zimbabwe quality assurance and quality improvement

Quality Assurance and QualityImprovement Strategy

2016-2020

Ministry of Health and Child Care

ZIMBABWE

Quality Assurance and QualityImprovement Strategy

2016-2020

Ministry of Health and Child Care

ZiMbabwe

Printed bySupporting the National Health Strategyto improve access to quality healthcare in Zimbabwe

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FOREWORD

e mission of the Ministry of Health and Child Care in line with the Primary Health CareApproach is “to provide, administer, coordinate, promote and advocate for the provisionof equitable, appropriate, accessible, affordable and acceptable quality health services andcare to Zimbabweans while maximizing the use of available resources.” It is thereforeimportant the country has a policy on Quality Assurance and Quality Improvement(QA/QI) with the ultimate aim of providing the highest quality of healthcare services tothe people of Zimbabwe. I sincerely believe that this is achievable and we have the potentialto deliver.

e development of the QA/QI Strategy was a consultative process involving multiplestakeholders in the Health Sector. is was led by the Ministry of Health and Child Careincluding, public, mission, private and public health programs and projects in the countrywith technical assistance from partners. ematic working groups with wide stakeholderrepresentation were instrumental in the development of this strategy. e two main focusareas of the strategy are the horizontal dimension of the strategy dealing with QI of cross-cutting issues related to health service organisation, and the vertical dimension of thestrategy dealing with QI for disease specific issues.

We are aware of the challenges in delivery of reliable and responsive high quality healthcareand improving people’s lives. is strategy provides a basis for all to focus our combinedefforts on what is required to address current and future challenges to ensure high qualityhealthcare for ourselves and generations to come.

Brigadier G. Dr. B.GwinjiSecretary Minister of Health and Child Care

Quality Assurance and Quality Improvement Strategy 2016-2020 Ministry of Health and Child Care, Zimbabwe i

ACKNOWLEDGEMENTS

Quality Assurance and Quality Improvement Strategy 2016-2020 Ministry of Health and Child Care, Zimbabweii

e Quality Assurance (QA) and Quality Improvement (QI) Department within theMinistry of Health and Child Care (MOHCC) would like to acknowledge the contributionof various individuals and organisations to the formulation of the QI Strategic plan forHealth in Zimbabwe. eir contributions were through providing information duringinterviews, relevant documents and participating in thematic group discussions. e listof contributing persons and organisations is listed in appendix section. Special thanks goesto Secretary for Health and Child Care Brigadier General Dr G. Gwinji and Dr D. G.Dhlakama Principal Director Policy Planning Monitoring and Evaluation for their excellentsupport throughout the strategy development process.

e QA and QI department acknowledges the Maternal and Child Health IntegratedProgram (MCHIP) for financial and technical support in hiring of the consultants andconvening of stakeholder meetings. e QA and QI department also acknowledges thetechnical contributions of Prof R Kambarami, Dr H Chiguvare from MCHIP, and Dr JKeatinge from USAID.

Likewise, the QA and QI department would like to also acknowledge the financial andtechnical contributions of the World Bank via support for a consultant and ongoingcontributions to the QA/QI policy and strategy documents.

e consultancy services for desk review, coordination, writing and final production of thedocument were provided by Dr N Masuka, Dr K Hill and Dr G Shambira. e QAdepartment led by Dr Z Chiware provided secretarial support and coordination ofstakeholders who participated in the formulation of this strategy. e final editing andproof reading was done by Drs Endris Mohammed, B. B. Khabo and J. Z. Chiware.

EXECUTIVE SUMMARY

e health sector in Zimbabwe is in recovery mode aer a decade of significant challengesspanning from inadequate financing and shortages of qualified staff, poor infrastructureand obsolete equipment. As the health sector recovers, it is important that QualityAssurance (QA) and Quality Improvement (QI) be embedded and become a culture ofdoing business in the Health Sector.

e development of the QA/QI strategy was led by the MOHCC through a consultativeprocess involving selected stakeholders including Provincial and District Health Executiveteams, public and private health workers, Non-Government Organisations and technicalpartners involved in the health sector. e process started in late 2012, with support froma team of two consultants who were hired with specific terms of reference. A series ofmeetings, key informant interviews and stakeholder workshops were conducted fromsituation analysis to draing of a policy framework culminating in the strategic plan. Fourmain thematic working groups were formed on: Standards of Healthcare; Patient/ClientSafety; Patient/Client Satisfaction; and Health Worker Attitudes and Performance.

Among major strengths noted were the existence of institutions for setting standards suchas Standards Association of Zimbabwe (SAZ) and regulatory bodies such as the HealthProfessions Authority. Political commitment to QA/QI was demonstrated by theestablishment of a Quality Assurance and Improvement Directorate in the MOHCC.Within the health sector there are a number of treatment guidelines and protocols whichif adhered to, will help in the standardization of care and improved outcomes.Opportunities that may enhance QA/QI include existence of patient and service charters,recent lessons from the Performance Based Financing pilot in 18 districts of Zimbabwe,as well as health centre committees for more meaningful participation of communities inhealth care. e Standardized Maternal Care project by MCHIP in Manicaland alsodemonstrated the feasibility of implementing QI initiatives with existing resources. reatsto successful implementation of QA/QI relate mainly to underfunding and donordependency on health financing.

e target audience for this QA/QI framework includes all health providers, planners,programme managers, implementers, teaching/academic institutions, partners in theprivate and public sectors, non-governmental organisations in the health sector, patients,families and communities. e aim of this strategy is to guide the process of ensuringquality as well as continual quality improvement in both public and private sectors in thehealth sector. e vision and mission are articulated in the main body of the document.

e strategy takes a systems approach to improving and sustaining high-quality healthservices in Zimbabwe, highlighting cross-cutting priority intervention areas related to theWorld Health Organisation’s health system building blocks and priority quality domains(e.g. safety, clinical effectiveness) and priority interventions in vertical disease control

Quality Assurance and Quality Improvement Strategy 2016-2020 Ministry of Health and Child Care, Zimbabwe iii

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programs targeting major causes of morbidity and mortality. e simultaneous focus onstrengthening essential cross-cutting health system functions and continuous improvementof vertical disease programs will help to build a strong health system capable of continuousimprovement for achieving optimum health for all Zimbabwean citizens.

Mechanisms for implementation of the strategic plan include the creation of a nationaladvisory committee and technical working groups, creation and support of regional anddistrict QI focal points, regular monitoring of priority quality measures within the healthinformation system tailored to specific stakeholders, as well as provisions for monitoringof the strategy implementation.

Executive Summary

TABLE OF CONTENTS

Foreword ............................................................................................................................................iAcknowledgements ...............................................................................................................................iiExecutive Summary .............................................................................................................................iiiTable of Contents ...................................................................................................................................vAcronyms .........................................................................................................................................viiDefinitions of Terms ............................................................................................................................ix

1. baCKGROUND............................................................................................................11.1 Strategy Development Process ......................................................................................21.2 Situation Analysis ............................................................................................................2

Zimbabwe Health Status.................................................................................................2Child Health.....................................................................................................................3Gaps in the quality of care for newborns, infants and under 5 years to be addressed by this strategy .....................................................................................5Maternal Health...............................................................................................................6Gaps in quality of maternal care to be addressed by this strategy ............................7HIV and AIDS .................................................................................................................7Gaps in HIV and AIDS quality of care to be addressed by this strategy .................9Malaria............................................................................................................................10Non Communicable Diseases (NCDs).......................................................................10

1.3 Strengths, Weaknesses, Opportunities and reats (SWOT) Analysis..................11Strengths: ........................................................................................................................11Weaknesses:....................................................................................................................11Opportunities: ...............................................................................................................12reats: ...........................................................................................................................12Experience and Progress so far in QI initiatives in Zimbabwe ...............................13Anti-Retroviral erapy (ART) Quality Improvement............................................13Quality Improvement in PMTCT ...............................................................................14Improving the quality of Maternal and Newborn Care in Zimbabwe ...................15

2. THe NaTiONaL QUaLiTY iMPROVeMeNT STRaTeGiC FRaMewORK ........17Rationale for a Strategy on Quality Improvement in Health Care .........................17

2.1 Aim and Guiding Principles of the Strategy..............................................................18Guiding Principles ........................................................................................................18

2.2 Strategic Objectives, Priorities and Interventions.....................................................19Conceptual Framework for National QI Strategy.....................................................19

2.3 Quality Improvement Principles and Methodologies ..............................................36

3. iMPLeMeNTaTiON OF THe Q1 STRaTeGY.........................................................37National Level ................................................................................................................39Government ...................................................................................................................41Private for Profit Sector (Private providers from different sectors including private hospitals, surgeries, laboratories, pharmacies) ...........................41

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Community Representatives, Civil Society, Non-governmental Organisations.................................................................................................................42

3.1 Perfomance Measurement in Quality.........................................................................42Quality Assessment Indicators ....................................................................................43Sources of Data ..............................................................................................................44

3.2 Monitoring and Evaluation..........................................................................................45Data Analysis and Reporting.......................................................................................46

aNNeXeS ...........................................................................................................................49Annex A: Quality Improvemnt Methodologies...............................................................49

Model For Improvement – Plan-Do-Study-Act Model ................................50Clinical Practice Improvement (CPI)..............................................................52Root Cause Analysis ..........................................................................................53Quality Improvement Collaborative................................................................53

Annex B: List of Participants in Strategy Plan Formulation..........................................56

TabLe OF FiGUReS

Figure 1: Life Expectancy at birth in Zimbabwe and sub-Saharan Africa 1992-2012 .............................................................................................................3

Figure 2: ZDHS Infant Mortality and Under 5 Mortality in Zimbabwe between 1999-2014:.........................................................................................................3

Figure 3: Fresh Still Births per 1000 live births by province and central institutions 2012...............................................................................................................4

Figure 4: Early Neonatal deaths per 1000 live births by province and institution Zimbabwe, 2012............................................................................................4

Figure 5: ZDHS Maternal Mortality Ratio Trends, Zimbabwe 1999-2014...............................6Figure 6: Institutional maternal deaths by province and institution,

Zimbabwe, 2012...............................................................................................................6Figure 7: ZDHS Trends in HIV Prevalence, Zimbabwe 2005-2011 ..........................................8Figure 8: Quality Improvement relationships ............................................................................38Figure 9: Support and Supervision for QI...................................................................................46Figure 10: Model for Improvement................................................................................................51

TabLeS

Table 1: Number of neonatal, infant and under 5 deaths by specific disease and rural provinces in Zimbabwe, 2012 .......................................................................5

Table 2: Delivery in health facility and skilled attendance at birth by province in Zimbabwe, ZDHS 2010/11 ........................................................................7

Table 3: HIV Prevalence by province, ZDHS 2010-11 ..............................................................8Table 4: Dimension 1 - Strategic and Intermediate Objectives, Key Activities,

Indicators and projected costs .....................................................................................20Table 5: Dimension 2 - Priority health areas and associated high impact

interventions, QI approaches, quality of care indicators and projected costs................................................................................................................28

Table of Contents

ACRONYMS

AMTSL Active Management of ird Stage of Labour

ART Anti-Retroviral erapy

BMI Body Mass Index

CCZ Consumer Council of Zimbabwe

CME Continuing Medical Education

CPD Continuing Professional Development

CQI Continuous Quality Improvement

CVD Cardiovascular Disease

DHE District Health Executive

EDLIZ Essential Medicine List of Zimbabwe

EMR Electronic Medical Record

ENND Early Neonatal Death

EPMS Electronic Patient Monitoring System

FSB Fresh Still Birth

HPA Health Professions Authority

HMIS Health Management Information System

ICU Intensive Care Unit

IMR Infant Mortality Rate

ISO International Standards Organization

IYCF Infant and Young Child Feeding

MCAZ Medicines Control Authority of Zimbabwe

MDPCZ Medical and Dental Professions Council of Zimbabwe

MIMS Multiple Indicator Monitoring Survey

MNCH Maternal Newborn and Child Health

MMR Maternal Mortality Ratio

MOHCC Ministry of Health and Child Care

MOU Memorandum of Understanding

NCD Non-Communicable Diseases

NDTPAC National Medicines and erapeutics Policy Advisory Council

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NIHFA National Integrated Health Facility Assessment

NQIC National Quality Improvement Committee

ORT Oral Rehydration erapy

PDSA Plan-Do¬-Study-Act

PHC Primary Health Care

PHE Provincial Health Executive

PMTCT Prevention of Mother to Child Transmission

PPH Post-Partum Haemorrhage

QA Quality Assurance

QAD Quality Assurance Department

QI Quality Improvement

QMS Quality Management System

RBM Results Based Management

RBF Results Based Financing

ROM Rupture of Membranes

RUTF Ready to Use erapeutic Feeds

SAZ Standards Association of Zimbabwe

SOP Standard Operating Procedures

STI Sexually Transmitted Infection

SWOT Strength Weaknesses Opportunities and reats

TB Tuberculosis

U5MR Under 5 Mortality Rate

VMAHS Vital Medicines Availability and Health Services Survey

WHO World Health Organisation

ZANSP Zimbabwe AIDS National Strategic Plan

ZDHS Zimbabwe Demographic and Health Survey

ZINARA Zimbabwe National Road Authority

ZNHS Zimbabwe National Health Strategy

ZINQAP Zimbabwe Quality Assurance Programme (ZINQAP)

Acronyms

DEFINITION OF TERMS

best Practice: A way or method of accomplishing a function or process that is consideredto be superior to all other known methods. In health care, it is oen used torefer to tools, materials, and models of care, organisational arrangements, andother practices that have been shown in multiple settings to facilitatecompliance with evidence-based standards of care.

Collaborative: A systematic approach to health care quality improvement in whichorganisations and providers test and measure practice innovations, then sharetheir experiences in an effort to accelerate learning and widespreadimplementation of best practices.”Everyone teaches, everyone learns”

Continuous Quality improvement: An approach to health care based on evaluation ofa product or the outcome(s) of a process, and an understanding the needs andexpectations of the consumers of these products or processes.

