A critical analysis of discovery health's claims-based risk adjustment of mortality rates in South African private sector hospitals

In 2019, Discovery Health published a risk adjustment model to determine standardised mortality rates across South African private hospital systems, with the aim of contributing towards quality improvement in the private healthcare sector. However, the model suffers from limitations due to its design and its reliance on administrative data. The publication's aim of facilitating transparency is unfortunately undermined by shortcomings in reporting. When designing a risk prediction model, patient-proximate variables with a sound theoretical or proven association with the outcome of interest should be used. The addition of key condition-specific clinical data points at the time of hospital admission will dramatically improve model performance. Performance could be further improved by using summary risk prediction scores such as the EUROSCORE II for coronary artery bypass graft surgery or the GRACE risk score for acute coronary syndrome. In general, model reporting should conform to published reporting standards, and attempts should be made to test model validity by using sensitivity analyses. In particular, the limitations of machine learning prediction models should be understood, and these models should be appropriately developed, evaluated and reported.

Developing and prioritising strategies to improve the implementation of maternal healthcare guidelines in South Africa: The nominal group technique

Background: In South Africa, maternal healthcare guidelines are distributed to primary health care (PHC) facility for midwives to refer and implement during maternal healthcare services. Different training was offered for the use of maternal care guidelines. However, poor adherence and poor implementation of guidelines were discovered. Aim: This study aimed to develop and prioritise strategies to improve the implementation of maternal healthcare guidelines at PHC facilities of Limpopo province, South Africa. Method: Strengths, weaknesses, opportunities and threats analysis and its matrix together with the nominal group technique were used to develop the current strategy. Midwives, maternal, assistant and operational managers from PHC facilities of the two selected district of the Limpopo province were selected. Criterion-based purposive sampling was used to select participants. Data collection and analysis involved the four steps used in the nominal group technique. Results: Strategies related to strengths and weaknesses such as human resources, maternal health services and knowledge deficit were identified. Opportunities and threats such as availability of guidelines, community involvement and quality assurance as factors that influenced the provision of maternal healthcare services were identified. Conclusion: Researchers formulated actions that could build on identified strengths, overcome weaknesses such as human resources, explore opportunities and mitigate the threats such as quality assurance

Improving the quality of care for female rape survivors at Scottish Livingstone Hospital, Molepolole, Botswana: a quality improvement cycle

Background: Rape is prevalent in Botswana, but there has been limited research undertaken to improve the quality of healthcare for female rape survivors in this clinical setting. Research can not only influence the health outcomes of victims but also has the potential to inform policy. Aim: The aim of this study was to improve the quality of care for female rape survivors in Scottish Livingstone Hospital, Molepolole, Botswana. Setting: The setting is Scottish Livingstone Hospital, Molepolole, Botswana. Methods: This study was a qualitative cycle, using the normal steps of performing a baseline audit of clinical practice, planning and implementing changes and re-audit. Results: A total of 124 patient records were audited, comprising 62 patient records at baseline and re-audit. The mean age of victims was 23 years and the age category with the highest incidence of rape ranged between 12 and 20 years, constituting 47% of patients' records. During the baseline audit, only one out of 10 structural standards was met, while at re-audit eight structural standards were fully met. Although none of the process standards were met during both audits, statistically significant improvements in performance (p < 0.05) were shown in six out of 10 criteria at re-audit. Conclusion: The quality of care for female rape survivors is suboptimal in our setting. However, simple interventions to improve the structure in place for patients and upskilling the entire practice team to align care to current international standards can improve the overall quality of healthcare

Assessment practices in undergraduate clinical medicine training: what do we do and how we can improve?

