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Keywords:

  • clinical audit;
  • Tanzania;
  • health care quality assurance;
  • maternal mortality;
  • perinatal mortality;
  • obstetrics
  • audit clinique;
  • Tanzanie;
  • assurance de la qualité des soins de santé;
  • mortalité maternelle;
  • mortalité périnatale;
  • obstétrique
  • auditoría clínica;
  • Tanzania;
  • calidad servicios sanitarios;
  • mortalidad materna;
  • mortalidad perinatal;
  • obstetricia

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Objective  To explore barriers to and solutions for effective implementation of obstetric audit at Saint Francis Designated District Hospital in Ifakara, Tanzania, where audit results have been disappointing 2 years after its introduction.

Methods  Qualitative study involving participative observation of audit sessions, followed by 23 in-depth interviews with health workers and managers. Knowledge and perceptions of audit were assessed and suggestions for improvement of the audit process explored.

Results  During the observational period, audit sessions were held irregularly and only when the head of department of obstetrics and gynaecology was available. Cases with evident substandard care factors were audited. In-depth interviews revealed inadequate knowledge of the purpose of audit, despite the fact that participants regarded obstetric audit as a potentially useful tool. Insufficient staff commitment, managerial support and human and material resources were mentioned as reasons for weak involvement of health workers and poor implementation of recommendations resulting from audit. Suggestions for improvement included enhancing feedback to all staff and managers to attend sessions and assist with the effectuation of audit recommendations.

Conclusion  Obstetric staff in Ifakara see audit as an important tool for quality improvement. They recognise, however, that in their own situation, insufficient staff commitment and poor managerial support are barriers to successful implementation. They suggested training in concept and principles of audit as well as strengthening feedback of audit outcomes, to achieve structural health care improvements through audit.

Objectif:  Explorer les obstacles et les solutions pour l’implémentation effective d’audit des soins obstétricaux à l’hôpital de district désignéà Saint Francis (SFDDH) à Ifakara, en Tanzanie, où les résultats des audits ont été décevants deux ans après leur introduction.

Méthodes:  Etude qualitative impliquant l’observation participative des séances d’audit, suivie de 23 interviews détaillées avec les agents de santé et les gestionnaires. Les connaissances et perceptions sur l’audit ont étéévaluées et des suggestions pour l’amélioration du processus de l’audit ont été explorées.

Résultats:  Au cours de la période d’observation, les sessions d’audit ont été organisées de façon irrégulière et seulement lorsque le chef du département d’obstétrique et de gynécologie était disponible. Les cas avec une évidence de facteurs de soins inférieurs aux normes ont été vérifiés. Les entretiens détaillés ont révélé une connaissance insuffisante de l’objectif de l’audit, bien que les participants considéraient l’audit obstétrical comme un outil potentiellement utile. L’insuffisance de l’engagement du personnel, de l’appui aux gestionnaires et des ressources humaines et matérielles, a étéévoquée pour expliquer la faible implication des agents de santé et de l’implémentation insuffisante des recommandations issues de l’audit. Des suggestions pour l’amélioration comprennent la transmission des critiques à tout le personnel et pour les gestionnaires, l’utilité d’assister aux séances et d’aider à l’application des recommandations de l’audit.

Conclusion:  Le personnel obstétrique à Ifakara voit l’audit comme un outil important pour améliorer la qualité. Ils reconnaissent toutefois que dans leur propre situation, l’engagement insuffisant du personnel et le soutien insuffisant aux gestionnaires sont les obstacles à une mise en œuvre réussie. Ils ont suggéré la formation sur le concept et les principes de l’audit ainsi que le renforcement de la rétroaction des résultats de l’audit, pour atteindre des améliorations structurelles des soins de santé grâce à l’audit.

Objetivo:  Explorar las barreras y las soluciones para una implementación efectiva de la auditoría obstétrica en el Hospital Distrital de Saint Francis en Ifakara, Tanzania, en donde los resultados de la auditoría han sido desalentadores, dos años después de su introducción.

Métodos:  Estudio cualitativo que incluía una observación participativa de las sesiones de auditoría, seguidas por 23 entrevistas en profundidad con trabajadores sanitarios y gestores. Se evaluaron los conocimientos y las percepciones sobre la auditoría y se exploraron sugerencias para la mejora del proceso de auditoría.