Quality assurance: A system to support performance according to standards. It impliesa systematic way of establishing and maintaining quality improvementactivities as an integral and sustainable part of systems or organisations. isincludes all activities that contribute to the design, assessment, monitoring ofstandards agreed upon by all stakeholders and improving quality of servicedelivery, client satisfaction and effective utilization.

Quality improvement: An interdisciplinary process designed to raise the standards ofthe delivery of preventive, diagnostic, therapeutic and rehabilitative measuresin order to restore and improve health outcomes of individuals and populationsfocusing on systems, clients, processes, team work and use of data.

Quality Management: e application of management practice to systematically maintainand improve organisation-wide performance.

indicator: A measurable variable (or characteristic) that can be used to determine thedegree of adherence to a standard or the level of quality achieved.

Quality: ere are many definitions, but for our purposes, quality is defined as theextent to which health care, services, systems, and programmes conform tonational or international standards/ requirements/ specifications. Accordingto the Institute of Medicine (IOM), health care is of high quality if it is safe,effective, patient-centred, timely, efficient; and equitable.

Quality Assurance and Quality Improvement Strategy 2016-2020 Ministry of Health and Child Care, Zimbabwe ix

Quality Assurance and Quality Improvement Strategy 2016-2020 Ministry of Health and Child Care, Zimbabwex

Quality improvement initiatives: Cycles of interventions that are linked to assessmentand that have the goal of improving the process, outcome, and efficient ofcomplex systems or simply put: interventions for assessing, measuring, definingand resolving health care delivery issues with an aim to improving the safety,timeliness, equity, access, and appropriateness of health care services.

Patient Centred Care: Providing care that is respectful and responsive to individualpreferences, needs and values and ensures that patient values guide all clinicaldecisions

Patient Safety: e prevention of errors and adverse events to patients associated withhealth care.

Standard of Care: Preformed and agreed upon statements issued for the purpose ofinfluencing decisions and health interventions.

Plan-Do-Study-act (PDSa) Cycle: A process to describe quality improvement cycleusing four steps: Plan, Do, Study, Act. It is sometimes referred to as the Shewartor as the Deming cycle.

Definition of Terms

BACKGROUND

Overview of the Zimbabwe Health System

At Independence in 1980, Zimbabwe adopted the Primary Health Care (PHC) Approachin line with the Alma Ata Declaration of 1978. e implementation of the PHC approachresulted in decentralization of health service provision from central level (cities and towns)to administrative wards at district level in the rural communities. Four tiers for healthservice delivery were established as follows:

l Quaternary Level: Central Teaching Hospitals with specialist medical services in thecapital city Harare, the second largest city Bulawayo and in Chitungwiza.

l Tertiary Level: Provincial Hospitals with ambulatory and inpatient specialist servicesin the eight rural provinces of Zimbabwe.

l Secondary Level: District Hospitals with emergency, ambulatory and inpatientservices in the sixty-two districts of Zimbabwe.

l Primary Level: Rural Health Centers with primary care services in the 220 wards ofZimbabwe.

is decentralization was associated with a significant improvement of most healthindicators in the 1980s and early 1990’s. It is in the context of a decentralized health systemthat quality of care will be viewed in this strategy. In addition there is a private for profitsector whose operations will also be guided by this strategy.

e Zimbabwe health system has been undergoing a revitalization process since the launchof the Zimbabwe Health Sector Investment case in 2009, aer a near collapse on thebackground of socio-economic challenges which reached a peak in 2008. is process isembedded in the Zimbabwe National Health Strategy (ZNHS 2009-2015) in which thevision of the Ministry of Health and Child Care (MoHCC) is “to have the highest possiblelevel of health and quality of life for the citizens of Zimbabwe”.

e mission of the MoHCC as stated in the ZNHS 2009-15 is "to provide, administer,coordinate, promote and advocate for the provision of equitable, appropriate, accessible,affordable and acceptable quality health services and care to Zimbabweans whilemaximizing the use of available resources, in line with the primary health care approach.e provision of these services is guided by the Results Based Management system (RBM),which was adopted by the Zimbabwean government in 2005 as a performance monitoringand evaluation system.

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Quality Assurance and Quality Improvement Strategy 2016-2020 Ministry of Health and Child Care, Zimbabwe2

1.1 STRATEGY DEVELOPMENT PROCESS

e development of the QI Strategy was a consultative process involving stakeholders inthe Health Sector. is was led by Task Force on quality improvement chaired by theMinistry of Health and Child Care directorate of Quality Assurance and Improvement.e Task Force comprised technical experts from MCHIP, USAID, the World Bank andtwo local consultants. e Task Force facilitated a desk review of policy and strategicdocuments in the MOHCC, and the two consultants carried out key informant interviewsand undertook a situational analysis of the quality of care within the public health facilities and institutions. Consultations with stakeholders from public, mission, private, civil society,technical partners and public health programs and NGO projects in the country wereundertaken.

Dimensions of Quality of Care

Major dimensions of quality of health care guiding the formulation of this strategy arenoted below. All except coordination of care are adopted from the Institute of Medicine(IOM) dimensions of quality:

effectiveness: delivering health care that is adherent to an evidence base and results inimproved health outcomes for individuals and communities, based on need.

efficiency: delivering health care in a manner which maximizes resource use and avoidswaste.

accessibility: health care that is timely, geographically reasonable, and provided in a settingwhere skills and resources are appropriate to medical need.

acceptable/patient-centred: health care, which takes into account the preferences andaspirations of individual service users and the cultures of their communities.

equity: health care, which does not vary in quality because of personal characteristics suchas gender, race, ethnicity, geographical location, or socioeconomic status.

Safety: delivering health care which minimises risks and harm to service users.

Coordination and continuity of care: Access to care provided by families andcommunities, by outpatient and outreach services, and by clinical services throughout thelifecycle, including adolescence, pregnancy, childbirth, the postnatal period, and childhood.Saving lives depends on high coverage and quality of integrated service-delivery packagesthroughout the continuum, with functional linkages between levels of care in the healthsystem and between service-delivery packages, so that the care provided at each time andplace, contributes to the effectiveness of all the linked packages.

1.2 SITUATION ANALYSIS

Zimbabwe Health Status

e life expectancy at birth for Zimbabwe decreased from 61 years in 1992 to 41 years in2002, which was lower than the average life expectancy at birth in sub-Saharan Africa.

Background1

According to the Zimbabwe Demographic Health Survey (ZDHS) 2010/11, this figure hasrecently risen to 52 years matching the overall increasing trends in sub-Saharan Africa asshown in figure 1. e QI strategy will therefore aim to contribute to improved lifeexpectancy by strengthening quality of health promotion, prevention and curative servicesfor high-burden diseases in Zimbabwe.

Child Health

e status of newborn, infant and child health in Zimbabwe has been deteriorating in thepast 15 years as depicted by figure 2 above. According to the ZDHS 2010/2011, the InfantMortality Rate (IMR) and Under 5 Mortality rate (U5MR) were 57/1000 live births and87/100 live births respectively. e majority of deaths, 86% occur during the first year oflife of which 37% occur in the first month of life. e neonatal mortality rate is 36 per 1,000live births (State of the World’s Children 2009, UNICEF) with 75% of deaths occurringwithin the first week of life. Of these, 50% occur within the first 24 hours of life. irtynine percent of neonatal deaths are caused by preterm birth complications followed bybirth asphyxia (27%), and neonatal sepsis (14%). ese statistics show how critical theperinatal period is in improving overall child survival in Zimbabwe.


Background 1

010203040506070

1992 2002 2012

Figure 1: Life expectancy at birth in Zimbabwe and sub-Saharan africa 1992-2012

020406080

100120140160

1999 ZDHS 2005 ZDHS 2010 ZDHS 2012Census 2014 MICS

Under 5 Mortality Rate/1000Infant Mortality Rate/1000

Figure 2: ZDHS infant Mortality and Under 5 Mortality in Zimbabwe between 1999-2014

Zimbabwe Life Expectancy at BirthSub-Saharan Africa Life Expectancy at birth

0


e Fresh Still Birth (FSB) rate is a strong indicator of the quality of intra-partum care.Figure 3 shows that the country still has unacceptably high rates ranging from 40/1000 inMutare Provincial hospital to 7/1000 at Harare Central hospital and Mashonaland Eastprovince. e QI strategy must therefore give direction on ways to improve the quality ofcare to reduce the FSB rate.

Figure 4 below shows the Early Neonatal Deaths (ENND) per 1000 live births by institutionand province in 2012. ese ranged from a highest of 88/1000 in Harare Central hospitalto 11/1000 in Mashonaland Central, Matebeleland South and St Lukes hospital. e QIstrategy will prioritize strategies for reducing ENND in high-mortality institutions andprovinces by strengthening quality of Essential Newborn Care and early detection andevidence-based care for major causes of early neonatal mortality (asphyxia, sepsis andprematurity).

Background1

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FSB Rate/1000 live births

Figure 3: Fresh Still births per 1000 live births by province and central institutions 2012

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ENND/1000 live births

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Figure 4: early Neonatal deaths per 1000 live births by province and institution Zimbabwe, 2012

Note: Data is from the national T5 series HMIS


e top causes and absolute numbers of infant and under five mortality are shown in thetable below for the eight rural provinces according to data from the HMIS for 2012. eQI strategy will prioritize cross-cutting essential health system functions and delivery ofevidence-based high impact services for leading causes of neonatal and childhood mortalityas described in Table 1.

In addition, the Multiple Indicator Monitoring Survey (MIMS) of 2009, reports that 32%of all the children who had anthropometric measurements were stunted. is strategy musttherefore address issues to improve quality in prevention and management of malnutritionto improve the quality of health care to reduce morbidity and mortality in children.

Gaps in the quality of care for newborns, infants and under 5years to be addressed bythis strategy

e quality improvement strategy will address gaps in quality of antenatal care to reducepremature labor, quality of intra-partum care to reduce incidence of birth asphyxia, andquality of newborn care to reduce neonatal sepsis.

l Late diagnosis and management of maternal conditions and infections that may leadto preterm labour.

l Inconsistent availability of dexa-methasone to facilitate lung maturity for the pretermbabies.

l Non-availability of resuscitation equipment and commodities at newborn corners tomanage preterm and term babies.

l Late referral to higher levels of care.

l Non-availability of oil heaters.

l Inadequate numbers of incubators.


Background 1

Table 1: Number of neonatal, infant and under 5 deaths by specific disease and rural provinces in Zimbabwe, 2012


Province Pneu-monia Malaria Mal-nutrition Dia-rrhoea

Manicaland 446 342 278 302

Mashonaland East 594 134 484 11

Matebeleland South 124 43 0 51

Midlands 59 44 0 41

Mashonaland West 44 27 29 41

Matebeleland North 32 39 1 15

Mashonaland Central 42 20 0 11

Masvingo 17 23 0 9


l Inconsistent availability of cleaning materials for infection control.

l Poor or no monitoring and evaluation of infection control procedures e.g. by doingswabs for microscopy culture and sensitivity.

l Inconsistent use of the partograph leading to failure by health workers to react in atimely and appropriate manner when emergencies or complications occur.

l Late diagnosis of neonatal sepsis.

l Inconsistent availability of antibiotics for treatment of neonatal sepsis.

l Inadequate staff trained in IMNCI guidelines

l Poor adherence to IMNCI guidelines on management of illnesses (pneumonia,diarrhoea and malaria)

l Late infant diagnosis of HIV and commencement of pediatric ART

l Late diagnosis and management of severe malnutrition

Maternal Health

Trends in maternal and child health are an indicator of the general socio-economic statusof a country and of the overall strength of the health system since maternal health outcomesdepend on a robust health system capable of providing coordinated routine and emergencyobstetric care. e Maternal Mortality Ratio (MMR) has been increasing in the past 15years as shown in Figure 5. e QI strategy will address critical quality gaps in provisionof high-impact routine and emergency best practices for prevention and management ofmajor causes of maternal mortality and morbidity (PPH, eclampsia, sepsis, obstructedlabor, and abortion).

Background1

0200400600800

10001200

1999 ZDHS 2005 ZDHS 2010 ZDHS 2012 Census 2014 MICS

Maternal Mortality Ratio/100,000

Figure 5: ZDHS Maternal Mortality Ratio Trends, Zimbabwe 1999-2014

e graph in figure 6 shows the number of maternal deaths by institution and province in2012. e QI strategy will aim to prioritize strategies to reduce maternal deaths ininstitutions and provinces where the numbers are high. is graph is however anunderestimate of the actual numbers since community deaths are not captured in theroutine Health Management and Information System (HMIS).

Reduction of maternal morbidity and mortality depends on achieving coverage of highquality and well-coordinated ANC, delivery and postpartum maternal health servicesprovided by a skilled birth attendant and staff working in an enabling environment (whichrequires essential commodities, 24/7 availability of competent staff, supervision, etc).According to the ZDHS 2010/11, 90% of women had at least one ANC attendance andwere attended by a skilled health worker in their previous pregnancy. However, skilledattendance at birth demonstrated striking disparities between urban areas (86%) and ruralareas (58%). Table 2 below shows delivery in health facilities and skilled attendance atdelivery. e quality strategy will seek to improve equity of coverage of high-impact servicesfor disadvantaged regions and populations of women (e.g. poor women).


Background 1

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Number of Ins tu onal Maternal deaths

Figure 6: institutional maternal deaths by province and institution, Zimbabwe, 2012


Province Skilled attendance at delivery (%) Delivery in facility (%)Bulawayo 88.4 88.3Harare 83.5 82.7Masvingo 75.2 73.4Matebeleland South 71.6 69.3Matebeleland North 65.7 63.5Midlands 64.7 63.5Manicaland 60.3 60.7Mashonaland East 59.9 59Mashonaland West 55 52.6Mashonaland Central 51.4 50.3

Table 2: Delivery in health facility and skilled attendance at birth by province in Zimbabwe, ZDHS 2010/11


Gaps in quality of maternal care to be addressed by this strategy

Some of the gaps in quality of maternal care are as follows:

l Poor history taking leading to missing of critical information to identify at riskpregnancies.

l Unavailability of BP machines and urinalysis kits.

l High patient midwife ratio in some institutions.

l Low skilled attendance at birth especially in rural institutions.

l Inconsistent utilization of the partograph leading to poor monitoring of labourresulting in delayed reactions.

l Non-availability of quality checklists in labour ward.

l Inconsistent availability of theatre drugs and commodities including oxygen.

l Late referral of critical cases.

l Lack of on-the-job supervision and mentorship.

l Inconsistent availability of blood and blood products.

l Inappropriate management of pregnancy induced hypertension, pre-eclampsia andeclampsia.

l Inconsistent availability of antibiotics for management of HIV related co morbidity.

