Quality and Safety Management of Health Care Service Delivery among Public Hospitals in Rwanda: a Cross-Sectional Survey

Background of the study

Quality and safety of health care services delivery is an important global health concern. Patients experiencing adverse events result in 23 million Disability Adjusted Life Years (DALYs) lost annually. Lack of patient safety includes harm from inpatient adverse events such as medication errors, hospital- acquired infections, foreign body left in body during surgical procedure, etc.^1,2 Research shows that the way hospitals are managed can influence the quality and safety of health care services.³ Hospital management comprises strategic plan, data- centered activities, quality improvement measures, implementation of policies and procedures related to quality and safety standards, tracking changes, and providing feedback. However, there is insufficient engagement of hospital management efforts to improve the quality of health care services delivery.⁴

Low quality and unsafe delivery of health care in hospitals are likely to be caused by diagnostic errors and inappropriate medical procedures. This, in turn, can lead to injury, permanent harm, and adjust the natural history of a disease.⁵ One study demonstrated that incorrect diagnoses were given at first to 87% of individuals with fibrodysplasia ossification progressiva (FOP).⁵ In the same vein, the safety of patients in U.S. hospitals is a critical issue, medical errors affecting a significant portion of admitted patients. Adverse events were found in 56% of the reviewed records of six Belgian Hospitals for unexpected referrals to the Intensive Care Unit or an inpatient medical emergency, of which practically half were considered highly preventable.⁶

Quality and safety of health care services is essential for health care effectiveness and efficiency as recognized by the World Health Organization's (WHO) agenda for health care reinforcement in Low and Middle Income Countries (LMICs).⁷ Even if current practices that refine quality health care are progressively used worldwide, their implementation is a challenge in developing countries.⁷

WHO patient safety resolution (WHA55.18) established the World Alliance for Patient safety by Secretariat in 2004; the program was renamed in 2009 as World Health Organization's Patient Safety Program.⁸ Since that time, the WHO has worked hard to address the challenges of quality and safety of health care services delivery. For example, in 2011, the WHO Director General renewed momentum for patient safety with a five-year strategy encompassing the following strategic objectives:

(1) to give worldwide authority for patient safety; (2) to harness knowledge, expertise and innovation to improve patient safety; and (3) to connect with health care systems, nongovernmental organizations, civil society and the expert community in the global endeavor of making medicinal services more safer.⁸

Rwanda, like many low- and middle-income countries (LMICs), pursues health care reforms in order to achieve universal health coverage (UHC). The advancement of national accreditation frameworks has become a quality system supported by payers, including Ministries of Health (MOH) and has made much progress in health care quality improvement.⁹ Three million Rwandans live in rural areas with accessibility to health facility within a distance of five (5) kilometers from their homes which results in increased access to health care services.¹⁰

The Rwanda Ministry of Health and all stakeholders have improved the health status of the population within five years since 2005. This was after the launch of the nation's Health Sector Strategic Plan which resulted in a blend of vigorous national ownership; an execution based condition with common responsibility at all dimensions; and a groundbreaking community based health insurance (CBHI) system across the country with an enrollment of 91% which increased the health care services's accessbility.¹¹

Similalry, Rwanda has made a lot of progress in rebuilding its health sector in the last 22 years; and by 2015, it had met almost all the Millenium Development Goals health indicators.¹² Health care system accreditation in Rwanda started with the University Teaching Hospitals, facilitated by Council of Health Care Service Accreditation of Southern Africa (COHSASA) in 2006, after which MOH started implementing the accreditation policy into district hospitals with their critical and core standards.¹³ The leadership and management support are crucial for improving quality and patient safety, given that strong leadership is important in making and continuing an organizational culture that underpins quality care delivery. Rwanda MOH called on all hospitals to improve quality of health care services delivery and consider the demand and supply of health care services to meet the the population needs.¹³ Accreditation is key to enhancing quality and safety of health care delivery system.¹⁴

Objectives of the study

The objective of this study was to examine the status of quality and safety management of health care service delivery among public hospitals in Rwanda. The specific aims were to: (1) establish the occurrence and factors that contribute to preventable adverse events in public hospitals; (2) determine quality and safety measures put in place for maintaining quality and safety of health care services delivery among public hospitals; (3) explore the needs and priorities for health care services improvement among public hospitals; and (4) explore the managerial aspects associated with patient-centered care and safety culture. Findings from this study will be useful for researchers, government, health care providers, and general public. The results will help health care providers to identify various ways to improve quality and safety of health care services delivered across Rwandan health care delivery systems.

Study variables

The researcher used Google form to design an email-based questionnaire with detailed variables of information to be collected into a Google spreadsheet as raw data. The questionnaire was divided into four categories: (1) Biography of respondents and their hospital settings, (2) Quality of health care service delivery, (3) Safety of health care services, and (4) Management of quality and safety of clinical services. The independent variables consist of biography of respondents, health facility descriptions, and quality and safety management; the intervening variables were accreditation and health care strategies; and the outcome variables were quality and safety of health care services delivery.

