A South African Medical Research Council (SAMRC) - led qualitative study recently published in PLOS ONE reports on the performance of Quality Improvement (QI) teams working in maternal and neonatal health in South Africa. The qualitative study was part of a mixed-methods evaluation of the effectiveness of the Mphatlalatsane Project, which sought to reduce maternal and neonatal deaths and stillbirths, improve mothers’ experience of care, and strengthen health services.
Mphatlalatsane was implemented by the National Department of Health (NDoH), between 2018 and 2022 in selected districts in the Eastern Cape, Limpopo, and Mpumalanga. Mphatlalatsane was a multi-component health system strengthening intervention, with implementation support from the Clinton Health Access Initiative, SAMRC/University of Pretoria Maternal and Infant Health Care Strategies Research Unit (SAMRC-UP), University of Limpopo Trust Initiative for Newborn Care (ULT) and the Institute for Healthcare Improvement (IHI). The evaluation of the project, commissioned by NDoH, was led Prof. Ameena Goga, Dr. Terusha Chetty and Prof. Helen Schneider, and funded by the SAMRC and ELMA Philanthropies.
Part of multi-component was to establish a QI programme for maternal and neonatal health (MNH) services in 21 public health facilities, seven in each participating province. QI teams were established and healthcare workers (HCWs) in participating facilities were trained on the Plan-Do-Study-Act QI model to improve their MNH services.
Dr Willem Odendaal, lead author of the qualitative paper, and Programme Manager at the Health Systems Research Unit and the HIV and Other Infectious Diseases Research Unit, SAMRC, said: “To my knowledge, Mphatlalatsane is the second MNH QI programme in South Africa that focused on health services beyond those specifically for mothers and babies living with HIV/AIDS.”
Study objectives
The qualitative study aimed to explore the perceptions and experiences of the Mphatlalatsane QI team leaders, team members, and advisors (who provided technical support to the teams), of how leaders, members, implementation processes, and facility contexts, shaped variation in QI uptake and team performance across the teams.
Study findings
Implementation processes and contextual variables make for well-performing QI teams
Mphatlalatsane confirmed that the global QI evidence on the ‘four pillars’ of QI programmes, process, context, leader skills, and teamwork, holds true in South Africa, even in the context of COVID-19. The evaluation found that a combination of implementation process and contextual variables, such as how leaders were selected and higher-level support to the teams, makes for a well-performing QI team. This research conceptualises a ‘life course lens’ for setting up and managing a QI team and identified good practices to optimise team performance. The two most impactful practices to optimise the performance of a QI team were:
- selecting HCWs with quality improvement-specific characteristics, for example, an aptitude to use routine data to identify service delivery gaps, and
- appointing advisors whose interpersonal skills match their technical QI competencies.
Leadership qualities needed for effective teams
Dr Odendaal and the research team concluded as follows: “For QI teams to work effectively, one needs a leader with an aptitude for data use and the ability to promote teamwork; who can create psychological safety for team members; and who is mentored by a trained advisor with sound interpersonal skills. Moreover, our findings suggest that a QI programme should start with focusing on the ‘hearts and minds’ of HCWs recruited into the programme: the leader should not by default be the most senior clinician, nor should the programme be set up in a context of disharmony amongst staff from whom members will be recruited.”
Implications
Dr Odendaal advised: “QI should be introduced to HCWs as a methodology that strengthens back-to-basics practices detailed in existing standard operating procedure, and not as an add-on to their existing scope of practice. This will secure HCW’s buy-in and to strengthen team performance. The good practices will serve as useful tool for decision makers and practitioners who plan to use QI to address shortcomings in MNH services, so that their central goal of improving the quality of care and patients' lives may ultimately be met.”