Using basic quality improvement tools (including a series of PDSA cycles), we were able to identify resource gaps and systemic problems, then work to improve them. We began to backfill. Or rather, the nurses themselves began to backfill, addressing resource deficits and improving the systems organization and efficiency. They received full support in this effort from Kirehes leadership, including Shema Jean Ren, Philbert Kanama, Henry Epino, and others. Recognizing that half-an-hour after the morning meeting was not enough time for the day nurse to perform vital signs and give out medications before 9 AM, they transferred this task to the night nurse (a move that had long been discussed but not yet implemented). This led to a wholesale reorganization of the nursing staff from a nomadic rotation where nurses worked several days in each ward then moved on, to one where nurses were assigned to a ward and elected a chief who would be responsible for quality of care and training of junior nurses.

Every Thursday, the all-staff meeting was replaced by local troubleshooting rounds in each ward, where the ward chief and nurses would review supplies, any problems from the previous week, and solve problems directly if they could. Systemic problems identified in these meetings would be discussed on a monthly basis with the head of nursing and the hospital medical director. This is only a partial list. Change was occurring organically throughout the system, driven by nurses who felt motivated and empowered to see a problem, fix a problem the defining feature of a high-performing, self-correcting system.

We found that, by spotlighting keystone patient care processes, we helped illuminate resource gaps and opportunities for better use of existing resources all along the health care delivery chain. For example, by counting a medication stock-out as a medication not-given (since the patient did not receive it), we provided an incentive for the ward nurses to strengthen our pharmacy supply chain by promptly requesting medication re-supply and reminding their pharmacy colleagues to anticipate stock-outs before they occurred.

Substantial resource inputs are essential to successful improvement work in resource-poor settings. At Kirehe, for example, nurses in the outpatient department were initially doing more than fifty patient consultations per day and had no time to talk with patients about their diagnoses. We had two major resource gaps here: not enough nurses, and not enough consultation rooms.

In your own experience, how have you seen resource inputs play a critical role in improvement efforts in resource-poor settings?

Can you think of at least one instance where missing resources also hindered improvement efforts in a resource-rich setting?