Resultados:  Durante el periodo de observación, las sesiones de auditoría fueron mantenidas regularmente y solo cuando el jefe del departamento de ginecología y obstetricia estaba disponible. Se auditaron los casos con factores evidentes de cuidados por debajo del estándar. Las entrevistas en profundidad revelaron unos conocimientos inadecuados sobre el propósito de la auditoría, a pesar de que los participantes percibían la auditoría obstétrica como una herramienta potencialmente útil. La falta de compromiso del personal, la falta de apoyo en la gestión y de recursos humanos y materiales, fueron las razones dadas para una implicación pobre de los trabajadores sanitarios y una implementación deficitaria de las recomendaciones dadas tras la auditoría. Las sugerencias para una mejoría incluyen mejorar el proceso de retroalimentación con el personal, y para los gestores el participar en las sesiones y ayudar con la ejecución de las recomendaciones surgidas de la auditoría.

Conclusión:  El personal de obstetricia en Ifakara percibe la auditoría como una herramienta importante para mejorar la calidad del servicio. Reconocen, sin embargo, que en su situación, la falta de compromiso por parte del personal y un apoyo insuficiente en la gestión son barreras para una implementación exitosa. Sugieren que, con el fin de alcanzar mejoras estructurales en los cuidados sanitarios mediante el proceso de auditoría, se brinde entrenamiento en los conceptos y principios de la auditoría, así como en que se fortalezca la retroalimentación con respecto a los resultados de la misma.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Complications of pregnancy and childbirth still pose enormous threats to mothers and their children, especially in low-income countries (WHO 2005). Tanzania is among the sub-Saharan African countries with high numbers of maternal and perinatal deaths, with a maternal mortality ratio of 449 per 100 000 live births (Hogan et al. 2010) and a perinatal mortality rate of 59 per 1000 live births (WHO 2007). Obstetric audit is a tool for quality insurance, which is seen as a simple and cost-effective strategy to improve obstetric care at facility level (van den Akker et al. 2009, 2011; Nyamtema et al. 2010).

There are different forms of obstetric audit (WHO 2004). An example is ‘critical incident audit’, a comprehensive facility-based case review of individual cases of maternal and perinatal deaths, or maternal near-miss events (Muffler et al. 2007). An effective obstetric critical incident audit consists of a repetitive cycle of five steps: identifying cases, collecting information, analysing the results by comparing with standards of care and formulating recommendations for change, making an effort to implement change and re-evaluating practice (WHO 2004; Drife 2006).

Literature about audit prerequisites, facilitating factors and barriers is mostly limited to high-income settings (Lord & Littlejohns 1996; Johnston et al. 2000; Pattinson et al. 2005; Jamtvedt et al. 2006). These reviews show a moderate positive effect of audit on the quality of care and emphasise the need for more research in this area. Knowledge about the performance of audit in low-income settings has increased in recent years. Both successful (van den Akker et al. 2009, 2011) and unsuccessful (Muffler et al. 2007; Richard et al. 2009) attempts of implementing audit have been described. Requirements for audit include managerial and government support, a blame-free environment without fear of repercussions, proper documentation and sufficient staffing. Failure to meet these requirements has been seen to inhibit the successful implementation of audit (Weeks et al. 2003; Kongnyuy & van den Broek 2008; Richard et al. 2009). In addition, commitment of staff towards conducting audit themselves and their acceptance of being evaluated by peers are of vital importance (Johnston et al. 2000; Pattinson et al. 2005; Richard et al. 2009; Nyamtema et al. 2010; Bakker et al. 2011).

To reduce maternal and perinatal mortality and morbidity, obstetric audit was introduced in Ifakara, Tanzania in 2008. However, barriers to effective audit were encountered, including inadequate managerial support and shortage of staff (Nyamtema et al. 2011a). To increase the impact of local audit, these barriers and the perceptions held by health workers about the local audit process were further explored in this study.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Study setting

This study was conducted in 2010 in Saint Francis Designated District Hospital (SFDDH) in Ifakara, Kilombero district, one of the rural districts in Morogoro region in the southeast of Tanzania. The hospital serves an area with a population of 600 000. Around 5000 deliveries are conducted at the facility every year (Schennach 2010). The facility is run by the Catholic Diocese of Mahenge, together with the Ministry of Health.