Background: Assessment should form an integral part of curriculum design in higher education and should be robust enough to ensure clinical competence. Aim: This article reports on current assessment practices and makes recommendations to improve clinical assessment in the undergraduate medical programme at the University of the Free State. Methods: A descriptive cross-sectional study design was used. Qualitative and quantitative data were gathered by means of open- and closed-ended questions in a self-administered questionnaire, which was completed by teaching and learning coordinators in 13 disciplines. Results: All disciplines in the undergraduate medical programme are represented. They used different assessment methods to assess the competencies required of entry-level healthcare professionals. Workplace-based assessment was performed by 30.1% of disciplines, while multiple-choice questions (MCQs) (76.9%) and objective structured clinical examinations (OSCEs) (53.6%) were the main methods used during formative assessment. Not all assessors were well prepared for assessment, with 38.5% never having received any formal training on assessment. Few disciplines (15.4%) made use of post-assessment moderation as a standard practice, and few disciplines always gave feedback after assessments. Conclusion: The current assessment practices for clinical students in the undergraduate medical programme at the University of the Free State cover the spectrum that is necessary to assess all the different competencies required. Multiple-choice questions and OSCEs, which are valid and reliable assessment methods, are used frequently. Poor feedback and moderation practices should be addressed. More formative assessments, and less emphasis on summative assessment, should be considered. Workplace-based and continuous assessments may be good ways to assess clinical competence

CLEVER maternity care: a before-and-after study of women's experience of childbirth in Tshwane, South Africa

Background: Birthing care matters to women and some women experience mistreatment during childbirth. Aim: To determine the effect the 'CLEVER Maternity Care' package, a multi-faceted intervention to improve respectful, quality obstetric care. Setting: Ten midwife-led obstetric units in Tshwane health district, South Africa; five intervention and five control units. Methods: We conducted an anonymous baseline and end-line survey to measure the change in women's perceptions and experiences of childbirth care after the implementation of the CLEVER package. A convenience sample of women returning for a postnatal follow-up visit was obtained at baseline (n = 653) and after implementation of CLEVER (n = 679). Results: Six survey items were selected as proxies for respectful clinical care. There was no significant change in proportions of responses regarding one question, and with regard to patients receiving attention within 15 min of arrival, both the intervention and control group units showed a significant increase in positive responses (odds ratios of 8.4 and 6.1, respectively, and p values of 0.0001 and 0.0007). For the remaining four items (asking permission before doing an examination, positive communication, respectful treatment and overall satisfaction), only the intervention group showed a significant positive change (odds ratios ranging from 2.4 to 4.3; p ≤ 0.0018), with no significant change for the control group (odds ratios between 1.0 and 1.8; p ≥ 0.0736). Conclusion: After the implementation of CLEVER Maternity Care, women reported a more positive experience of childbirth. The CLEVER intervention is a potential strategy for addressing respectful, quality obstetric care that warrants further investigation

Challenges around COVID-19 at a tertiary-level healthcare facility in South Africa and strategies implemented for improvement

SARS-CoV-2 has resulted in a global pandemic within months following its initial detection. South Africa (SA), like many other countries, was not prepared for the impact this novel infection would have on the healthcare system. In this paper, the authors discuss the challenges experienced while facing COVID-19 at a tertiary-level institution in Gauteng province, SA, and the dynamic strategies implemented to deal with the epidemic

Challenges of quality improvement in the healthcare of South Africa post-apartheid: A critical review

There is overwhelming evidence that the quality of health care in South Africa has been compromised by various challenges that impact negatively on healthcare quality. Improvement in quality care means fewer errors, reduced delays in care delivery, improvement in efficiency, increased market share and lower cost. Decline in quality health care has caused the public to lose trust in the healthcare system in South Africa.Objectives: The purpose of this study was to identify challenges that are being incurred in practice that compromise quality in the healthcare sector, including strategies employed by government to improve the quality of health delivery.Method: Literature search included the following computer-assisted databases and bibliographies: Medline (Medical Literature Online), EBSCOhost, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google, Google Scholar and ScienceDirect. Furthermore, websites were used to source policy documents of organisations such as the National Department of Health in South Africa and the World Health Organization.Results: Seventy-four articles were selected from 1366 retrieved. These articles quantify problems facing quality care delivery and strategies used to improve the healthcare system in South Africa.Conclusion: The findings revealed that there were many quality improvement programmes that had been initiated, adapted, modified and then tested but did not produce the required level of quality service delivery as desired. As a result, the Government of South Africa has a challenge to ensure that implementation of National Core Standards will deliver the desired health outcomes, because achieving a lasting quality improvement system in health care seems to be an arduous challenge

