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|