Because of a critical shortage of skilled health care personnel (only one physician per 100 000 people in 2010, WHO 2011) the government of Tanzania has allowed non-physician clinicians to provide more advanced emergency obstetric care (McCord et al. 2009). A wide range of staff categories provide obstetric care in this hospital, including two obstetricians, two general doctors, several intern doctors, 14 midwives and one non-physician clinician (assistant medical officer). During the study period, the hospital suffered a high turnover of staff. A considerable proportion of experienced midwives left because of a salary increase in the government health sector, forcing the hospital to hire relatively young and inexperienced midwives.

Audit sessions were planned on a weekly basis. Approximately an hour and a half was scheduled for these sessions that took place during working hours. Audit sessions were supposed to be attended by hospital and district management as recommended by national guidelines (Nyamtema et al. 2010) and by all staff providing obstetric care who were available on the day of audit. The head of the obstetric department chaired the sessions. After presenting a case summary, areas of mismanagement or missed opportunities were discussed using a gate-to-gate approach, meaning that the review concerned events from admission to discharge or death (Filippi et al. 2004; Muffler et al. 2007). The implementation of recommendations emerging from audit was assigned to specific individuals at the end of each session.

Data collection

This qualitative study involved participative observation of audit sessions followed by in-depth interviews (all performed by the first two authors) using a semi-structured interview guide based on earlier studies [courtesy of F. Richard, Institute of Tropical Medicine, Antwerp, Belgium (Richard et al. 2009; Bakker et al. 2011)]. Twenty-three participants were conveniently selected for in-depth interviews. Inclusion criteria were health workers in the obstetrics and paediatrics departments as well as hospital and district managers, as these were the intended attendees of the audit meetings. Study participants were one obstetrician, two paediatricians, four general doctors (two from both departments), one assistant medical officer, one intern doctor, six midwives, four nurses, the medical officer in-charge, the matron, the district medical officer and the district nursing officer.

The in-depth interviews explored their knowledge about audit, perceptions about the conduct of audit (proceedings and staff participation), perceptions of the effects (implementation and follow-up of recommendations, benefits and disadvantages) and ideas about how audit could be improved. Some of the selected participants could not easily express themselves in English. Therefore, seven of the interviews were conducted in Swahili (by EHM). Participants’ informed verbal consent was obtained for each interview and for the use of a tape recorder. Two interviews were not recorded at participants’ request, which meant that only written notes were taken. Participants’ anonymity was protected by keeping the tape records and written information confidential by storing the data encrypted and only accessible for the first two authors. Permission to conduct this study was obtained from the hospital and district administration as part of a larger study (Nyamtema et al. 2011a).

Data analysis

The recordings were transcribed manually and then analysed by using inductive coding. All interviews in Swahili were recorded, transcribed and translated into English. During the study period, points of key interest were analysed and used to refine questions and elaborate on certain areas whilst maintaining the structure of the interview guide. Further analysis grouped the codes into categories and cross-links within the data as well as between data, and literature were identified (Hardon et al. 2001). The first two authors independently analysed the data, after which results were compared with increase reliability.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Observation findings

During 9 weeks of observation, four audit sessions were held. When the head of department was absent or there was no case prepared, there was no meeting. The head of obstetrics and gynaecology was present at all four, other members of staff including doctors, intern doctors, managers, nurses and nursing students attended irregularly. The number of audit attendees ranged from nine to 23. Of all attendees, the doctors, managers and head nurses participated actively whilst other nurses and nursing students were less active, despite having their opinions asked. The head of obstetrics and gynaecology organised the meetings, invited other health workers to come and selected the cases or delegated this task to other doctors. There were no strict criteria for selection, although attempts were made to address subjects where staff was known to have gaps in knowledge and skills. In three of the sessions, a single case was reviewed each time regarding malaria during pregnancy, uterine rupture, and birth asphyxia. The remaining session was used to assess the management of birth asphyxia by assessing nine cases of perinatal mortality.