HiV and aiDS

ere has been a slight decrease in HIV prevalence in Zimbabwe from 18% (ZDHS 2005-6) to 15% (ZDHS 2010-11). As more and more people survive on Anti-retroviral erapy(ART), the quality of care will need to be a major focus for treatment programmes. ereis an Early Warning Indicator survey for HIV drug resistance which is being implementedwhich needs to be further disseminated and strengthened. However, there is need tointroduce viral load testing to closely monitor patients in order to measure the quality ofcare in a more objective way.

Background1

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1515

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Total 15-49 years Women 15-49 years Man 15-49 years

2005-6 ZDHS 2010-11 ZDHS

Figure 7: ZDHS Trends in HiV Prevalence, Zimbabwe 2005-2011

Table 3 below shows the HIV prevalence in Zimbabwe by province. e highest prevalenceis in Matebeleland South province (21%) and the lowest prevalence is in Harare province(13%). Quality issues on the delivery and reach of HIV/STI prevention programmesespecially in the high burdened provinces needs to be addressed in this strategy.

Gaps in HiV and aiDS quality of care to be addressed by this strategy

e gaps in quality of care for people living with HIV are outlined and are related to thetesting, treatment and care cascade as follows:

l Low population coverage of HIV testing.

l Unavailability of a mechanism to track linkage to care for those who test positive.

l Weak counseling on disclosure, behavior change and adherence.

l Lack of an effective measure of adherence to treatment.

l Lack of an implementation plan for treatment as prevention strategies.

l Lack of an effective means of tracking patients lost to follow-up.

l Monthly reviews and drug pick-ups in view of competing priorities

l Inconsistent availability of CD4 testing.

l Unavailability of biochemistry and liver function tests in most institutions.

l Lack of access to viral load testing.

l Unavailability of HIV resistance testing.


Background 1

Province HiV Prevalence (%)

Matebeleland South 21

Bulawayo 19

Matebeleland North 18

Mashonaland East 16

Mashonaland West 15

Midlands 15

Masvingo 14

Manicaland 14

Mashonaland Central 14

Harare 13

Table 3: HiV Prevalence by province, ZDHS 2010-11


MalariaMalaria incidence has been on the decline in Zimbabwe in the past ten years and with oneprovince, Matebeleland South province entering the pre-elimination stage of malariacontrol. According to the ZDHS 2010-11, 41% of households had at least one mosquitonet and 29% had at least one insecticide treated mosquito net (ITN). Seventeen per cent ofhouseholds reported that they had received indoor residual spraying in the past 12 months.On the night before the survey, 14% of children under the age of 5 years slept under amosquito net.

Malaria case management audits have demonstrated above average adherence to malariadiagnosis and first line therapy. However, inadequate monitoring of in-patients with severemalaria has been associated with high case fatality rate. (Malaria Case Management Audit,2010).

Gaps in malaria quality of care to be addressed by this strategye gaps in quality of care in malaria care are related to prevention, suspicion, diagnosisand case management of malaria as outlined below;

l Low coverage of indoor residual spraying, inadequate insecticide treated nets, and lownumbers of children under 5 sleeping under treated nets.

l High suspicion of malaria at the expense of other differential diagnosis.

l Late diagnosis of malaria.

l Inappropriate case management of malaria.

l Poor management of complicated malaria.

l Late referral of complicated malaria cases.

Non Communicable Diseases (NCDs)Hypertension and its associated complications (stroke, heart and kidney failure) is themajor NCD affecting the Zimbabwean population and is now contributing more to theburden of disease in Zimbabwe. e WHO Stepwise approach to Surveillance (STEPs)survey conducted in Zimbabwe in 2005 showed a high prevalence of hypertension: 23.2%among adult males and 29% among adult females.1 increasingly, younger persons underthe age of 40 years are presenting with hypertension which is oen poorly controlled. isis against a background of low awareness of hypertension in the population and poor bloodpressure control among those on treatment, high prevalence of risk factors such as obesityamong females (32% prevalence), and alcohol and tobacco consumption among males.Evidence suggests that tertiary hospitals in Harare are now overwhelmed with increasingnumbers of individuals presenting with complications of uncontrolled NCDs such asstroke, heart and renal failure with increasing bed occupancy levels. ere has been asignificant increase in the incidence of cancers such as cervical, breast and prostate cancerin an environment where diagnostic and treatment facilities are limited.

Gaps in quality of care for Non-Communicable diseases to be addressed by this strategye gaps in quality of care of patients with non-communicable diseases remain extensivesince these conditions have been largely ignored over the past 10 years because of the focus

Background1

on MOHCC’s priorities which are mostly communicable disease control programs. Someof the gaps are:

l Non-availability of screening facilities and equipment for NCDs.

l Lack of diagnostic facilities for NCDs.

l Late presentation of patients with NCDs leading to avoidable deaths.

l Poor clinical management and monitoring of NCDs.

l Unavailability of drugs and commodities for the management of NCDs.

l Lack of effective follow-up mechanisms for patients with NCDs.

1.3 STRENGTHS, WEAKNESSES, OPPORTUNITIES ANDTHREATS (SWOT) ANALYSIS

ere are crosscutting health system weaknesses impairing optimal health systemfunctioning and delivery of high quality services in Zimbabwe. An overall SWOT analysisfor the provision of quality healthcare is summarised below:

Strengths:

l Existence of institutions responsible for setting standards of care such as the StandardsAssociation of Zimbabwe and regulatory bodies such as the Health ProfessionsAuthority among others.

l Commitment and leadership from the MOHCC to ensure QA&QI processes areadopted as evidenced by the formation of the Quality Assurance Department in theMOHCC.

l Existence of some clinical treatment, infection control, and clinical audit guidelines.

l Well established proficiency testing system for laboratories.

weaknesses:

l Underfunding of health services.

l Variable provider competence to deliver best practices.

l Low staffing levels against a background of high workload.

l Lack of well-defined quality management systems in health training institutions.

l Inconsistent and poor staff support and supervision, assessment of competences andevaluation of performance aer training.

l Non-systematic undertaking of clinical audits.

l Inadequate capacity of the QA department within the MOHCC to oversee QA&QIactivities.

l Lack of inclusion of quality of care (content) measures, including regular analysis ofsuch measures as part of routine facility health services and national and local HealthManagement and Information Systems.


Background 1


l Lack of improvement capacity and experience among mid-level managers and front-line health service delivery staff to support continuous improvement to overcomeimportant quality of care gaps.

l Lack of pre- and in-service competency based training on quality of care.

l Lack of data on major quality of care gaps and service delivery and health systemobstacles related to priority health conditions.

l Lack of good monitoring and feedback mechanism to allow two-way flow ofinformation.

l A health system fragmented along vertical programmes.

l Availability of essential commodities and stock management.

Opportunities:

l Political commitment at national level to the importance of quality for achievingpriority national health outcomes.

l Existence of Quality Assurance Department within the MOHCC.

l Commitment of partners and professional associations to QA&QI initiatives.

l Examples/models of good functional hospital quality management systems in placeto adopt.

l Several QA&QI initiatives in the country to learn from e.g. HIV/TB QA&QIinitiatives, Maternal, Newborn and Child Health QA&QI initiatives, Results BasedFinancing experiences.

l Existence of QA&QI policies and guidelines for some national programmes.

l New constitutional provisions prioritizing health as a human right.

l Institutional memory on QA&QI activities during the “good old days”.

l Existence of a patient’s charter.

l Existence of health centre committees.

l Availability of intrinsically motivated community health workers.

reats:

l Underfunding and inefficiencies in the utilisation of health care resources.

l Dependence on donors for funding of QA&QI activities.

l Expectations for remuneration from staff whenever QA&QI is mentioned.

l Lack of empowerment (education and knowledge of the patient’s charter).

l Resistance to change among providers and managers.

l Lack of data on the quality of care of the leading conditions of morbidity and mortalityin Zimbabwe.

Background1

Experience and Progress so far in QI initiatives in Zimbabwe

e MOHCC formed a Directorate of Quality Assurance at national level under thePrincipal Director of Policy Planning Monitoring and Evaluation, which is a sign of highlevel commitment to fulfil the mission of delivering quality health services. e Directorateof Quality Assurance with assistance from technical partners and stakeholders led theformulation of a QA&QI policy, which is now at final dra level and awaits approval andlaunching. is strategy recognises and seeks to build on QI initiatives already undertakenand in progress in different programmes, levels of care and areas of Zimbabwe. Severalquality improvement initiatives undertaken in Zimbabwe are briefly described below,highlighting key elements that have informed this strategy.

anti-Retroviral erapy (aRT) Quality improvemente MOHCC has piloted a quality improvement initiative in 83 of the 700 ART sites. eprogramme has 5 key elements:

l Performance measurement - using mostly process indicators along the ART cascadee.g. % of patients retained in care 6 and 12 months from enrollment (ART eligible andART-ineligible).

l Quality improvement - problem identification using management tools such asprocess mapping, 5 Whys fishbone analysis and prioritization of interventions usinga decision making matrix.

l Coaching and mentoring including peer learning and exchange visits.

l Consumer involvement - clients involved during training and development of QIimplementation plans. However no indicators have been developed to monitor thisinvolvement.

l Quality management system - organisational assessment to build the necessaryinfrastructure that supports QI.

Of the 83 sites that have been trained and participated in the initial phase of theperformance measurement process, 35 of them have started using the information gatheredto undertake quality improvement activities through ART QI subcommittees, which reportto the overall QI committee at the respective institution aer getting the training on basicprinciples of quality improvement. e ART quality improvement initiative is closely linkedto the recently introduced Electronic Patient Management system (EPMS) in 84 main ARTsites countrywide. is system allows the ART programme to easily capture qualityindicators used for performance measurement at both local and central levels.

e ART model of QI including the EPMS, provides a base on which this strategy can buildon. Other programmes and clinical disciplines can adapt this strategic framework to suittheir needs for QI.

electronic Patient Management System – Since the inception of HIV/TB programme, allpatient related data has been collected using a manual paper based system. e manualsystem has been unable to function properly owing to increased number of patientsrequiring HIV/TB services and this affected accurate monitoring, tracking and reporting


Background 1


of patients accessing HIV/TB services. e quality of data was suffering because of the highworkload but also because of the challenge of tracking the ‘drop-out’ rate of patients fromthe system (e.g. moving to another clinic, death, not coming to an appointment etc.). Inaddition, health workers are spending significant amounts of time entering data intoregistries or generating monthly monitoring tallies. To address this gap and to ensure thatHIV/TB data is collected in a timely manner and is of good quality, the MOHCC resolvedto establish an electronic system to collect and manage patient level HIV/TB data.

e roll out of the EPMS is on course although there are some challenges. ese include:

l Inadequate funding to conduct supportive visits to sites.

l Internet Service Provider (ISP) Network not covering all health facilities

l Frequent power cuts.

l Few teams responsible for installations, maintenance and trainings.

l Inadequate IT skills among most health care workers.

Quality improvement in PMTCTIn 2012, the MOHCC with support from EGPAF piloted a QI initiative for PMTCT atfacility level that started with the sensitization of District Medical Officers, District NursingOfficers and PMTCT District Focal Persons. Concepts, processes, planning anddocumentation tools were developed focusing on 4 specific areas:

l CD4 count testing for pregnant women.

l ART initiation for eligible pregnant women.

l Early Infant diagnosis.

l Early infant ART initiation.

Aer the introduction of Option B+ for PMTCT in 2014, the indicators on CD4 count,Early infant ART initiation and ART initiation for eligible pregnant women were revisedaccordingly and a new additional indicators was added. e revised and the newlyindicators are:

l ART initiation in ANC for all HIV positive pregnant women

l Pediatric ART initiation for <2 years HIV positive children

l Retention in care of HIV positive women and children < 2 years aer being initiatedon ART

Almost all districts were involved. However, only 125 sites were consistently reporting onall or any of the indicators of the specific areas mentioned above. Some experiencesencountered in implementing QI include:

l Local initiatives have demonstrated improvements on some indicators e.g. related tobetter communication between facilities and communities.

l Improvement were also seen on some of the indicators on which the sites are workingon e.g.the percentage of HIV positive pregnant women who were initiated on ARTthe same day has increased from 70 to 96%.

Background1

l e QI implementing sites were provided coaching visits through QI coaches and peerlearning meetings were also conducted.

l Lack of agreed measurable and verifiable standards hindered the objective assessmentof progress made.

l Overlap in training across the concepts of Quality Assurance, Quality Managementand Quality improvement might have led to challenges to participants grasping theconcept of QI.

l Protocol issues oen necessitated the need for repeat sensitization of stakeholdersleading to increased costs and delays in implementation.

l Low capacity of providers at service delivery point in appreciating and using local datafor decision making. is is happening in the context of perceived low morale amonghealth workers.

l Inadequate resources for coaching, support and supervision and a general lack ofaccountability at various levels of the MOHCC.

l e community lacks a culture of interrogating the quality of service rendered inrelation to their rights. Feedback on QI activities or surveys has generally not beenrelayed back to clients.

improving the quality of Maternal and Newborn Care in Zimbabwe

e MOHCC with support from Maternal and Child Health Integrated Programme(MCHIP) piloted a QI initiative in 2 districts in Manicaland Province from 2010 to 2013.is programme used the Standards Based Management and Recognition (SBM-R) qualityimprovement approach which has been successfully implemented in several othercountries. e SBM-R consists of:

l Setting performance standards based on national norms, policies, and guidelineswhich are consistent with international best practices and evidence based.

l Implementing standards through a systematic and structured approach.

l Measuring progress continuously to guide performance improvement activities.Recognizing achievement of the target performance improvement standards

Following an inclusive consultative process, standards for Maternal, Newborn and ChildHealth (MNCH) were identified and packaged into 5 clinical areas (process) and 5 areasof support systems (context) and written on a standard template. e implementation ofthe QI approach was modular in nature and followed the following steps:

1. Measuring the performance gaps using Standards set (expected level of quality) tomeasure the actual performance.

2. Analyzing the cause(s)/root cause analysis for the performance gaps, selecting priorityinterventions, implementing interventions (training, procurements, supervision,refurbishments, and others).

