs 93 days; p<0.001). There was no significant difference in survival following treatment initiation. Conclusion This study shows that early treatment outcomes suggest that decentralised care for MDR-TB patients is superior to that in a centralised setting.
IntroductionPoor patient outcomes in South African maternal health settings have been associated with inadequately performing health care providers and poor clinical leadership at the point of care. While skill deficiencies among health care providers have been largely addressed, the provision of clinical leadership has been neglected. In order to develop and implement initiatives to ensure clinical leadership among frontline health care providers, a need was identified to understand the ways in which clinical leadership is conceptualized in the literature.DesignUsing the systematic quantitative literature review, papers published between 2004 and 2016 were obtained from search engines (Google Scholar and EBSCOhost). Electronic databases (CINHAL, PubMed, Medline, Academic Search Complete, Health Source: Consumer, Health Source: Nursing/Academic, ScienceDirect and Ovid®) and electronic journals (Contemporary Nurse, Journal of Research in Nursing, Australian Journal of Nursing and Midwifery, International Journal of Clinical Leadership) were also searched.ResultsUsing preselected inclusion criteria, 7256 citations were identified. After screening 230 potentially relevant full-text papers for eligibility, 222 papers were excluded because they explored health care leadership or clinical leadership among health care providers other than frontline health care providers. Eight papers met the inclusion criteria for the review. Most studies were conducted in high-income settings. Conceptualizations of clinical leadership share similarities with the conceptualizations of service leadership but differ in focus, with the intent of improving direct patient care. Clinical leadership can be a shared responsibility, performed by every competent frontline health care provider, regardless of the position in the health care system.ConclusionConceptualizations of clinical leadership among frontline health care providers arise mainly from high-income settings. Understanding the influence of context on conceptualizations of clinical leadership in middle- and low-income settings may be required.
BackgroundIntegrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under-5 years by improving management of common illnesses at primary level. IMCI has been shown to improve health worker performance, but constraints have been identified in achieving sufficient coverage to improve child survival, and implementation remains sub-optimal. At the core of the IMCI strategy is a clinical guideline whereby health workers use a series of algorithms to assess and manage a sick child, and give counselling to carers. IMCI is taught using a structured 11-day training course that combines classroom work with clinical practise; a variety of training techniques are used, supported by comprehensive training materials and detailed instructions for facilitators.MethodsWe conducted focus group discussions with IMCI trained health workers to explore their experiences of the methodology and content of the IMCI training course, whether they thought they gained the skills required for implementation, and their experiences of follow-up visits.ResultsHealth workers found the training interesting, informative and empowering, and there was consensus that it improved their skills in managing sick children. They appreciated the variety of learning methods employed, and felt that repetition was important to reinforce knowledge and skills. Facilitators were rated highly for their knowledge and commitment, as well as their ability to identify problems and help participants as required. However, health workers felt strongly that the training time was too short to acquire skills in all areas of IMCI. Their increased confidence in managing sick children was identified by health workers as an enabling factor for IMCI implementation in the workplace, but additional time required for IMCI consultations was expressed as a major barrier. Although follow-up visits were described as very helpful, these were often delayed and there was no ongoing clinical supervision.ConclusionThe IMCI training course was reported to be an effective method of acquiring skills, but more time is required, either during the course, or with follow-up, to improve IMCI implementation. Innovative solutions may be required to ensure that adequate skills are acquired and maintained.
BackgroundAn integrated chronic disease management (ICDM) model consisting of four components (facility reorganisation, clinical supportive management, assisted self-supportive management and strengthening of support systems and structures outside the facility) has been implemented across 42 primary health care clinics in South Africa with a view to improve the operational efficiency and patient clinical outcomes.AimThe aim of this study was to assess the sustainability of the facility reorganisation and clinical support components 18 months after the initiation.SettingThe study was conducted at 37 of the initiating clinics across three districts in three provinces of South Africa.MethodsThe National Health Service (NHS) Institute for Innovation and Improvement Sustainability Model (SM) self-assessment tool was used to assess sustainability.ResultsBushbuckridge had the highest mean sustainability score of 71.79 (95% CI: 63.70–79.89) followed by West Rand Health District (70.25 (95% CI: 63.96–76.53)) and Dr Kenneth Kaunda District (66.50 (95% CI: 55.17–77.83)). Four facilities (11%) had an overall sustainability score of less than 55.ConclusionThe less than optimal involvement of clinical leadership (doctors), negative staff behaviour towards the ICDM, adaptability or flexibility of the model to adapt to external factors and infrastructure limitation have the potential to negatively affect the sustainability and scale-up of the model.
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