External quality assessment on CD4+ T-Cell Count using in-house proficiency testing panels for CD4 Count laboratories in Addis Ababa, Ethiopia

BACKGROUND: CD4+ T-cell count External Quality Assessment program is important for the evaluation of performance of CD4 count laboratories. The aim of this study was to assess the quality of CD4count laboratory performance using in-house Proficiency testing panels that perform routineCD4 counts in Addis Ababa, Ethiopia, 2013/14. METHODS: Participating laboratories were 20, 23 and 25 in trials 1, 2 and 3, respectively. In-house prepared fresh whole blood samples both with "normal" and "low" CD4 values were sent to participating laboratories. Percentage and absolute counts of CD4+ T-lymphocytes were done using their routine procedures. Data were analyzed for each trial including trimmed mean, standard deviation (SD), percent coefficient of variation (%CV), residual, and standard deviation index (SDI) values for both absolute counts and percentages of CD4+ lymphocytes (%CD4). RESULTS: Most participating laboratories produced results that were within 2SD of the mean. Average inter-laboratory precision (trimmed %CV) was 10.87% and 5.14% for CD4 absolute counts and %CD4, respectively. For normal material, the trimmed mean %CV was 9.59% and3.23% for CD4 absolute counts and %CD4, respectively. For low material, the trimmed mean % CV was 12.15% and 7.05% for CD4 absolute counts and %CD4 respectively. BDFACSCount™ users showed the best accuracy and precision as evidenced by longitudinal analysis. CONCLUSION: This study was found to help facilities in early identifying their gaps with regard to their CD4 count performance and in avoiding the challenges encountered during participation in external EQA providers like the high cost, transportation problem, feedback delay and CD4laboratory coverage

Improving voluntary medical male circumcision standards adherence and post-procedure follow-up in Uganda: A mixed methods study

Voluntary medical male circumcision (VMMC) has been demonstrated to reduce the transmission of HIV by 60%. Scaling up VMMC services requires that they be of high quality, socially accepted, and effective. We evaluated an intervention aimed at improving VMMC standards adherence and patient follow-up rates in nine facilities in Uganda. We also qualitatively explored why some men return for follow-up care and others do not. The completeness and quality of clinical documentation was poor at baseline, but significantly improved at endline. We observed significant improvements in management systems; supplies, equipment, and environment; and monitoring and evaluation. Due to the volume of missing data, results were less clear for registration, group education, and information, education and communication; individual counselling and HIV testing; and infection prevention. Significant improvements were also observed in follow-up rates at 48 hours and 7 days, and 6 weeks. Interviews revealed the importance of peers, including female partners, in deciding to get circumcised and in seeking follow-up care. Among the men who did not return for follow-up services, most reported they had no problems and did not see it as necessary. For those who did have mild or moderate adverse events, follow-up care was often sought at a facility closer to the patients' home rather than the circumcising facility. However, information systems were unable to capture this. Applying improvement approaches to VMMC services can promote improved standards adherence and follow-up rates and should be integrated into scale-up plans

Implementation of the world health organization regional office for africa stepwise laboratory quality improvement process towards accreditation