3. Evaluating progress through continuous self and peer assessments, and scheduledexternal assessments.


Background 1


In the baseline assessment conducted in 2010-11, less than 40% of the MNH standardswere fully met at any facility. e performance was particularly poor in the clinical areas.Following implementation of SBM-R, there was a demonstrated statistically significantincrease in performance scores for MNCH Services from 2010 to 2013 with the scoreincreasing from approximately 20% to 80%. A notable reduction in early neonatal mortalitywas clearly documented during the intervention period.

ese initiatives although mostly donor funded have a common purpose of improvingquality of care. While they differ in terms of approach to implementation, the conceptsand principles are largely similar. Linking performance to minimal institutional incentivessuch as in Results Based Financing (RBF) has also shown some association withimprovement in quality of care from the community perspective for example patientsatisfaction with staff attitudes as noted in the Mid-Term Review of the RBF program.(RBFmid-term Review Report, June 2013).

is initiative is now being implemented in all districts in Manicaland province.

Results based Financing (RbF) program as pay for quality improvement initiative

RBF programme funded by World Bank has been implemented by CORDAID- Zimbabwein 18 districts since 2011. e health facilities have been receiving subsidies with a focuson MNCH indicators. e subsidies are provided according to the results obtained fromquantity verification, quality supervision checklists for hospitals and health centres andclient tracer satisfaction survey results. e quality supervision checklist has both structuraland clinical indicators and is administrated by DHEs and PHEs. e PHEs and DHEs wereprovided adequate training on the use of the quality supervision checklist.

e client tracer satisfaction surveys are conducted by CBOs on the clients identified duringthe quantify verification exercises from registers using the systematic random samplingtechnique. CBO were trained on how to effectively conduct client satisfaction surveys andwrite a report on the findings. e findings from quality supervision, quantity supervisionand client satisfaction surveys have been discussed at provincial, district, and HCcommittee level. Some provinces and districts have designed and implemented a postassessment support mechanism to address the identified gaps. In order to maintain thequality of the verification mechanism, external verification has been conducted byUniversity of Zimbabwe Community Health Department quarterly on selected healthfacilities.

Preliminary evaluation results have shown improvement on few quality process indicatorse.g. an increase of 13 and 12 % were seen on in facility delivery rate and post natal coverage,respectively and most women received full package of ANC services. Taking in to accountthe preliminary findings and the findings from the quality supervision checklists, MoHCCdecided to scale up the RBF approach to 42 additional districts in 2014 using HTF. isapproach has paved the way for the institutionalization of the pay for quality model ofimprovement.

Background1

e National QualityImprovement StrategicFramework

Rationale for a Strategy on Quality Improvement in Health Care

e Quality Improvement strategy is expected to help ensure the rational application ofdifferent quality approaches and streamline efforts through the introduction of priorities,targets and milestones. Since this strategy is introduced on the background of a multitudeof factors hindering the provision of quality services, a phased approach is suggested thattakes into account the resource constrained environment in which it will be implemented.e earlier phases of implementation will focus on the most immediate health challengesthat help build necessary foundations for quality, measurement, accountability and changeare in place to enable further success.

National Qi Strategy

e QI Strategy has ten strategic priorities to:

1. Strengthen leadership structures and mechanisms that will develop, advocate for,implement and sustain QA/QI processes in the health sector.

2. Increase patients’ participation and empowerment by promoting client awareness oftheir rights when interfacing with the health system.

3. Address and prioritise issues of access, effectiveness, efficiency and equity of healthcare.

4. Improve patient/client safety, reducing errors in health care and improving health carewaste management to reduce possible harm to staff, patients and communities.

5. Develop long-term mechanisms that attract and retain staff in the health system.

6. Strengthen supportive supervision as well as routine self-assessment of performance.

7. Develop accountability frameworks that hold providers and staff responsible for thequality of services provided.

8. Ensure efficiency in service provision through reorganisation and inte-gration ofdifferent programmes.

9. Strengthen the health information management system to adequately monitor andevaluate quality in health care and facilitate operations research on QA&QI in healthand dissemination of levels of provider achievement in quality of care.

10. Mobilise and leverage financial and non-financial resources (expertise andtechnology) from other sectors towards the resuscitation of health services thatincorporates a culture of QI.


2


2.1 AIM AND GUIDING PRINCIPLES OF THE STRATEGY

Aim: To provide quality preventive, curative and rehabilitative health services which areaccessible, acceptable, effective, safe and equitable, as efficiently as possible and within thecontext of continuous improvements. e ultimate aim is to deliver the highest qualityhealthcare services to the people of Zimbabwe.

Guiding Principles1. Patient-centred care recognising and reflecting the uniqueness of the individual, their

experience of their health, illness and healthcare, and enabling them to share indecision-making about their care, to manage their own health and illness, throughsupport and access to advice and information for them, their families and carers.

2. Delivering services through empowered staff enabling people working in the healthsector to use their skills, further improving staff experience, staff engagement, andbuilding capacity, providing support and incorporating a culture of continuous QualityImprovement into routine practice.

3. Health Systems approach guided by the six building blocks for health systemsstrengthening.

4. a culture of continuous Quality improvement that recognises the centrality ofmeeting client expectations and values and delivering safe, effective health care. isculture will permeate health care organisations which will be reorganised to deliverbased on client needs and evidence-based care.

5. Reward for performance that encourages and rewards proactively, collaborativeefforts that emphasise prevention and improves positive health outcomes.

6. Standardising processes of care and ensuring adherence to these will lead to betterutilisation of resources and better patient outcomes.

7. Creating a shared learning culture that uses lessons learned to modify systems toprevent negative occurrences and enhance patient safety and which actively spreadsthese lessons in support of continuous shared learning. Sharing of data collected onquality indicators and activities in a transparent manner will promote shared learningto accelerate the uptake of best practices from QI efforts.

8. innovative ways of problem solving will require an agreed methodology for problemroot cause analysis.

9. basing approaches on evidence-based strategies/practices which whenimplemented will lead to more favourable patient outcomes.

10. Collective effort and team work where QI committees are composed of the rightbalance of stakeholders is crucial to the success of improvement efforts.

11. Results-driven processes with regular real-time measurement and analysis ofprioritised results will be critical for a strong QI approach.

ese guiding principles for quality improvement cut across all the six building blocks ofhealth systems strengthening approach which are summarised below.a. Leadership and Governance: Quality improvement increases oversight, stewardship

and accountability in governance of the health system as well as more meaningfulparticipation of citizens in healthcare.

e National Quality Improvement Strategic Framework2

b. Service delivery: QI fosters the delivery of proven high impact interventions in astandardised way leading to the closure of the gap between minimum expectedstandards and actual practice.

c. Human Resources: QI enhances the responsiveness, performance, satisfaction andretention of staff ensuring adequate numbers of appropriately skilled staff can operatein an efficient manner.

d. information: QI will increase the capacity of health institutions to collect analyse andutilise reliable and timely health information on quality of care.

e. Financing: QI helps optimize the efficient use of resources for greater impact and mayact as a stimulus for resource mobilisation.

f. Medical supplies, vaccines and technology: QI promotes a scientifically sound andcost-effective use of these commodities. e.g. adherence to guidelines on rational useof medicines.

2.2 STRATEGIC OBJECTIVES, PRIORITIES ANDINTERVENTIONS

Conceptual Framework for National Qi Strategy

e strategy introduces a two-dimensional framework to support continuous improvementand sustaining of high quality care at all levels of the Zimbabwe health system and acrossall priority technical areas (e.g. MNCH, HIV/AIDS, TB, Malaria, NCDs).

e horizontal dimension defines a set of specific strategic objectives along the dimensionsof quality of care(based on national QI/QA policy strategic priorities and priority qualitydimensions) designed to achieve broad-ranging improvements in essential health systemfunctions and health services in the coming five to eight years in support of the nationalQI/QA Policy. Each strategic objective includes intermediate sub-objectives and specificactivities to achieve the intermediate objectives and overall strategic objective. Strategicobjectives and related interventions are designed to improve the capacity of the healthsystem to provide high quality services.

Strategic objectives along dimensions of care are:

l Improving patient safety.

l Providing client centred services.

l Strengthening data recording, reporting system and use of this data for decisionmaking.

l Improving clinical practices (effectiveness of care).

l Building pre-service and in-service capacity to continuously improve.

l A professional and motivated health workforce with an enforceable code of ethics.

l Improved and efficient, cost effective supply of equipment, medicines, consumablesand health related commodities.


e National Quality Improvement Strategic Framework 2


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ipat

ing

in g

radi

ng o

fLa

bs a

ccor

ding

to W

HO

scor

ing

syst

em (s

tars

awar

ded)

•%

of L

abs a

ccre

dite

d•

% o

f Cer

tified

Lab

orat

orie

s•

Nos

. of c

ertifi

ed st

aff o

n Q

ualit

yM

anag

emen

t Sys

tem

cou

rses

•N

os. o

f non

-con

form

ities

tost

anda

rds.

•N

os. o

f Qua

lity

Impr

ovem

ent

Proj

ects

taki

ng p

lace

at in

stitu

tions

1.Re

vive

hea

lth ce

ntre

com

mitt

ees l

inke

d to

eac

h ru

ral h

ealth

faci

lity

2.A

dvoc

ate

for i

ntro

duct

ion

of h

ealth

com

mitt

ees i

n ur

ban

loca

lau

thor

ities

3.Re

vive

com

mun

ity h

ealth

coun

cils

for d

istric

t hos

pita

ls.4.

Stre

ngth

en a

nd/o

r rev

ive

Hos

pita

l Boa

rds i

n pr

ovin

cial

and

cent

ral h

ospi

tals.

5.

Iden

tify

and

incl

ude

patie

nt re

pres

enta

tives

on

heal

th ce

ntre

,pr

ovin

cial

and

dist

rict Q

I tea

ms.

1.Ev

alua

te th

e cu

rren

t inf

orm

ed co

nsen

t sys

tem

to id

entif

y ga

psin

clud

ing

revi

ewin

g al

l con

sent

form

s cur

rent

ly in

pra

ctic

e.2.

Revi

se a

ny co

nsen

t for

ms w

here

nec

essa

ry.

3.D

evel

op a

chec

klist

to g

uide

hea

lth w

orke

rs to

stre

ngth

endi

ssem

inat

ion

to p

atie

nts o

n co

nsen

ting

to su

rgic

alin

terv

entio

ns.

4.Q

I ins

titut

iona

l tea

ms t

o m

onito

r con

sent

pro

cedu

res a

t eac

hin

stitu

tion

on a

qua

rter

ly b

asis.

5.Q

I Dist

rict t

eam

s to

mon

itor c

onse

nt p

roce

dure

s at R

HC

leve

lon

an

annu

al b

asis.

1.A

sses

s the

avai

labi

lity

of p

rivat

e co

unse

lling

(visu

al a

ndau

dito

ry) i

n ou

tpat

ient

and

hos

pita

l clin

ical

car

e se

tting

s.2.

Dev

elop

Pro

vinc

ial p

lans

to a

ddre

ss st

reng

then

ing

of th

e pr

ivac

yin

fras

truc

ture

and

mob

ilise

reso

urce

s.3.

Emph

asise

and

enf

orce

the

prin

cipl

e of

pat

ient

confi

dent

ialit

y as

part

of p

rofe

ssio

nal c

ode

of e

thic

s.

1.Sc

ale

up m

ento

rshi

p pr

ogra

ms o

n ac

cred

itatio

n of

med

ical

and

anal

ytic

al la

bs.

2.Tr

ain

appr

opria

te m

anag

ers a

nd st

aff u

sing

the

Labo

rato

ryM

anag

emen

t tow

ards

Acc

redi

tatio

n co

urse

(SLM

TA).

3.Tr

ain

clin

ic a

nd h

ospi

tal s

taff

on h

ow to

com

ply

with

the

requ

irem

ents

of I

SO 9

000,

4.

Eval

uate

inst

itutio

ns fo

r acc

redi

tatio

n an

d ce

rtifi

catio

n.

Stra

tegi

c Obj

ectiv

ein

term

edia

te O

bjec

tive

Key

act

iviti

esin

dica

tors

Proj

ecte

dC

ost



To e

stab

lish

and

stre

ngth

en d

ata

reco

rdin

g an

dre

port

ing

syst

em a

ndus

e da

ta fo

r dec

isio

nm

akin

g in

qua

lity

impr

ovem

ent b

y 20

18

1.To

impr

ove

data

col

lect

ion

and

med

ical

reco

rds a

nd to

prom

ote

use

of re

leva

ntin

form

atio

n ac

ross

all

tiers

of th

e he

alth

syst

em

2. T

o im

prov

e re

port

ing

syst

ems

and

feed

back

mec

hani

sms

acro

ss a

ll tie

rs o

f the

hea

lthsy

stem

3.To

colle

ct a

nd v

erify

hig

hle

vel p

erfo

rman

ce in

dica

tors

that

dem

onst

rate

the

qual

ity

of h

ealth

serv

ices

•%

faci

litie

s reg

ular

ly c

olle

ctin

g an

dan

alys

ing

a co

re se

t of q

ualit

y of

car

epr

oces

s and

out

com

e m

easu

res”

(whe

ther

via

pap

er- o

r ele

ctro

nic-

base

d m

etho

ds)

•N

umbe

r of f

acili

ties w

ith li

st o

f cor

equ

ality

of c

are

indi

cato

rs

•N

umbe

r of i

nstit

utio

ns re

ceiv

ing

qual

ity im

prov

emen

t fee

dbac

kre

port

s•

Num

ber o

f ins

titut

ions

with

Das

hbo

ard

syst

em to

trac

k co

re o

f set

sent

inel

qua

lity

mea

sure

s

•N

o. o

f hea

lth fa

cilit

ies w

ithgu

idel

ines

to a

sses

s wai

ting

and

disc

harg

e tim

es•

No.

of h

ealth

faci

litie

s with

ann

ual

plan

s to

addr

ess w

aitin

g tim

e iss

ues

•N

o. o

f hea

lth fa

cilit

ies c

ondu

ctin

gpa

tient

flow

man

agem

ent a

naly

sis•

No.

of h

ealth

faci

litie

s with

cor

e hi

ghpe

rfor

man

ce q

ualit

y of

indi

cato

rsan

d gu

idel

ines

for c

olle

ctio

n an

dre

port

ing

on in

dica

tors

1.D

evel

op st

anda

rd o

pera

ting

proc

edur

es (S

OP)

on

data

colle

ctio

n, re

port

ing

and

anal

ysis

for q

ualit

y im

prov

emen

t.2.