Statistical analysis

We conducted multivariable and logistic regression analyses. All analyses were performed using the Statistical Package for Social Sciences (SPSS), version 21 (IBM Corporation, 2017). For statistical tests, a p-value of <0.05 was considered to be statistically significant with 95% confidence interval [95% CI].

Ethical approval

The proposal was submitted for and received approval by the following: Institutional Review Board of Mount Kenya University, National Health Research Committee, Mount Kenya University, and Ministry of Health. The study followed the basic ethical principles, respected the research participants, and participation in the study was voluntary with informed consent. The study maintained confidentiality of private information and the study participants were informed of the study prior to data collection. Written informed consent was obtained from all study participants.

Sociodemographic characteristics of study participants

Managers from all provinces in Rwanda participated in the study with a slight difference in number of respondents. The percent of participants in the study included 23.9% from Kigali City; 20.9% from Northern Province; 19.2% equally from Southern and Western Provinces; and 16.7% from Eastern Province.

Most of the respondents were males; of 235 responses received, 72.3% (170) were males and 27.7% (65) were females. Table 1 shows that of the 235 respondent-managers, 16 (6.8%) had advanced diplomas; 150 (64.1%) had bachelor's degree; and 68 (29.1%) had master's degree. The distribution of work experience among managers who responded were as follows: 60.7% of them had >5 years of experience; 39.5% of them with 2-5 years; and 3.4% of them had <2 years of work experience. A majority of the respondents representing 188 (80%) were from district hospitals, and, as would be expected, 76.6% were from public hospitals; 25 (11%) were from referral hospitals; and 22 (9%) were from provincial hospitals (Table 1).

Clinician-patient-ratio and prevalence of adverse events

The results show that Rwanda has on average 44.25 ± 13.46 (SD) consultations per clinician per day. Rwanda in general has 0.044 (IQR: 0.032-0.060) doctors per 1,000 population; Eastern Province had 0.049 and Kigali City had 0.046, both representing a slightly higher staffing ratio compared to the rest of the provinces. The country also has 0.25 (IQR: 0.18-0.33) nurses per 1,000 population (Table 2). Staffing regulations consist of limiting the number of patients assigned to each nurse and doctor.

On average, the prevalence of adverse events among public hospitals in Rwanda was 0.007 (p: 0.02, 95% CI: 0.017-0.023) and risk of incidents was 0.073.

The results showed that referral hospitals have higher risk of incidents at 0.084%, as compared to district hospitals that had 0.074% and provincial hospitals that had 0.033%. The southern province had high risk of incidents (0.14%) and a relatively low prevalence of incidents (0.005%) when compared to others provinces, and both are different from Kigali with high risk of 0.10% and high prevalence of 0.012% (Table 3).

The majority of respondents (76.5%) reported that variation of consultation time is between 10-15 minutes which is associated with 0.12% of risk of incidents. More than a half of respondents, (54.3%) reported that 10-20% of treatments given to patients were not needed and are significantly associated with high risk of incidents (Table 3).

A high number of preventable incidents were found in Kigali City, Southern Province, and Western Province compared to the rest of the provinces.

The results show that most pressing incidents were adverse drug event (25.3%), lost to follow-up/referrals (25%), and surgical site infection (20%). The above incidents representing 70% could have been prevented. The 39.3% of the public hospitals reported all types of incidents; in addition, 10.3% exclude deep vein thrombosis (DVT) and 6% exclude DVT and injury due to medication (Figure 1).

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Figure 1:

Distribution of incidents by location of hospitals

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Quality of health care services delivery

The Pearson correlation coefficient of 0.091 indicates a strong positive correlation between number of consultations per clinician per day and risk of incidents, sim and 0.067 indicates a strong positive correlation between health utilization rate and risk of incidents.

Using the four Levels of Effort (LoE) scores for reaching their patient delivery expectations, we found that the average score of public hospitals in terms of quality of health care services delivery in Rwanda was Level 1: documentation (p=0.016, 95% CI: 0.014-0.019). Over half of public hospitals scored on level 2: implementation, under 10% scored level 0: no documentation, and under 5% scored level 3: outcome. The completion of post-operative notes within 48 hours scored high at 62% for level 2; 30.8% for level 1; 3.8% level 3; and 3.4% level 0, the infection control measures flow (Figure 2).