Background: The increase in disease burden has continued to weigh upon health systems in Africa. The role of the laboratory has become increasingly critical in the improvement of health for diagnosis; management and treatment of diseases. In response; the World Health Organization Regional Office for Africa (WHO AFRO) and its partners created the WHO AFRO Stepwise Laboratory (Quality) Improvement Process Towards Accreditation (SLIPTA) program.SLIPTA implementation process: WHO AFRO defined a governance structure with roles and responsibilities for six main stakeholders. Laboratories were evaluated by auditors trained and certified by the African Society for Laboratory Medicine. Laboratory performance was measured using the WHO AFRO SLIPTA scoring checklist and recognition certificates rated with 1-5 stars were issued. Preliminary results: By March 2015; 27 of the 47 (57%) WHO AFRO member states had appointed a SLIPTA focal point and 14 Ministers of Health had endorsed SLIPTA as the desired programme for continuous quality improvement. Ninety-eight auditors from 17 African countries; competent in the Portuguese (3); French (12) and eng (83) languages; were trained and certified. The mean score for the 159 laboratories audited between May 2013 and March 2015 was 69% (median 70%; SD 11.5; interquartile range 62-77). Of these audited laboratories; 70% achieved 55% compliance or higher (2 or more stars) and 1% scored at least 95% (5 stars). The lowest scoring sections of the WHO AFRO SLIPTA checklist were sections 6 (Internal Audit) and 10 (Corrective Action); which both had mean scores below 50%.Conclusion: The WHO AFRO SLIPTA is a process that countries with limited resources can adopt for effective implementation of quality management systems. Political commitment; ownership and investment in continuous quality improvement are integral components of the process

Improving quality in national reference laboratories: the role of SLMTA and mentorship

Background: The Nigerian Institute of Medical Research houses two reference laboratories: the virology and tuberculosis laboratories. Both were enrolled in the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme. Objective: To describe the impact of SLMTA and discuss factors affecting the results; with an emphasis on mentorship Methods: The SLMTA programme was implemented from April 2010 through November 2012. Participants attended three workshops and executed quality improvement projects; laboratory auditors evaluated performance using a standard checklist. The virology laboratory did not receive mentorship; however; the tuberculosis laboratory had an international mentor who visited the laboratory four times during the programme; spending two to four weeks embedded within the laboratory during each visit. Results: There was an overall improvement in the performance of both laboratories; with the virology laboratory increasing 13% (from 80% at baseline to 93% at exit audit) and the tuberculosis laboratory increasing 29% (from 66% to 95%). These scores were maintained nine months later at the surveillance audit. Conclusion: The SLMTA programme resulted in improved and sustained quality management performance for both laboratories. Mentoring was a possible factor in the substantial improvement made by the tuberculosis laboratory and should be considered in order to augment the training received from the SLMTA workshops

Innovative strategies for a successful SLMTA country programme: the Rwanda story

Background: In 2009; to improve the performance of laboratories and strengthen healthcare systems; the World Health Organization Regional Office for Africa (WHO AFRO) and partners launched two initiatives: a laboratory quality improvement programme called Strengthening Laboratory Management Toward Accreditation (SLMTA); and what is now called the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA). Objectives: This study describes the achievements of Rwandan laboratories four years after the introduction of SLMTA in the country; using the SLIPTA scoring system to measure laboratory progress.Methods: Three cohorts of five laboratories each were enrolled in the SLMTA programme in 2010; 2011 and 2013. The cohorts used SLMTA workshops; improvement projects; mentorship and quarterly performance-based financing incentives to accelerate laboratory quality improvement. Baseline; exit and follow-up audits were conducted over a two-year period from the time of enrolment. Audit scores were used to categorise laboratory quality on a scale of zero ( 55%) to five (95% - 100%) stars. Results: At baseline; 14 of the 15 laboratories received zero stars with the remaining laboratory receiving a two-star rating. At exit; five laboratories received one star; six received two stars and four received three stars. At the follow-up audit conducted in the first two cohorts approximately one year after exit; one laboratory scored two stars; five laboratories earned three stars and four laboratories; including the National Reference Laboratory; achieved four stars.Conclusion: Rwandan laboratories enrolled in SLMTA showed improvement in quality management systems. Sustaining the gains and further expansion of the SLMTA programme to meet country targets will require continued programme strengthening