Defi

ne q

ualit

y of

car

e in

dica

tors

(pro

cess

and

out

com

e)ap

prop

riate

for m

onito

ring

as p

art o

f rou

tine

HM

IS b

ased

on

the

diffe

rent

nee

ds o

f the

nat

iona

l, pr

ovin

cial

and

dist

rict

leve

ls.

3.D

evel

op a

nd im

plem

ent a

n ap

prop

riate

inte

grat

ed el

ectr

onic

patie

nt d

atab

ase

that

is se

nsiti

ve to

issu

es o

f pat

ient

confi

dent

ialit

y, se

curit

y an

d po

tent

ial a

buse

of d

ata.

4.Tr

ain

peop

le o

n th

e in

form

atio

n sy

stem

and

pro

vide

pos

t-tr

aini

ng fo

llow

-up.

5.In

stitu

tiona

lise

regu

lar a

naly

sis o

f dat

a to

iden

tify

prog

ress

inQ

I effo

rts a

nd h

ighl

ight

shor

tfalls

of Q

I pro

ject

s.6.

Prov

inci

al a

nd D

istric

t Hea

lth In

form

atio

n O

ffice

rs a

ndQ

ualit

y Im

prov

emen

t Offi

cers

to re

gula

rly v

isit s

ites t

osu

perv

ise a

nd m

ento

r on

data

colle

ctio

n, a

naly

sis a

ndut

ilisa

tion.

7.

e H

ealth

Info

rmat

ion

Uni

t at H

ead

Offi

ce to

regu

larly

visi

tC

entr

al H

ospi

tals

to su

perv

ise a

nd m

ento

r on

data

colle

ctio

n,an

alys

is an

d ut

ilisa

tion.

1.St

reng

then

feed

back

mec

hani

sms i

n th

e H

MIS

for q

ualit

yim

prov

emen

t for

all

tiers

of t

he h

ealth

syst

em.

2.C

onsid

er th

e de

velo

pmen

t of a

faci

lity,

dist

rict,

prov

inci

al a

ndna

tiona

l das

hboa

rd sy

stem

to tr

ack

a co

re se

t of s

entin

el q

ualit

ym

easu

res a

nd p

atie

nt o

utco

mes

.3.

Each

Pro

vinc

e an

d D

istric

t to

inco

rpor

ate

cons

olid

ated

QI

repo

rts i

nto

gene

ric re

port

ing

syst

em.

1.D

evel

op g

uide

lines

for h

ealth

faci

litie

s to

anal

yse

and

addr

ess

issue

s to

do w

ith lo

ng w

aitin

g tim

es, d

ischa

rge

times

.2.

Sens

itise

hea

lth fa

cilit

ies o

n gu

idel

ines

.3.

Inst

itutio

ns in

clud

ing

heal

th fa

cilit

ies t

o dr

aw u

p an

nual

pla

nsw

ith m

easu

res t

o re

duce

wai

ting

times

.4.

Car

ry o

ut p

erio

dic s

ched

uled

inte

rnal

audi

ts to

mon

itor

prog

ress

.5.

Dev

elop

gui

delin

es o

n pa

tient

flow

man

agem

ent t

o ad

dres

siss

ues s

uch

as w

aitin

g tim

es/T

urna

roun

d tim

e/di

scha

rge

times

etc.

Stra

tegi

c Obj

ectiv

ein

term

edia

te O

bjec

tive

Key

act

iviti

esin

dica

tors

Proj

ecte

dC

ost



To im

prov

e Pa

tient

Safe

ty1.

To h

arm

onise

and

stan

dard

ise sy

stem

s to

reco

rd a

nd a

naly

se fo

r all

adve

rse

even

ts a

nd n

ear

miss

es

2. T

o es

tabl

ish a

nd st

reng

then

a sa

fe su

rger

y ch

eckl

istpr

ogra

m in

all

dist

rict,

prov

inci

al a

nd ce

ntra

lho

spita

ls

3.To

stre

ngth

en in

fect

ion

prev

entio

n an

d co

ntro

lm

echa

nism

s in

all h

ealth

inst

itutio

ns

indi

cato

rs a

nd g

uide

lines

for

colle

ctio

n an

d re

port

ing

onin

dica

tors

•N

o. o

f hea

lth fa

cilit

ies r

epor

ting

onqu

ality

of i

ndic

ator

s•

Nat

iona

l qua

lity

of se

rvic

eas

sess

men

t too

l•

Nat

iona

l qua

lity

of se

rvic

eas

sess

men

t rep

orts

•N

umbe

r of

adve

rse

even

tsre

port

ing

form

at d

issem

inat

ed•

No.

hea

lth fa

cilit

ies r

epor

ting

adve

rs e

vent

s

•N

umbe

r of a

dapt

ed su

rgic

al sa

fety

chec

klist

diss

emin

ated

•N

o. o

f hos

pita

ls us

ing

surg

ical

safe

ty ch

eckl

ist•

Porp

ortio

n of

surg

ical

site

infe

ctio

ns at

hos

pita

ls•

Prop

ortio

n of

dea

ths w

ithin

24

hour

s ae

r sur

gery

at h

ospi

tals

•%

of h

ealth

faci

litie

s with

an

infe

ctio

n co

ntro

l pla

n•

Nos

. of H

Ws t

rain

ed o

n in

fect

ion

cont

rol

6.Im

plem

enta

tion

of S

OPs

and

mea

surin

g co

mpl

ianc

e to

the

SOP.

7.Sc

hedu

led

Inte

rnal

Aud

its8.

Sche

dule

d M

anag

emen

t rev

iew

s9.

Defi

ne a

cor

e nu

mbe

r of h

igh

leve

l per

form

ance

qua

lity

indi

cato

rsfo

r diff

eren

t pro

gram

mat

ic a

reas

10. D

evel

op g

uide

lines

for c

olle

ctio

n an

d re

port

ing

on in

dica

tors

11.D

issem

inat

e an

d or

ient

ate

thes

e in

dica

tors

to h

ealth

faci

litie

sth

roug

h in

-ser

vice

and

on-

the-

job

trai

ning

12.D

esig

n a

repo

rtin

g sy

stem

and

colle

ct d

ata

on a

qua

rter

ly b

asis

13.C

arry

out

dat

a qu

ality

ass

essm

ents

to v

erify

dat

a14

.ro

ugh

Dist

rict a

nd P

rovi

ncia

l rev

iew

mee

tings

ana

lyse

dat

a an

dde

velo

p pl

ans t

o ad

dres

s iss

ues a

risin

g15

.Con

duct

nat

iona

l qua

lity

of se

rvic

e as

sess

men

ts

1.D

evel

op a

nd h

arm

onise

an

inte

grat

ed sy

stem

for a

dver

se e

vent

and

near

miss

es re

port

ing

in h

ospi

tals.

2.Im

plem

ent t

he a

dver

se a

nd n

ear m

isses

repo

rtin

g sy

stem

acr

oss a

llpr

ogra

ms.

3.U

tiliz

e th

is in

form

atio

n to

info

rm p

rovi

ders

and

man

ager

s on

QI

activ

ities

.

1.Ev

alua

te th

e cu

rren

t saf

e su

rger

y ch

eckl

ists u

sed

pre-

oper

ativ

ely,

intr

a-op

erat

ivel

y an

d po

st-o

pera

tivel

y.2.

Ado

pt a

nd a

dapt

safe

surg

ery

chec

klist

s for

rout

ine

use

in a

ll di

stric

ts, p

rovi

ncia

l and

cent

ral h

ospi

tals.

3.M

onito

r and

stre

ngth

en im

plem

enta

tion

of su

rger

y ch

eckl

ists.

1.Es

tabl

ish st

anda

rd a

nd fu

nctio

nal i

nfec

tion

cont

rol s

yste

ms a

ndst

anda

rds i

n al

l hea

lth fa

cilit

ies.

2.D

issem

inat

e pr

otoc

ols,

guid

elin

es a

nd jo

b ai

des o

n IP

C

to si

tes.

3.M

obili

se re

sour

ces t

o pr

ovid

e in

fect

ion

cont

rol i

nfra

stru

ctur

e an

dre

sour

ces i

n al

l hea

lth fa

cilit

ies.

4.Tr

ain

and

carr

y ou

t ref

resh

er co

urse

s for

hea

lth w

orke

rs o

nin

fect

ion

cont

rol.

5.In

clud

e ad

here

nce

to in

fect

ion

cont

rol i

n sc

hedu

led

quar

terly

supp

ort

and

supe

rvisi

on

Stra

tegi

c Obj

ectiv

ein

term

edia

te O

bjec

tive

Key

act

iviti

esin

dica

tors

Proj

ecte

dC

ost



To im

prov

e he

alth

wor

kfor

ce c

apac

ity,

mot

ivat

ion

and

acco

unta

bilit

y fo

r

4.To

stre

ngth

en co

ntin

uous

prof

essio

nal d

evel

opm

ent

(CPD

) and

staff

appr

aisa

l

5.To

impr

ove

safe

ty o

fm

edic

ines

6.To

impr

ove

patie

nt sa

fety

awar

enes

s

1. In

tegr

ate

QI c

apac

itybu

ildin

g in

to p

re- a

nd in

-se

rvic

e tr

aini

ng

•%

of h

ealth

wor

kers

who

hav

e ha

dan

ann

ual p

erfo

rman

ce ap

prai

sal

•N

umbe

r of h

ealth

faci

litie

s with

adve

rse

even

ts re

port

ing

form

ats

•N

o. o

f hea

lth w

orke

rs o

rient

ed o

nad

vers

e ev

ents

repo

rtin

g fo

rmat

san

d ph

arm

acov

igila

nce

syst

em•

No.

of s

uper

visio

n vi

sits c

ondu

cted

to st

reng

then

med

icin

em

anag

emen

t

•A

dapt

ed W

HO

pat

ient

safe

tyca

mpa

ign

mat

eria

ls an

d jo

b ai

ds•

No.

of

times

med

ia in

form

atio

n on

patie

nt sa

fety

diss

emin

ated

•N

o. o

f pl

anne

d su

perv

ision

and

men

torin

g vi

sits d

one

•N

atio

nal Q

A a

nd Q

I tra

inin

gm

ater

ials

•Q

I int

egra

ted

into

pre

-ser

vice

curr

icul

um•

No.

of c

linic

ians

trai

ned

as tr

aine

rsth

roug

h To

T pr

ogra

ms

1.Ev

alua

te th

e ex

istin

g C

PD sy

stem

s for

hea

lth w

orke

rs.

2.Re

vise

or a

dapt

nat

iona

l pro

toco

ls fo

r CPD

and

staff

appr

aisa

ls an

ddi

ssem

inat

e to

all

heal

th fa

cilit

ies.

3.In

trod

uce

CPD

syst

ems f

or h

ealth

wor

kers

who

cur

rent

ly d

o no

tha

ve.

4.Tr

ain

and

orie

ntat

e re

leva

nt su

perv

isors

and

man

ager

s to

carr

y ou

tre

gula

r sta

ff ap

prai

sals

and

supp

ort t

he d

evel

opm

ent o

f ind

ivid

ual

CPD

pla

ns w

hich

are

com

mun

icat

ed to

the

rele

vant

lice

nsin

g or

prof

essio

nal r

egul

ator

y bo

dies

.5.

Supe

rviso

rs a

nd m

anag

ers t

o ca

rry

out a

nnua

l sta

ff ap

prai

sals

and

link

thes

e to

awar

d of

the

annu

al b

onus

.

1.C

apac

itate

MC

AZ

to st

reng

then

pha

rmac

ovig

ilenc

e fo

r all

heal

thfa

cilit

ies b

y st

reng

then

ing

the

AE

repo

rtin

g sy

stem

2.D

issem

inat

e dr

ug a

dver

se e

vent

repo

rtin

g fo

rmat

s to

all

inst

itutio

ns.

3.O

rient

ate

heal

th w

orke

rs o

n ph

arm

acov

igile

nce

syst

em a

ndre

port

ing.

4.

roug

h th

e Pr

ovin

cial

pha

rmac

ists,

stre

ngth

en h

ealth

faci

litie

sm

edic

ines

man

agem

ent a

nd d

ispen

sing

prac

tices

thro

ugh

regu

lar

site

visit

s, on

-the

-job

trai

ning

and

men

tors

hip.

1.D

issem

inat

e in

form

atio

n on

pat

ient

safe

ty-p

rom

ote

awar

enes

s of

patie

nt sa

fety

thro

ugh

natio

nal c

omm

emor

atio

ns, m

edia

etc

2.Re

view

and

ada

pt W

HO

Pat

ient

Saf

ety

cam

paig

n m

ater

ials

and

job

aids

as a

ppro

pria

te fo

r Zim

babw

e co

ntex

t (e.g

. WH

O H

and

was

hing

and

Inje

ctio

n Sa

fety

cam

paig

ns)

1.A

sses

s and

eva

luat

e cu

rren

t ind

ivid

ual p

rogr

amm

e sp

ecifi

c QI

appr

oach

es in

det

ail a

nd d

raw

up

a be

st p

ract

ice

docu

men

t on

inno

vatio

ns in

QI p

roce

sses

in Z

imba

bwe.

2.Id

entif

y Q

I foc

al p

erso

ns at

clin

ic a

nd h

ospi

tal l

evel

to le

ad th

eim

plem

enta

tion

of Q

I act

iviti

es th

roug

h th

e Pl

an-D

o-St

udy-

Act

met

hodo

logy

.3.