Barriers to quality care identified during audit included lack of staff, poor availability of equipment, insufficient record keeping, referral-related factors (transport delays, insufficient treatment at the periphery and poor monitoring during transport) and individual patient-related factors (delay in seeking treatment), for which workable solutions were sought. For example, with regard to record keeping, training in partograph filling was proposed. Although no minutes were kept during the audit session, some recommendations were written down in an attempt to establish an action plan, whilst others were only formulated verbally.

The analysis categorised the results of the in-depth interviews into three subjects: (i) general knowledge of audit, (ii) perception of the effects of audit, and (iii) perception of audit requirements.

General knowledge of audit.  Responding to questions about the purpose of audit, interviewees mentioned that it is ‘to know where our gaps are’ or to find out ‘how to solve those gaps which are occurring’, or gave similar explanations. At least half of the participants only recognised direct benefits of a single session, such as ‘learning’, ‘improving my skills’ or ‘know how to manage the patient’ as the purpose for audit. Only four participants, including two of the managers, specifically mentioned that the purpose was to collect data and analyse these for evidence-based policy improvement to benefit quality of care in the longer run.

Other participants saw inadequate knowledge of the purpose of audit among health workers as one of the explanations for their poor attendance. One participant said: ‘People are not motivated to come because they don’t know what they are doing there. If you know then you wouldn’t want to miss this session.’ Many interviewees suggested offering training to enhance knowledge of audit: ‘People should be trained on how to conduct and the importance of audit meeting. Therefore after the training they will get the concept.’

Perception of the effects of audit.  The most positive effect, as perceived by the participants, was learning during the sessions: ‘you know, medicine is a daily learning process, in the audit sessions you get new inputs.’ Education was said to be the biggest motivator to attend sessions and continue the audit process. Another advantage of audit that was mentioned was the possibility for communication between different cadres of health workers within a department. It was noticed by nurses that since the onset of the audit sessions, cooperation between nurses and doctors improved. Lastly, the increase in the monitoring of staff performance resulting from audit was primarily considered an advantage. One nurse explained: ‘I think it is good, because it gives us a good challenge, that we have to be careful when we work.’ Only one doctor admitted that monitoring of daily practice through audit made him feel uncomfortable.

In contrast to these possible benefits of audit, many interviewees expressed dissatisfaction with the limited implementation of audit recommendations, particularly those that required managerial support. Interviewees felt that this was owing to poor attendance of managers (The administrators should be there because we need to get their response right there’), lack of feedback to the managers of the suggested recommendations so they can act on them (‘So we find ourselves repeating the same things again and again, you start wondering whether they get this information or not’) and lack of funds (‘You can recommend something, but if the administrators say they don’t have that fund, it dies right away’).

Inadequate feedback to members of the audit team about the implementation of recommendations was also reported, as most of the participants did not know whether the suggested recommendations were worked on or not; nor who was responsible for implementation (‘All the outcome feedback should be open for all’). One nurse suggested a more structural follow-up: ‘When we are in the meeting, before starting, we should quickly go back to what we discussed in a previous meeting.’

Many suggestions were made for improvement, including proper use of action plans, writing the recommendations on notice boards, assigning a key-person to monitor progress and to have the nurse-in-charge give feedback to all other nurses. Despite the problems with implementation, all participants responded positively to the question if audit should be continued.

Perception of audit requirements.  Inadequate staff commitment to audit was manifested by low attendance and participation in audit meetings, although none admitted to having low commitment him/herself. As one participant said: ‘They (staff members) don’t feel to be questioned. They want to skip them and find excuses.’ Lack of staff commitment also became apparent when discussing absenteeism. It was revealed that audit depended too much on the head of department: when he is not there, most of the time no one else took the initiative to organise an audit meeting. Considering its importance, delegation of organising audit was suggested.

Low participation in the audit discussion was said to be caused by personnel not being used to speak in public, fear of people higher in rank and inadequate medical knowledge. Despite efforts to maintain anonymity, blaming and using harsh language were also mentioned, as inhibiting participation, attendance and staff commitment. Another problem was that people ‘prolong on matters, other than the main points’, causing the discussion to be ‘not focussed to the point.’ It was suggested that staff should be skilled in using a blame-free and efficient manner to improve discussion.