Medical education and the quality improvement spiral: a case study from Mpumalanga, South Africa

Background: The short timeframe of medical students' rotations is not always conducive to successful; in-depth quality-improvement projects requiring a more longitudinal approach.Aim: To describe the process of inducting students into a longitudinal quality-improvement project; using the topic of the Mother- and Baby-Friendly Initiative as a case study; and to explore the possible contribution of a quality-improvement project to the development of student competencies.Setting: Mpumalanga clinical learning centres; where University of Pretoria medical students did their district health rotations.Method: Consecutive student groups had to engage with a hospital's compliance with specific steps of the Ten Steps to Successful Breastfeeding that form the standards for the Mother- and Baby-Friendly Initiative. Primary data sources included an on-site PowerPoint group presentation (n = 42); a written group report (n = 42) and notes of individual interviews in an end-of-rotation objectively structured clinical examination station (n = 139). Results: Activities in each rotation varied according to the needs identified through the application of the quality-improvement cycle in consultation with the local health team. The development of student competencies is described according to the roles of a medical expert in the CanMEDS framework: collaborator; health advocate; scholar; communicator; manager and professional. The exposure to the real-life situation in South African public hospitals had a great influence on many students; who also acted as catalysts for transforming practice.Conclusion: Service learning and quality-improvement projects can be successfully integrated in one rotation and can contribute to the development of the different roles of a medical expert. More studies could provide insight into the potential of this approach in transforming institutions and student learning

The impact of brief quality improvement (QI) projects by medical students in primary care in Gauteng or the North West Province, South Africa

Background: The Integrated Primary Care (IPC) rotation is undertaken over six weeks by final year medical students at the University of Witwatersrand. Students are placed in either rural or urban primary health care centres based in Gauteng or the North West Province. As part of the IPC rotation; students undertake short quality improvement (QI) projects. The purpose of this study is to evaluate the impact of the QI projects undertaken over the period stretching from 2006 to 2010. Methods: An observational study of QI reports done by students. Project reports assessed and compared to site marks; indicators of learning assessed and individual and group marks compared. Results: Of 274 projects undertaken; 223 (81.4) were available for evaluation. Geographical placements and QI themes were categorised. Management issues were most frequently identified as being problematic followed by chronic illnesses. Understanding and applying the principles of QI was partially achieved and gaps were identified for future projects. The most common intervention was training of personnel and design and distribution of posters or pamphlets. Conclusions: Most QI projects were well thought out and relevant to the chosen setting. In the majority of cases; a great deal of effort and creativity went into the process and skills other than clinical skills were employed such as writing; presentation of data in graphs and tables. Integration of theory and practice was achieved only partially

Adequacy of Pain Management in HIV-Positive Patients

"Background: A growing body of literature supports the view that people infected with HIV suffer significant pain and that pain is not well recognised or managed by health care professionals. This study investigated the prevalence; severity; recognition and management of pain in adult patients with HIV infection in a South African hospital setting. Methods: The Brief Pain Inventory (BPI) (short form) questionnaire was administered to 100 consecutive; consenting HIV positive patients admitted to an urban district-level hospital in KwaZulu-Natal. Convenience sampling was employed with participants recruited on consecutive days. Data sources comprised patient interviews and review of hospital records. A Pain Management Index derived from the BPI was calculated to establish the adequacy of pain management. Descriptive statistics were tabulated for the recognition of pain; pain severity and appropriateness of analgesia. Correlation analyses were used to assess the association between pain and daily life. Results: Ninety-one per cent of participants reported pain with 83 experiencing significant pain; in other words a ""worst pain"" rating of five or above on the BPI (short form) questionnaire. The correlation analysis between the severity of pain and its interference with daily life suggests that moderate and severe pain interferes with the patients' daily functioning. Pain was documented on 71 of the patients' medical charts that were reviewed; however; only 34 were considered to be adequately managed for their pain. Conclusion: Pain prevalence is high in the sample. While pain was recognised and noted in the majority of patients' medical records; the management of pain was considered to be inadequate in a third of those experiencing pain."

