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Broad consensus is critically important to ensure the success of programs in developing settings. Consensus-building includes earning trust, listening, and giving local stakeholders a central role in planning and leadership. We learned this lesson the hard way when, after training our first health center team off-site at Kirehe hospital, the program stalled for the first few weeks. Nurses at the health center saw the new program as a kind of police squad, rather than as an enabler for them to improve the system and provide the highest standard of care to their community, and they resisted it. When our Kirehe team went on-site to the health center, engaged the staff in open discussion, and framed the intervention in terms of service and solidarity, the improvement project quickly took off. Since then, we have made sure to involve the entire team from Day One and tailor our goal setting to the most important local problems.

Keeping a small footprint - that is, minimizing the burden on staff and resources - prevents improvement efforts from disrupting existing services. Now that we are looking to scale our QI program to all our sites in Rwanda, it helps a great deal that improvement work in our model is a part-time job, requiring only 30 minutes daily for a single nurse per site and 30 minutes weekly for staff discussion. When staff members are already over-extended covering clinical services (the usual case in resource-poor areas such as rural Rwanda), the prospect of carving out half-an-hour per day for one nurse versus reassigning that nurse full time can make all the difference for the local buy-in and long-term sustainability of an improvement program.

Making effective use of performance data can help accelerate and drive change. We found that by spotlighting two keystone patient care processes - taking vital signs and giving medications properly - we helped illuminate resource gaps and opportunities for system improvement all along the healthcare delivery chain. We observed downstream changes such as reorganized nurse staffing to promote ownership and accountability, anticipation of pharmacy stock outs before they occurred, and a higher overall standard of care - all without direct prompting from our QI team. These changes were driven by an empowered medical staff, responding to daily performance feedback and motivated by early successes. Properly timed and targeted performance feedback can be a powerful agent for change, and should be thoughtfully integrated into improvement work.

Finally, and perhaps most importantly:in resource-poor settings, substantial resource inputs are necessary to both initiate and sustain improvement. In the area of Rwanda where Partners In Health works, for example, we had to build and renovate the district hospitals, outfit the health clinics with electricity and equipment, strengthen the supply chain for essential medicines and diagnostics, hire, train, and pay a fair wage to hundreds of Rwandan staff, supply food and bed sheets, and fill resource gaps all across the system. As Paul Farmer has observed, "In order to improve clinical services, you need to improve (and often build) the clinic itself." Building capacity through substantial infrastructure and resource investments is an essential step toward breaking the poverty cycle and bringing about meaningful improvement.

Discussion Questions:

Imagine you are a successful QI program director who has led several high impact interventions from startup through independence in developing settings. Several proposals for QI interventions cross your desk and you have the option of funding only one of them. How would you decide which proposal to fund? What advice might you offer this new QI team as they get started?

Imagine you are a successful QI program director who has led several high impact interventions from startup through independence in developing settings. Several proposals for QI interventions cross your desk and you have the option of funding only one of them. How would you decide which proposal to fund? What advice might you offer this new QI

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team as they get started?