Exploring healthcare workers’ perceptions on the use of morbidity and mortality audits as an avenue for learning and care improvement in Kenyan hospitals’ newborn units

Abstract

Background In many sub-Saharan African countries, including Kenya, the use of mortality and morbidity audits in maternal and perinatal/neonatal care as an avenue for learning and improving care delivery is sub-optimal due to structural, organizational, and human barriers. While attempts to address these barriers have been reported, lots of emphasis has been paid to addressing the role of tangible inputs (e.g., availing guidelines and training staff in the success of mortality and morbidity audits), while process-related factors (i.e., the role of the people, their experiences, relationships, and motivations) remain inadequately explored. We examined the processes of neonatal audits, their potential in promoting learning from gaps in care and improving care delivery, with a deliberate focus on process-related factors that generally influence mortality and morbidity (M&M) audits. Methods This was an exploratory qualitative study, conducted in three hospitals, in Nairobi and Muranga counties. We employed a mix of in-depth interviews (17) and observation of 12 mortality and morbidity audit meetings. Our study participants included: nurses, doctors, trainee clinicians (i.e., junior doctors on internships), and nursing students involved in providing newborn care. These data were coded using NVivo12 employing a thematic content analysis approach. Results Perceived shortcomings in the conduct of M&M audits such as unclear structure was reported to have contributed to its sub-optimal nature in promoting learning. These shortcomings, in addition to hierarchy and power dynamics, poor implementation of audit recommendations, and negative experiences, (e.g., blame) also demotivated health workers from attendance and participation in audits. Despite these, positive outcomes linked to audit recommendations, such as revision of care protocols, were reported. Overall, leadership and a blame-free culture enabled positive changes and promoted learning from audit-identified modifiable factors. Conclusion Our findings indicate that M&M audits provide a space for meaningful discussions, which may lead to learning and improvement in care delivery processes. However, a lack of participation, lack of observed positive outcomes, and negative experiences may reduce their usefulness. An enabling environment characterized by minimized effects of hierarchy and positive use of power and a blame-free culture may promote active participation, enhancing positive relationships and interactions thus promoting team learning.

Maternal and perinatal death surveillance and response: a systematic review of qualitative studies

“…Learning from mistakes was a powerful behaviour-change mechanism mentioned by several respondents and was facilitated by a learning environment in the facility 47 and community-based review meetings. 35 Behaviour change was also motivated by the emotional experience of hearing the stories about the maternal and perinatal deaths and how these cases had been (mis)managed.…”

“…3 ), where people feel safe to honestly report deaths, disclose accurate information and openly discuss the cases, including any mistakes in their management. 47 , 53 , 56 , 74 Learning environments assure confidentiality, anonymity and separation from blame or any disciplinary process. Although several respondents recommended legal protection at the national level to prevent data from maternal and perinatal death surveillance and response being used in litigation, only South Africa had enacted this protection which “has been ratified by relevant judicial bodies.” 81 …”

“…Second, more research is needed to understand how to achieve the optimal balance between a blame-free anonymous process, while maintaining accountability. 47 Although WHO has suggested high-level strategies to minimize the blame culture, 5 , 84 challenges exist because a completely blame-free, anonymous process may also remove accountability and responsibility for implementing actions, 73 while a focus on accountability may instil fear of blame. 73 Completely removing blame from the maternal and perinatal death surveillance and response process is almost impossible, because negligence will be uncovered and will need to be tackled.…”

Moving beyond audit: driving system learning using a novel mortality classification system in a tertiary training hospital in Kenya

“…Reactive processes, especially when led by supervisors, tend to feel punitive-and the 'blame game' when things go wrong does not facilitate a healthy learning environment. 17 One advantage of the mortality classification system is that it gives a common language to all departments. In our experience at Kijabe where all departments meet every Friday and different departments share presenting their own data, the mortality classification mechanism promotes and supports a goal of collaborative learning across institutional departments, not just within the department.…”

Understanding intra- and interprofessional team and teamwork processes by exploring facility-based neonatal care in kenyan hospitals

“…With the silos broken, we observed more team cohesion and a shared drive for patient care and therefore more patient-centred care and more learning occurred, as demonstrated by initiatives taken by emergency teams in hospital Y, such as audits conducted within twenty hours of infant mortality, to primarily reflect on provided care and address any gaps in care [34].…”