An Evaluation of a Refresher Training Intervention for HIV Lay Counsellors in Chongwe District; Zambia

To address a severe shortage of human resources for health; the Zambian Ministry of Health has begun to make use of lay counsellors for HIV counselling and testing. However; their skills and knowledge rarely have been reviewed or refreshed. We conducted a two-day refresher workshop for lay counsellors to review their performance and refresh their skills and knowledge. The objective of this study was to evaluate the refresher training intervention for HIV lay counsellors in the rural district of Chongwe in Zambia. The two-day refreshertraining workshop was held in November 2009. Twenty-five lay counsellors were selected by District Health Office and participated in the workshop. The workshop included: the opening; a pre-training exercise; lectures on quality assurance with regard to testing and safety precautions; lectures on counselling; filling the gap/QetA session; and a post-training exercise. In both the pre- and post-trainingexercise; participants answered 25 true/false questions and tested 10 blood panel samples to demonstrate their knowledge and skill on HIV counselling and testing. The average overall knowledge test score increased from 79 to 95 (p0.001). At the baseline; knowledge test scores in topic of standard precaution and post-exposure prophylaxis were relatively low (58) but rose to 95 after the training (p0.001). The per cent agreement of HIV testing by lay counsellors with reference laboratory was 99.2. Participants' knowledge was improved during the workshop and skill at HIV testing was found to remain at a high level of accuracy. Relatively weak knowledge of standard precautions and post-exposure prophylaxis suggests that lay counsellors are at risk of nosocomial infections; particularly in the absence of refresher training interventions. We conclude that the refresher training was effective for improving the knowledge and skills of lay counsellors and provided an opportunity to monitor their performance

Scaling up community-based services and improving quality of care in the state psychiatric hospitals: the way forward for Ghana

Objective: This paper aims to explore the options available for developing community-based care and improving the quality of care in psychiatric hospitals in Ghana. Method: Semi-structured interviews (SSIs) and focus group discussions (FGDs) were conducted with a cross-section of stakeholders including health professionals; researchers; policy makers; politicians; users and carers. The SSIs and FGDs were recorded digitally and transcribed verbatim. Apriori and emergent themes were coded and analysed with NVivo version 7.0; using a framework analysis. Results: Psychiatric hospitals in Ghana have a mean bed occupancy rate of 155. Most respondents were of the view that the state psychiatric hospitals were very congested; substantially compromising quality of care. They also noted that the community psychiatric system was lacking human and material resources. Suggestions for addressing these difficulties included committing adequate resources to community psychiatric services; using psychiatric hospitals only as referral facilities; relapse prevention programmes; strengthening psychosocial services; adopting more precise diagnoses and the development of a policy on long-stay patients. Conclusion: There is an urgent need to build a credible system of community-based care and improve the quality of care in psychiatric hospitals in Ghana

Interaction of Continuing Professional Development; Organizational Culture and Performance in Health Service Organizations: a Concept Paper

Whereas Continuing Professional Development (CPD) has been acknowledged as a tool for improving performance through updating and widening of professionals' knowledge and skills; there is no concrete evidence to support this claim. Recent studies on this subject have either shown contradicting evidence or remained utterly inconclusive posing an empirical dilemma. This paper posits that CPD is highly context-dependent and therefore best supports performance where a positive organisational culture plays a moderating role. The paper aims to provide a framework that can be used to analyse the interplay between CPD; organisational culture and performance. It is argued that for CPD to support performance there is need for a culture that is adaptive and receptive to learning; change; innovation and performance improvement