Ada

pt

e K

ampa

la-b

ased

Reg

iona

l Cen

tre

for Q

ualit

y in

Hea

lthC

are

(RC

QH

C) s

et o

f im

prov

emen

t com

pete

ncy

mod

ules

.4.

Ada

pt a

dditi

onal

rele

vant

mat

eria

ls fo

r com

pete

ncy

base

d tr

aini

ng.

Stra

tegi

c Obj

ectiv

ein

term

edia

te O

bjec

tive

Key

act

iviti

esin

dica

tors

Proj

ecte

dC

ost



To im

prov

e cl

inic

alpr

actic

es a

ndeff

ectiv

enes

s of c

are

2.St

reng

then

inte

grat

edsu

ppor

t and

supe

rvisi

onfo

r all

heal

th in

stitu

tions

and

faci

litie

s by

2015

3. T

o im

prov

e he

alth

wor

ker

attit

udes

and

satis

fact

ion

by ra

ising

awar

enes

sth

roug

h di

ssem

inat

ion

ofth

e Se

rvic

e C

hart

er

4.Re

cogn

ize

perf

orm

ance

1.St

reng

then

the

refe

rral

and

coun

ter-

refe

rral

syst

em

2.St

reng

then

lice

nsin

g an

din

trod

uce

accr

edita

tion

ofho

spita

ls

•N

o. o

f pla

nned

supe

rvisi

on a

ndm

ento

ring

visit

s don

e•

Supp

ortiv

e su

perv

isory

syst

emev

alua

tion

tool

dev

elop

ed•

Supp

ortiv

e su

perv

isory

syst

emev

alua

tion

repo

rts

•N

o of

serv

ice

char

ters

diss

emin

ated

•St

anda

rd re

war

d an

d re

cogn

ition

syst

em d

evel

oped

•N

o. o

f pro

vide

rs re

cogn

ized

and

rew

arde

d

•N

o. o

f ser

vice

pac

kage

s dist

ribut

ed•

No.

of r

efer

ral s

heet

s, re

gist

ers

dist

ribut

ed•

Ana

lysis

repo

rt o

n re

ferr

al a

ndco

unte

r ref

erra

l sys

tem

s

•N

o. o

f hos

pita

ls en

rolle

d in

accr

edita

tion

prog

ram

s

5.Tr

ain

clin

icia

ns w

ho w

ill d

evel

op in

stitu

tiona

l pla

ns a

nd o

rient

othe

r sta

ff th

roug

h re

gula

r mee

tings

and

mon

itor i

mpl

emen

tatio

npr

ogre

ss.

1.D

issem

inat

e th

e re

vise

d na

tiona

l int

egra

ted

supp

ortiv

e su

perv

ision

tool

to a

ll su

perv

isors

and

man

ager

s.2.

Orie

ntat

e al

l sup

ervi

sors

on

new

supp

ortiv

e su

perv

ision

tool

.3.

Supe

rviso

rs to

car

ry o

ut q

uart

erly

supe

rviso

ry v

isits

at a

ll he

alth

faci

litie

s.4.

Act

ion

plan

s to

be d

evel

oped

at e

ach

heal

th fa

cilit

y ba

sed

onsu

perv

isory

visi

ts a

nd m

onito

red

on q

uart

erly

bas

is as

par

t of

supe

rviso

ry v

isits

.5.

Eval

uate

supp

ortiv

e su

perv

isory

syst

em o

n an

ann

ual b

asis.

1.A

follo

w u

p on

the

resu

lts o

f the

Hea

lth S

ervi

ces B

oard

surv

eysh

ould

pro

vide

a b

asel

ine

of st

aff sa

tisfa

ctio

n an

d iss

ues w

hich

nee

dto

be

addr

esse

d to

impr

ove

staff

satis

fact

ion.

2.

Diss

emin

ate

the

Serv

ice

Cha

rter

to a

ll he

alth

pro

vide

rs a

nd o

rient

staff

on

Cod

e of

Eth

ics.

Prov

ider

s.

1.C

reat

e a

stan

dard

rew

ard

and

reco

gniti

on sy

stem

at a

ll le

vels

of th

ehe

alth

syst

em.

2.C

arry

out

regu

lar r

ewar

d an

d re

cogn

ition

Dist

rict c

erem

onie

sin

volv

ing

indi

vidu

al h

ealth

faci

litie

s. 3.

Use

cere

mon

ial a

war

ds a

nd p

ublic

ity e.

g. th

e cu

rren

t Hea

lthW

orke

r of t

he y

ear a

war

ds.

4.U

se a

com

petit

ion

appr

oach

for h

ospi

tals.

5.Es

tabl

ish C

entr

es o

f Exc

elle

nce.

1.St

reng

then

the

refe

rral

and

coun

ter-

refe

rral

syst

em b

y di

sse-

min

atin

g th

e pa

ckag

es o

f car

e fo

r the

diff

eren

t tie

rs o

f car

e.2.

Ensu

re av

aila

bilit

y of

refe

rral

shee

ts, n

otes

, doc

umen

tatio

n an

dm

edic

al re

cord

kee

ping

serv

ices

at te

rtia

ry a

nd ce

ntra

l lev

elin

stitu

tions

and

dev

elop

a sy

stem

so th

at in

form

atio

n on

refe

rred

patie

nts i

s fed

bac

k to

the

refe

rrin

g in

stitu

tion.

1.H

ealth

Pro

fess

ion

Auth

ority

to in

spec

t and

lice

nce

publ

ic h

ealth

inst

itutio

ns a

ccor

ding

to st

anda

rds

2.A

rran

ge le

arni

ng v

isits

to C

hitu

ngw

iza

hosp

ital a

s a b

est p

ract

ice

mod

el to

enc

oura

ge o

ther

hos

pita

ls to

bec

ome

ISO

cert

ified

.

Stra

tegi

c Obj

ectiv

ein

term

edia

te O

bjec

tive

Key

act

iviti

esin

dica

tors

Proj

ecte

dC

ost



To b

uild

cap

acity

for

cont

inuo

us q

ualit

yim

prov

emen

t by

2018

3.Im

prov

e av

aila

bilit

y,co

nsist

ency

and

equi

tabi

lity

of se

rvic

es

4.St

reng

then

clin

ical

audi

tsan

d pe

er re

view

5.A

pply

the

mod

el fo

rim

prov

emen

t to

impr

ove

deliv

ery

of h

igh-

impa

ctev

iden

ce-b

ased

car

e

1.To

mak

e qu

ality

impr

ovem

ent

the

resp

onsib

ility

of e

very

one

wor

king

in th

e he

alth

sect

or

2.To

gui

de le

ader

s and

supe

rviso

rs in

ado

ptin

gsu

stai

nabl

e c

ontin

uous

qual

ity im

prov

emen

t

3.To

est

ablis

h a

mec

hani

smfo

r, en

cour

agin

g,su

ppor

ting

and

stre

ngth

enin

gco

llabo

ratio

n an

dco

ordi

natio

n of

qua

lity

impr

ovem

ent e

ffort

s

•Se

rvic

e m

appi

ng re

port

on

rem

ote,

poor

and

vul

nera

ble

com

mun

ities

avai

labl

e

•%

of h

ospi

tals

with

audi

t gui

delin

es•

% o

f hos

pita

ls w

ith C

linic

al A

udit

Com

mitt

ees

•N

o of

hos

pita

ls co

nduc

ting

clin

ical

audi

ts a

nd p

eer r

evie

w

•%

faci

litie

s dem

onst

ratin

g ad

here

nce

with

bes

t pra

ctic

es

•N

umbe

r of Q

ualit

y su

perv

ision

chec

klist

diss

emin

ated

•N

o. q

ualit

y su

perv

ision

visi

tsco

nduc

ted

by M

oHC

C H

Q, P

HEs

and

DH

Es

•%

of p

erso

ns in

lead

ersh

ip a

ndsu

perv

isory

pos

ition

s tra

ined

inLe

ader

ship

and

Gov

erna

nce,

Publ

icH

ealth

, Man

agem

ent

and

QI

•N

atio

nal Q

I ste

erin

g co

mm

ittee

and

TWG

est

ablis

hed

•N

o. o

f pro

vinc

ial a

nd d

istric

t lev

elQ

I tas

k fo

rces

•N

o. m

eetin

gs c

ondu

cted

by

natio

nal

QI s

teer

ing

and

TWG

s•

Nat

iona

l QI a

ppro

ach

defin

ed a

ndde

velo

ped

Supe

rviso

ryvi

sits

1.C

ondu

ct a

map

ping

exe

rcise

to id

entif

y re

mot

e, po

or a

nd v

ulne

rabl

eco

mm

uniti

es, a

nd a

naly

se a

cces

s to

heal

th se

rvic

es fo

r the

seco

mm

uniti

es.

2.D

esig

n an

d im

plem

ent a

pro

gram

me

of ta

rget

ing

serv

ices

(bot

hpr

even

tive

and

cura

tive)

to th

ese

com

mun

ities

such

as c

urre

ntly

bein

g im

plem

ente

d on

EPI

out

reac

h.

1.Re

vita

lise

the

clin

ical

audi

t and

pee

r sup

port

syst

ems a

t bot

h ho

spita

lan

d cl

inic

leve

l2.

Con

tinue

to c

arry

out

qua

rter

ly P

rovi

ncia

l Mat

erna

l and

Per

inat

alM

orta

lity

(MPM

) aud

its.

3.C

arry

out

a ra

pid

asse

ssm

ent t

o de

term

ine

good

pra

ctic

es in

clin

ical

audi

ts.

4.D

evel

op a

nd d

issem

inat

e gu

idel

ines

for c

linic

al au

dits

.5.

Diss

emin

ate

guid

elin

es o

n M

PM au

dits

&st

reng

then

com

plet

ion

ofm

ater

nal d

eath

cert

ifica

tion

form

s.6.

Esta

blish

and

pro

vide

supp

ort f

or C

linic

al A

udit

Com

mitt

ees i

nho

spita

ls.7.

Con

duct

clin

ical

audi

ts a

nd re

view

s.

1.U

se th

e m

odel

for i

mpr

ovem

ent t

o se

t mea

sura

ble

aim

s rel

ated

tode

liver

y of

evi

denc

e-ba

sed

best

pra

ctic

es (w

ith te

ams r

egul

arly

test

ing

chan

ges t

o im

prov

e ca

re a

nd tr

ack

prog

ress

aga

inst

defi

ned

indi

cato

rs)

1.M

anag

ers t

o em

bed

qual

ity im

prov

emen

t iss

ues i

nto

all j

obde

scrip

tions

whi

ch a

re th

en a

sses

sed

durin

g st

aff ap

prai

sals

on a

regu

lar b

asis.

2.Re

gula

r QI s

uper

viso

ry v

isits

to b

e un

dert

aken

at e

ach

leve

l on

aqu

arte

rly b

asis

- usin

g a

qual

ity su

perv

ision

chec

klist

.

1.A

ll m

anag

ers a

nd su

perv

isors

at n

atio

nal,

dist

rict a

nd p

rovi

ncia

l lev

elto

be

trai

ned

in L

eade

rshi

p an

d G

over

nanc

e, M

anag

emen

t and

QI o

na

sust

aine

d ba

sis.

1.Bu

ild th

e ca

paci

ty o

f the

Qua

lity

Ass

uran

ce D

irect

orat

e by

ens

urin

gad

equa

te st

affing

and

reso

urce

s are

pro

vide

d.2.

Ensu

re th

at th

e na

tiona

l QI T

ask

Forc

e m

eets

on

a qu

arte

rly b

asis

tore

view

pro

gres

s in

impl

emen

ting

the

QI s

trat

egy

and

polic

y.3.

Stre

ngth

en P

rovi

ncia

l and

Dist

rict Q

I tea

ms t

o co

ordi

nate

effo

rts.

4.H

old

bi-a

nnua

l nat

iona

l QI m

eetin

gs.

5.A

lign

exist

ing

qual

ity im

prov

emen

t ini

tiativ

es to

the

Nat

iona

l QI

polic

y an

d st

rate

gy.