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Figure 2:

Quality measures covered in hospital accreditation

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The average LoE score of public hospitals in terms of safety of health care services delivery in Rwanda was level 1 (p=0.209, 95%CI: 0.201-0.216). Approximately half of the public hospitals scored on level 2; one third scored level 0; and under 5% of public hospitals scored level 3. Handwashing practices scored high 57.3% on level 2 and 4.7% on level 3 (Figure 3). There were statistically significant relationships between nurse per 1,000 population ratio, patients per clinician per day ratio, and health utilization rate with risk of incidents. However, there was no significant relationship between doctor per 1,000 population ratio and risk of incidents.

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Figure 3:

Safety measures covered in hospital accreditation

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Safety of health care services delivery

The results show that 98.7% of public hospitals reported incidents. However, 1.3% of the hospitals did not report incidents due to lack of incident reporting policy. Thus, they did not provide feedback of outcome from incidents. In all, 43.2% of respondents confirmed that equitable, safety, effectiveness, efficiency, timeliness, patient-centered care, and correct diagnosis were the key domains of safety and quality covered during accreditation process.

The results show that 46.6% of respondents confirmed that doctors were not putting in enough efforts, and that doctors did not have enough time to make the correct decisions. About 28.6% of them reported that doctors not having enough time to make the correct decisions was the reason why the patients were incorrectly diagnosed and treated. Finally, 15.4% of the respondents said that doctors were not putting in enough efforts, lacked medical knowledge, and did not have enough time to make the correct decisions.

Management of quality and safety of health care services delivery

Out of the 235 manager-respondents, 53.8% (126) confirmed that all investment priorities are needed to improve quality health care; 31.6% (74) excluded improved financial protection when accessing health care; and 8.5% highlighted the needs of equipment and clinical research as priorities of health care system investment. The results indicated the differences in top priorities among the managers were as follow: 37.6% (88) prioritized improved health outcomes; 35.5% (83) prioritized improved physical access to health care; and 23.5% (55) prioritized improved financial protection when accessing health care. The managers identified their top priorities to improve quality health care: 27.2% would invest in financial support; 25.9% on education for health care professionals; 18.8% on policy analysis; 17.9% on indicators; and 10.1% on international comparative statistics. Also, 29.9% of respondents mentioned policy analysis, financial support, and education for health care professionals as priority needs to improve quality health care. In addition, 30.7% of them identified indicators and international comparative statistics as their priorities.

Responses on strategies needed to improve patient-centred care varied among the respondents. In all, 21.4% identified increased funding; 20.7% identified building good will; 19.9% identified training of more health care professionals; 13% identified new ideas; 12.7% on execution skills; and 12.3% on technological innovations. The findings indicate that of the 235 respondents, 23.5% confirmed that new ideas, building will, increased funding, and training of more health care professionals were strategies needed to improve patient-centred care. The study findings indicate that 28.6% of respondents confirmed that electronic ordering, medication safety, patient-centred care, and clinical decision support were among the needs for electronic health records, and 25.2% identified efficiency of care.

On what factor most positively impacts patient experience, 21.8% of respondent-managers identified quality of care and patient satisfaction; 21.7% identified safety/no harm; 20.9% identified respect; 18.4% identified communication; and 17.2% identified empathy. The results show that 47.4% of respondents indicated that respect, safety/no harm, empathy, quality of care and patient satisfaction, and communication positively impacted patient experience, while 13.7% of them excluded empathy and 12.8% excluded communication as impactors of patient experience. On factors that negatively impact patient experience, 22.9% of respondents identified poor communication, 22.6% identified negligence, 21.7% identified disrespect, 19.5% identified rudeness, and 13.3% reported cost. About half of the respondents (49.1%) said that disrespect, cost, negligence, rudeness, and poor communication negatively impacted patient experience. Among the managers, 38% said the first steps to improve patient experience were improving communication, engagement, attentiveness of clinicians, and adoption of electronic health records in their respective hospitals.

The study indicates that 61.9% of respondents confirmed that personal level, micro-system/unit level, organization level change were needed to improve safety culture and patient experience in their respective hospitals, while 20.1% of them reported external level change. About 47.4% of participants used many types of assessment of awareness regarding the importance of their hospitals including 23% who said they used patient interviews, clinician interviews, and surveys. About 33% of public hospitals use randomized control trials, observational studies, and descriptive studies to examine health care service delivery.

Limitations

The study participants were busy persons with limited time. The study excluded all private hospitals in Rwanda, and cannot be generalized to all hospitals in the country. Also, due to the many discrepancies in quality and accessibility of care worldwide, the study cannot be generalized globally. More studies are needed on quality and safety of health care services in Rwanda and Africa to enhance forecasting and better allocation of resources in health subsidies. Such studies should emphasis further on evidence-based research and practice. More studies are also required to establish the leverage of hospital managers on quality and safety of health care services delivery. Such studies should examine the impact of accreditation on improvement of quality health care. Further studies are essential to demonstrate the potency of quality measures framework approach underneath structures, processes and outcomes of health care.

Compliance with Ethical Standards