Many participants saw shortage of human resources as one of the major factors inhibiting successful audit. The high workload often prevented staff from attending because they felt like they could not leave their daily work. Employing more staff to reduce the workload was suggested as a way to increase attendance and staff motivation for audit. Different types of material resources such as a less distracting and uncomfortable venue and incentives for participation were suggested as areas for improvement. Others, however, considered this undesirable. The audit requirements and proposed improvements given by the interviewees are summarised in Box 1.

Table  Box 1 .   Audit requirements and solutions proposed by staff
Staff commitment: motivate staff to organise and attend the meetings
Support of managers to attend and implement recommendations under their supervision, as well as to give feedback to all staff
Adequate resources: human resources (reduce workload to be able to prepare and attend sessions) and material resources (a conducive venue and funds for implementation of recommendations)
Educate staff on the principles and importance of audit to increase motivation
Promote good documentation: training in partograph completion
Emphasise the importance of a blame-free environment
Promote proper communication skills, keeping the discussion focussed

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Audit has been described in the literature as an effective tool in some settings, yet in other settings the cycle has been seen to ‘all too easily lose its shape, stop short or simply vanish’ (Berger 1998). Our findings indicate insufficient health care providers’ and managers’ commitment to audit in Ifakara. This lack of commitment was never described by participants as pertaining to themselves; it was all too often about others.

Our findings suggest that organizational changes are required to overcome these barriers and enhance the impact of audit. These include involving a variety of staff and managers in all stages of audit, training of staff and managers on the principles and importance of audit, and strengthening feedback and transparency about implementation of audit recommendations.

Failure of decision makers (hospital and district health managers) to attend audit meetings could lead to inadequate implementation of recommendations. Leadership irresponsiveness has been reported to have higher explanatory power for lack of quality improvements compared with financial limitations (Van Lergberghe & De Brouwere 2001; Nyamtema et al. 2011b). In places where establishment of obstetric audits has led to improved quality of care, the success has been attributed to the accountability of both care providers and decision makers (Kongnyuy & van den Broek 2008; van den Akker et al. 2009). Although hospital and district managers may not be clinical experts, they have a big role to play when it comes to implementation of key recommendations resulting from clinical reviews.

The importance of training staff on a regular basis in audit methodology has been described as a necessary but ignored investment (Johnston et al. 2000; Muffler et al. 2007). Skills regarding teamwork and dealing with criticism (Johnston et al. 2000) as well as a basic understanding of audit principles must be present in all staff members involved in audit. The ability to challenge superiors and a blame-free environment should be guaranteed. Audit ought to be conducted in a blame-free manner, to ensure that substandard care factors do not remain hidden and to prevent animosity among staff (Kongnyuy & van den Broek 2008; Nyamtema et al. 2010). Fear of ‘blame and shame’ in Ifakara audits may have contributed to low staff involvement. Training staff on audit methodology and principles might diminish this fear. Since St. Francis Hospital is a training school for nurse midwives, assistant medical officers and intern doctors, one of the objectives of this training would be to make these young members of staff familiar with the concept and principles of audit. This can have a considerable spin-off in the different health facilities to which these health workers will be posted.

Staff mentioned a serious lack of feedback of the audit outcomes to participants and other health personnel. Structured and regular feedback to staff was mentioned as a solution to break the pattern of repeating recommendations over and over again without perceivable impact. Owing to this lack of impact, many staff members perceived direct learning from audit as its major effect, rather than structural health care improvements resulting from audit. Whilst most authors consider this direct effect inferior to implementing structural change (WHO 2004; Drife 2006), the educational value of audit has also been described as the primary outcome, particularly beneficial in settings where young and inexperienced health workers are eager to learn (Bakker et al. 2011).

Our findings suggest that to achieve structural health care improvements, greater efforts are required to guarantee audit prerequisites. These were identified by health workers as staff commitment, managerial support, adequate human and material resources, proper documentation, structured action plans to implement audit recommendations and transparent feedback to all staff members. For the moment, audit in Ifakara does not yet form an integrated part of the work routine necessary to acquire a group mentality allowing a change of practice (Healy 1998; Bakker et al. 2011).

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The authors thank the SFDDH staff and management for their support of this study.

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  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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