Stra

tegi

c Obj

ectiv

ein

term

edia

te O

bjec

tive

Key

act

iviti

esin

dica

tors

Proj

ecte

dC

ost


e National Quality Improvement Strategic Framework 2Vertical dimension of the national Qi strategic framework

Table 5 lays out the specific elements of the vertical dimension of the national QI strategicframework with regard to MOHCC priority health conditions. In each MOHCC priorityhealth care area, leading causes of mortality and morbidity and the associated high-impactinterventions able to reduce such mortality are summarised along with proposedimprovement activities and quality measures to assess progress toward meeting definedtargets. e following are the key priority areas as outlined in the National Strategic Plan:

l Maternal, Newborn and Child Care

l Nutrition

l Priority Communicable Diseases including HIV and AIDS, TB, Malaria, STI,Neglected Tropical Diseases

l Non-Communicable Diseases, Chronic Diseases and Mental Health

l Environmental Health


e National Quality Improvement Strategic Framework2Ta

ble

5:

Dim

ensi

on 2

- Pr

iori

ty h

ealth

are

as a

nd a

ssoc

iate

d hi

gh im

pact

inte

rven

tions

, Qi a

ppro

ache

s, qu

ality

of c

are

indi

cato

rs a

nd p

roje

cted

cost

s

Mat

erna

l and

New

born

Hea

lth

Post

part

umH

emor

rhag

e

Ecla

mps

ia

Seps

is

Obs

truc

ted

Labo

ur

New

born

Asp

hyxi

a

New

born

Sep

sis

Low

birt

h w

eigh

t/Pre

-te

rm b

irth

•D

esig

nate

and

bui

ldca

paci

ty o

f foc

al Q

I poi

ntpe

rson

at P

HE,

DH

E an

dho

spita

l lev

el te

am a

ndsu

ppor

t for

mat

ion

and

optim

al fu

nctio

ning

of

faci

lity

QI t

eam

s•

Regu

larly

trac

k an

d re

port

on q

ualit

y of

car

ein

dica

tors

•M

ater

nal,

Neo

nata

l de

ath

revi

ews a

nd au

dits

•Pr

omot

e re

gula

r sha

red

lear

ning

opp

ortu

nitie

s•

Impr

ove

refe

rral

syst

emin

clud

ing

tran

spor

tatio

n•

Com

pete

ncy

base

dtr

aini

ng o

n as

sess

men

t of

neon

ate

and

resu

scita

tion

of a

sphy

xiat

ed n

ewbo

rn(H

elpi

ng B

abie

s Bre

athe

)•

Esse

ntia

l new

born

car

ean

d K

anga

roo

Mot

her

Car

e

•M

MR

ratio

•%

mot

hers

of c

hild

ren

aged

0–2

3m

onth

s in

catc

hmen

t are

a th

at sa

w a

skill

ed p

rovi

der t

hree

or m

ore

times

durin

g la

st p

regn

ancy

•%

of p

regn

ant w

omen

who

had

Blo

odPr

essu

re M

easu

red

at le

ast 2

tim

esdu

ring

preg

nanc

y•

PPH

rate

and

cas

e-fa

talit

y ra

te•

% w

omen

del

iver

ing

adm

inist

ered

AM

TSL

•%

faci

litie

s with

ade

quat

e st

ock

Mag

nesiu

m S

ulfa

te•

% w

omen

with

PE/

E tr

eate

d w

ithM

gSO

4•

% o

f wom

en d

eliv

erin

g in

hea

lthfa

cilit

ies w

ho a

re m

onito

red

for a

t lea

st24

hrs

•%

of m

othe

rs a

nd n

ewbo

rns w

hore

ceiv

ed p

ostp

artu

m c

are

at e

ach

reco

m¬m

ende

d in

terv

al fr

om sk

illed

pers

onne

l•

Neo

nata

l Mor

talit

y ra

te•

% o

f fac

ilitie

s with

equ

ipm

ent f

ores

sent

ial p

ost-

deliv

ery

new

born

car

e•

% o

f fac

ilitie

s des

igna

ted

“Bab

yFr

iend

ly”

•%

of m

othe

rs/fa

mily

mem

bers

who

can

stat

e at

leas

t 3 d

ange

r sig

ns•

% o

f hea

lth fa

cilit

ies t

hat h

ave

met

with

com

mun

ities

con

cern

ing

mat

erna

l and

child

hea

lth m

atte

rs in

the

past

3 m

onth

s

•A

ctiv

e M

anag

emen

t of

ird S

tage

of

Labo

ur (A

MTS

L); p

ost-

part

umm

onito

ring

for P

PH; p

rom

ptm

anag

emen

t of P

PH (u

tero

toni

cs,

man

ual e

vacu

atio

n if

reta

ined

plac

enta

; lac

erat

ion

repa

ir; b

lood

tran

sfus

ion)

•M

agne

sium

Sul

phat

e

•In

fect

ion

prev

entio

n•

Ant

ibio

tics f

or p

rolo

nged

RO

M,

intr

apar

tum

and

pos

t-pa

rtum

mat

erna

l fev

er

•Sk

illed

Birt

h At

tend

ance

•Re

duce

d de

lay

in se

ekin

g ca

re•

Appr

opria

te u

se o

f the

par

togr

aph

•A

ssist

ed d

eliv

ery

•C

aesa

rian

sect

ion

•A

PGA

R to

ass

ess m

anag

emen

t •

Up

to d

ate

resu

scita

tion

skill

s,eq

uipm

ent a

nd su

pplie

s

•Po

st-p

artu

m m

onito

ring

of n

ewbo

rn(w

/incr

ease

d vi

gila

nce

if ris

k fa

ctor

s); I

V A

ntib

iotic

s and

shoc

k th

erap

y•

Mot

her’s

awar

enes

s of d

ange

r sig

ns

•A

nten

atal

cor

ticos

tero

ids

•K

anga

roo

Mot

her C

are

Prio

rity

Hea

ltha

rea

and

Hea

lthO

utco

me

Targ

et

Lead

ing

Cau

ses

of M

orta

lity

and

Mor

bidi

ty

Key

act

iviti

es to

Sup

port

Con

tinuo

us Q

iin

dica

tors

Out

com

e, P

roce

ss

and

inpu

tPr

ojec

ted

Cos

tH

igh-

impa

ct C

linic

al in

terv

entio

ns



esse

ntia

l New

born

Car

e; e

arly

initi

atio

n bF

excl

usiv

ebr

east

feed

ing

app

ropr

iate

intr

oduc

tion

ofC

ompl

emen

tary

Feed

ing

and

cont

inue

dbr

east

feed

ing

•U

nnec

essa

ry la

bour

and

deliv

ery

prac

tices

e.g.

Episi

otom

y, •

Mec

hani

cal a

ssist

edde

liver

ies,

•To

o ea

rly w

eigh

ing

of n

ewbo

rn,

•M

edic

ated

deliv

erie

s, •

Und

erly

ing

infe

ctio

ns in

clud

ing

HIV

•Po

or S

uckl

ing

refle

x,lo

w b

irth

wei

ght,

intr

oduc

tion

to p

re-

lact

eal f

eeds

,bi

rthi

ngco

mpl

icat

ions

, ear

lyin

trod

uctio

n of

solid

s, co

ngen

ital

defo

rmiti

es,

inte

rgen

erat

iona

ltr

ansf

er o

f stu

ntin

g

•N

on-a

vaila

bilit

y of

nutr

itiou

s and

dive

rse

diet

s at

hous

ehol

d le

vel

•Sh

ort d

urat

ion

ofbr

east

feed

ing/

prem

atur

e w

eani

ng

•M

ento

rshi

p to

impr

ove

com

pete

nce

(kno

wle

dge

and

skill

s) o

f ser

vice

prov

ider

s to

supp

ort

mot

hers

to in

itiat

ebr

east

feed

ing

early

.•

Supp

ortiv

e su

perv

ision

toin

clud

e ob

serv

atio

n of

Infa

nt F

eedi

ng S

ervi

cede

liver

y •

Prov

ision

of j

ob a

ids t

ogu

ide

serv

ice

deliv

ery

•M

ento

rshi

p to

impr

ove

com

pete

nce

(kno

wle

dge

and

skill

s) o

f ser

vice

prov

ider

s to

Supp

ort

mot

hers

to in

itiat

ebr

east

feed

ing

early

.•

Supp

ortiv

e su

perv

ision

toin

clud

e ob

serv

atio

n of

Infa

nt F

eedi

ng S

ervi

cede

liver

y

•Pr

ovisi

on o

f job

aid

s to

guid

e se

rvic

e de

liver

y•

Exit

Inte

rvie

ws w

ithpa

tient

s

•Pr

ovisi

on o

f Inf

ant F

eedi

ngC

ouns

ellin

g ca

rds

•A

dequ

ate

stoc

ks o

fV

itam

in A

cap

sule

s •

Prov

ision

of

anth

ropo

met

riceq

uipm

ent a

nd

child

hea

lth c

ards

•%

of m

othe

rs in

itiat

ing

brea

stfe

edin

gw

ithin

one

hou

r of b

irth

•Pr

opor

tion

of m

othe

rs d

eliv

ered

at th

ein

stitu

tion

who

exc

lusiv

ely

brea

stfe

dth

eir i

nfan

ts fo

r six

mon

ths

•%

of h

ospi

tals

accr

edite

d as

bab

yfr

iend

ly

•Pr

opor

tion

of m

othe

rs w

ith ch

ildre

nle

ss th

an 2

yea

rs w

ho w

ere

asse

ssed

for

nutr

ition

al st

atus

(wei

ght a

nd h

eigh

tm

easu

red

and

nutr

ition

stat

usre

cord

ed o

n C

hild

hea

lth C

ard

•Sk

in to

Ski

n co

ntac

t of m

othe

r and

baby

for a

t lea

st 1

hou

r ae

r del

iver

ySh

owin

g m

othe

r how

to b

reas

tfeed

(pos

ition

and

atta

chm

ent)

with

in 6

hrs

of d

eliv

ery

Kan

garo

o ca

re

•Ro

omin

g in

of m

othe

r and

new

born

•C

lean

cord

car

e; e

ye c

are

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ouns

ellin

g on

dan

gers

of m

ixed

feed

ing,

Tea

chin

g m

othe

rs to

pos

ition

and

atta

ch

•C

ouns

el o

n tim

ely

intr

oduc

tion

ofap

prop

riate

bal

ance

d di

et a

ndco

ntin

ued

brea

stfe

edin

g

•C

ouns

el o

n ag

e ap

prop

riate

mea

lfr

eque

ncy

•V

itam

in A

supp

lem

enta

tion

•

Ass

ess w

eigh

t for

hei

ght a

nd h

eigh

tfo

r age

•

Scre

en fo

r acu

te a

nd ch

roni

c

Prio

rity

Hea

ltha

rea

and

Hea

lthO

utco

me

Targ

et

Lead

ing

Cau

ses

of M

orta

lity

and

Mor

bidi

ty

Key

act

iviti

es to

Sup

port

Con

tinuo

us Q

iin

dica

tors

Out

com

e, P

roce

ss

and

inpu

tPr

ojec

ted

Cos

tH

igh-

impa

ct C

linic

al in

terv

entio

ns



Man

agem

ent o

fM

alnu

triti

on

Chi

ld H

ealth

PMTC

TTa

rget

- <5%

mat

erna

l HiV

tran

smis

sion

•In

corr

ect a

ndin

adeq

uate

feed

ing

durin

g an

d a

erill

ness

•U

nava

ilabi

lity

ofdi

vers

ified

die

ts at

hous

ehol

d le

vel,

Chi

ldho

od il

lnes

ses

inc

HIV

, Ina

dequ

ate

care

by

mot

hers

and

care

giv

ers,

acut

e fo

odsh

orta

ges a

tho

useh

old,

poo

rw

ater

and

sani

tary

faci

litie

s, po

orin

take

and

utili

zatio

n of

nutr

ient

s

•Pa

edia

tric

HIV

and

AID

S•

Poor

man

agem

ent

of ch

ildho

odill

ness

es (d

iarr

hoea

,m

alar

ia a

nd A

RI)

•Ba

rrie

rs to

imm

unisa

tion

agai

nst c

hild

hood

illne

sses

due

tore

ligio

us a

ndcu

ltura

l bel

iefs

Seve

re P

neum

onia

•Pr

ovisi

on o

fan

thro

pom

etric

equ

ipm

ent

•

IYC

F C

ouns

ellin

g C

ards

•Pr

ovisi

on o

f job

aid

s, qu

ick

refe

renc

e gu

ides

, na

tiona

lpr

otoc

ols,

med

ical

supp

lies

•A

dequ

ate

supp

lies o

f F75

,F1

00 a

nd R

eady

to U

se

erap

eutic

Foo

ds

•St

reng

then

ing

the

hum

anre

sour

ce c

apac

ity fo

rco

mpr

ehen

sive

paed

iatr

icH

IV p

reve

ntio

n, tr

eatm

ent

care

and

supp

ort

•Ex

pedi

tious

ly co

mm

ence

infa

nts w

ho re

quire

ART

on tr

eatm

ent

•Si

te tr

aini

ngs o

n PM

and

QI

•Su

ppor

t and

Men

torin

gvi

sits/

QI C

oach

ing

•3m

onth

ly c

ycle

CQ

Ipr

ojec

ts w

ith re

port

s fro

msit

es

•Pr

opor

tion

cure

d, d

ied,

def

aulte

rpa

tient

s vs.

the

reco

mm

ende

d gl

obal

sphe

re st

anda

rds

•%

child

ren

(x si

te in

x ti

me-

fram

e)w

ith a

cute

mal

nutr

ition

man

aged

acco

rdin

g to

stan

dard

(com

posit

epr

oces

s ind

icat

or)

•Pr

opor

tion

of H

IV p

ositi

ve ch

ildre

n(<

15yr

s) w

ho w

ere

initi

ated

on

trea

tmen

t dur

ing

the

repo

rtin

g pe

riod.

(Fro

m th

e su

bset

of e

ligib

le <

15ye

arol

ds)

•Pr

opor

tion

of H

IV in

fect

ed p

regn

ant

and

lact

atin

g m

othe

rs in

itiat

ed o

n A

RTon

the

sam

e da

y or

with

in

•Pr

opor

tion

of H

IV e

xpos

ed in

fant

sw

ho h

ad a

DN

A-PC

R H

IV te

stpe

rfor

med

at 6

-8 w

eeks

of a

ge a

ndre

ceiv

ed re

sults

with

in a

mon

th.

•Pr

opor

tion

of H

IV e

xpos

ed in

fant

sw

ho re

ceiv

ed e

xten

ded

NV

Ppr

ophy

laxi

s

•Sc

reen

for a

cute

and

chro

nic

mal

nutr

ition

•PI

TC

•D

ewor

min

g

•Pr

even

tion

of m

alnu

triti

on in

ear

lych

ildho

od th

roug

h th

e pr

omot

ion

ofim

prov

ed ch

ild fe

edin

g, c

are

givi

ngan

d ca

re se

ekin

g, g

row

th m

onito

ring

and

prom

otio

n pr

actic

es at

fam

ily,

com

mun

ity, a

nd fa

cilit

y le

vel

•

erap

eutic

feed

ing

usin

g F7

5, F

100

and

RUTF

•In

fant

and

you

ng C

hild

feed

ing

Cou

nsel

ling

•Ro

utin

e G

row

th M

onito

ring

•M

ER14

and

Opt

ion

B+•

Paed

s OI/

ART

trai

ning

•D

ecen

tral

izat

ion

of O

I/A

RT S

ervi

ces

•A

ntib

iotic

s and

Oxy

gen

•Pn

eum

ococ

cal v

acci

ne

Prio

rity

Hea

ltha

rea

and

Hea

lthO

utco

me

Targ

et

Lead

ing

Cau

ses

of M

orta

lity

and

Mor

bidi

ty

Key

act

iviti

es to

Sup

port

Con

tinuo

us Q

iin

dica

tors

Out

com

e, P

roce

ss

and

inpu

tPr

ojec

ted

Cos

tH

igh-

impa

ct C

linic

al in

terv

entio

ns



HiV

and

aiD

S an

dTb

Dia

rrho

ea w

ith se

vere

dehy

drat

ion

Seve

re u

nder

lyin

gm

alnu

triti

on

Adv

ance

dIm

mun

osup

pres

sion

and

TB

•Pe

er le

arni

ng v

isits

•En

surin

g co

ntin

uous

avai

labi

lity,

good

qua

lity

med

icin

es, d

iagn

ostic

s &su

pplie

s for

com

preh

ensiv

epa

edia

tric

HIV

pre

vent

ion,

care

, tre

atm

ent a

nd su

ppor

tse

rvic

es•

Effec

t sup

ervi

sion

for

com

preh

ensiv

e PM

TCT

and

paed

iatr

ic H

IVpr

even

tion,

trea

tmen

t car

ean

d su

ppor

t ser

vice

s at a

llle

vels

•En

sure

all

first

leve

l hea

lthfa

cilit

ies s

houl

d ha

ve at

leas

t tw

o IM

NC

I tra

ined

heal

th w

orke

rs•

Scal

e up

em

erge

ncy

tria

ging

syst

em (E

TAT)

toim

prov

e id

entifi

catio

n an

dm

anag

emen

t of s

ever

ely

illch

ildre

n at

all

leve

ls•

Ora

l reh

ydra

tion

er

apy

and

Zinc

for d

iarr

hoea

man

agem

ent

•Si

te tr

aini

ngs o

n PM

and

QI

•Su

ppor

t and

Men

torin

gvi

sits/

QI C

oach

ing

•3

mon

thly

cyc

le C

QI

proj

ects

with

repo

rts f

rom

sites

•Pe

er le

arni

ng v

isits

•Pr

opor

tion

of H

IV+

infa

nts <

2 ye

ars

old

initi

ated

on

ART

.•

% o

f chi

ldre

n un

der 5

with

pne

umon

iaw

ho re

ceiv

e ap

prop

riate

ant

ibio

tic

•%

of c

hild

ren

unde

r 5 w

ith d

iarr

hoea

rece

ivin

g O

RT a

nd Z

inc

•%

of i

nfan

ts fu

lly im

mun

ized

12-

23m

onth

s•

% p

atie

nts c

ompe

lled

to p

urch

ase

pres

crib

ed e

ssen

tial m

edic

ines

at a

priv

ate

phar

mac

y

•M

edia

n da

ys fr

om e

nrol

lmen

t to

ART

initi

atio

n fo

r elig

ible

pat

ient

s•

% o

f pat

ient

s ret

aine

d on

ART

at si

te.

(6m

onth

s Ret

entio

n)•

Prop

ortio

n of

pat

ient

s who

se A

RTad

here

nce

asse

ssm

ent w

as d

one

at th

em

ost r

ecen

t visi

t•

Prop

ortio

n of

OI/

ART

pat

ient

s who

se

•O

RT a

nd Z

inc

•Ro

tavi

rus v

acci

ne

•Pa

tient

and

Clin

icia

n re

min

der

syst

ems e

.g. T

B sc

reen

ing

tool

•Sc

reen

ing

of a

ll H

IV in

fect

edin

divi

dual

s for

TB

and

Sta

ndar

dize

dTB

trea

tmen

t•

Min

imiz

e tim

e ta

ken

to id

entif

y an

din

itiat

e A

RT-e

ligib

le p

atie

nts o

n lif

e-sa

ving

ther

apy

Prio

rity

Hea

ltha

rea

and

Hea

lthO

utco

me

Targ

et

Lead

ing

Cau

ses

of M

orta

lity

and

Mor

bidi

ty

Key

act

iviti

es to

Sup

port

Con

tinuo

us Q

iin

dica

tors

Out

com

e, P

roce

ss

and

inpu

tPr

ojec

ted

Cos

tH

igh-

impa

ct C

linic

al in

terv

entio

ns



Mal

aria

95%

of a

llsu

spec

ted

mal

aria

case

s to

hav

epa

rasi

tolo

gica

lco

nfirm

atio

n (R

DT

or m

icro

scop

y)

Non

-

•La

te P

rese

ntat

ion

and

dete

ctio

n

•In

adeq

uate

Cas

eM

anag

emen

t for

seve

re m

alar

ia

•Ro

utin

e m

onito

ring

ofEa

rly W

arni

ng In

dica

tors

with

feed

back

to fa

cilit

ies

•Pr

e-sh

ipm

ent s

pray

ing

chem

ical

ana

lysis

•C

ondu

ctin

g re

gula

r(m

onth

ly) b

ioas

says

on

spra

yed

hom

es•

Perio

dic b

ioas

says

of

Long

Las

ting

Inse

ctic

ide

Trea

ted

Net

s•

Ensu

re av

aila

bilit

y an

d us

eof

trea

tmen

t gui

delin

es•

Effec

tive

com

pete

ncy

base

d pr

e-se

rvic

e an

d in

-se

rvic

e tr

aini

ng o

nm

alar

ia p

reve

ntio

n,co

ntro

l and

cas

em

anag

emen

t and

emph

asiz

e co

rrec

t use

of

quin

ine

in th

e tr

eatm

ent

of se

vere

mal

aria

blo

odgl

ucos

e m

onito

ring

and

who

se la

st v

isit l

aste

d 2

hour

s or l

ess

•#

drug

stoc

k ou

ts in

last

qua

rter

for

first

-line

ART

dru

gs o

r cot

rimox

azol

e•

Prop

ortio

n of

pat

ient

s who

had

a(r

outin

e 6-

mon

thly

mon

itorin

g) C

D4

test

per

form

ed•

Prop

ortio

n of

ART

pat

ient

s scr

eene

dfo

r TB

at th

e m

ost r

ecen

t visi

t.(U

sing

the

TB S

cree

ning

Too

l, w

ithdo

cum

ente

d ev

iden

ce in

ART

Regi

ster

)•

% o

f pat

ient

s on

ART

requ

iring

switc

h to

seco

nd-li

ne th

erap

y fo

rtr

eatm

ent f

ailu

re at

12

and

24m

onth

s.

•Pr

oduc

t mee

ting

WH

O a

ccep

tabl

est

anda

rds

•M

osqu

ito k

nock

dow

n ra

tes f

orsp

raye

d ho

mes

•M

osqu

ito k

nock

dow

n ra

tes f

or L

ong

Last

ing

Inse

ctic

ide

Trea

ted

Net

s•

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iagn

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DT

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in 2

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ases

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gui

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atie

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corr

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t•

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d pr

ompt

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erity

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rity

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me

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ses

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orta

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bidi

ty

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act

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port

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Cos

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igh-

impa

ct C

linic

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terv

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r inv

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d el

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ete

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ided

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g in

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ality

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d us

er v

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o in

clud

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/sat

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ient

s and

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mun

ities

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rvisi

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kers

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ncia

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lity

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aff•

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ngth

ened

supp

ort

and

supe

r

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acili

ties n

ot re

port

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kou

ts o

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i mal

aria

med

icin

es a

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oditi

es in

mal

aria

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nedi

stric

ts

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et

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ses

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bidi

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port

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ct C

linic

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ns



Non

-C

omm

unic

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Dis

ease

s and

Men

tal H

ealth

Com

mon

Risk

Fac

tors

:•

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ealth

y lif

esty

les

whi

ch in

clud

e-U

nhea

lthy

diet

s-L

ack

of p

hysic

alac

tivity

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acco

use

d-H

arm

ful

cons

umpt

ion

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coho

l:

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afe

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Prac

tices

For t

he fo

llow

ing

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ditio

ns-C

ardi

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cula

rD

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lenc

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tory

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ases

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tal D

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on o

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etric

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ent

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plem

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e St

rate

gy o

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l Hea

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r he

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tal H

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age

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pete

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iliza

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or th

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ty o

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ent

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y ki

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opor

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f pat

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ndin

g O

PD sc

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r hyp

erte

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n or

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bete

s•

No.

of s

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/ fac

ility

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g to

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agem

ent p

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cols

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of p

atie

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ith c

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olle

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d gl

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% o

f fac

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s with

out s

tock

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s of

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er N

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ing

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y su

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ber o

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s rep

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nal r

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ral s

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ms

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e W

aitin

g tim

e be

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ndi

agno

sis o

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cer a

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mm

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men

t of e

ither

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mot

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py o

r Rad

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erap

y

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ary

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entio

n:1.

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lth p

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n pr

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ms a

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res

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itiza

tion

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ifica

tion

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oura

l and

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rly D

etec

tion(

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enin

g an

d ea

rlydi

agno

sis) o

f sel

ecte

d N

CD

(C

VD

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iabe

tes,

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cer,

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onic

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irato

ry D

iseas

es):

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Ds a

nd S

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es p

reve

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n us

ing

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ins,

aspi

rin fo

r all

indi

vidu

als w

ith>2

0% -3

0% ri

sk o

f CV

D e

vent

with

in10

year

s

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cond

ary

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entio

n of

(3i)

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y A

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r all

patie

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) Effe

ctiv

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t of N

CD

s, -

acco

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g to

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iona

l gui

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es ti

me

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n tr

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ent g

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eatm

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bilit

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d tr

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ent

supp

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nce

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mel

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e an

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gree

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njur

y

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rity

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ltha

rea

and

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et

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ses

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orta

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bidi

ty

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act

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port

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iin

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e, P

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igh-

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ct C

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ns



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ally

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smitt

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fect

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ronm

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ital U

lcer

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ase

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phili

s

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or h

and

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prov

e an

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erra

l sys

tem

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t pro

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r com

mon

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tal

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te tr

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n Sy

ndro

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STI

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and

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oduc

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ribut

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and

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lay

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e su

pply

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ssen

tial

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icin

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at in

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llST

I med

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ort a

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ento

ring

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s/Q

I Coa

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ual c

ycle

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sw

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port

s fro

m si

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ontin

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rcem

ent

of P

ublic

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lth A

ct a

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tion

in h

and

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hing

tech

nolo

gies

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of i

ndiv

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ls pr

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ting

with

spec

ific

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or S

TI sy

mpt

oms i

nhe

alth

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litie

s who

are

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d an

dtr

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d in

an

appr

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te w

ay(a

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atio

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% o

f pat

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s with

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re g

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, par

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and

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ong

all S

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ng S

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re•

% o

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d by

HC

Fs th

at h

ave

acu

rren

t sup

ply

of e

ssen

tial S

TI d

rugs

and

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rt n

o st

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outs

last

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long

erth

an o

ne w

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in th

e pr

eced

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12m

onth

s

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fe w

ater

and

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tatio

n co

vera

ge•

% o

f hou

seho

lds w

ith so

ap a

nd h

and

was

hing

faci

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s

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ppro

pria

te m

anag

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t of

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genc

ies i

nclu

ding

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ries a

t all

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l of t

he sy

stem

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Men

tal h

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s at

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mun

ity, f

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ty a

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y le

vel

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prop

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sych

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icat

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ndro

mic

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se o

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com

men

ded

hand

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tices

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rity

Hea

ltha

rea

and

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lthO

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me

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et

Lead

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ses

of M

orta

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and

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bidi

ty

Key

act

iviti

es to

Sup

port

Con

tinuo

us Q

iin

dica

tors

Out

com

e, P

roce

ss

and

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tPr

ojec

ted

Cos

tH

igh-

impa

ct C

linic

al in

terv

entio

ns


e National Quality Improvement Strategic Framework2It is important to note that the horizontal dimension strategic objectives provide a base forthe provision of quality healthcare services in the MOHCC priority areas listed above. Since“quality is everybody’s business”, the MOHCC QA division and all relevant technicaldivisions within the MOHCC, collaboratively worked together to define specificintermediate objectives, activities and indicators for defined QI strategic objectives. ishelped avoid duplication and ensured that current MOHCC strategies across all divisionsare optimally leveraged in support of the national QI strategy.

In order for this strategy to be implemented there is a need to create and maintain anenabling environment through:l Leadership and commitment at policy levell Advocacy and communicationl Training and Capacity buildingl Ensuring sustainabilityl Monitoring and Evaluation mechanisms

2.3 Quality Improvement Principles and Methodologies

Several principles underpin much of the improvement work implemented in high- andlow-resource settings.

Core principles of quality improvement include: l Effective teamwork (at all relevant system levels) that engages managers; providers,

staff, patients and relevant stakeholders to achieve a common quality improvementaim;

l An understanding of how systems and processes of care function within a healthsystem and the critical bottlenecks that impede reliable health care processes;

l Use of data (tailored to each system level) to continuously measure and track progresstoward an explicit improvement aim;

l An understanding and focus on patient needs; andl Taking into account the issue of sustainabilityl Regular shared learning.

ere are many QI methods in the literature that have been used in a number of settingswith varying degrees of success. e following 5 methodologies may be used inimplementing QI. ey have been selected owing to their success in other settings andtheir relative simplicity to understand and implement.1. 5S Method2. Model for Improvement – the Plan-Do-Study-Act (PDSA) model3. Clinical practice improvement (CPI) method4. Root cause analysis.5. Quality Improvement Collaborative

Annexe A provides a brief explanation of how these methodologies may be applied by QIteams for example.

Implementation of the QI Strategy

Phased ApproachIt will not be possible to implement all QI strategies and approaches at once. Hence aphased approach that recognizes the current operating environment and available resourcesis proposed. e phased approach also recognizes the importance of demonstrating quickwins in order to obtain buy in from the relevant stakeholders. Accreditation and pay forperformance, which is a value based payment system to encourage efficiency and improvedquality will occur at later phases the QI movement gains momentum.

Phase 1

l Establish QI teams at provincial, district and centrallevel

l Review and development of standards and guidelines of care where applicable.

l Strengthen licensing procedures and adherence to minimum standards by healthfacilities.

l Strengthen quality control of medicines, laboratories and radiology facilities.

l Strengthen and capacitate hospitals to adhere to infection control guidelines.

l Introduction of quality improvement work in at least one technical area in a subset ofdistricts in every province. An emphasis will be on Quality improvement training,activities and establishment of facility based quality improvement focal groups,overseeing continuous real-time monitoring of agreed quality of care measures(process measures and outcome measures). Each technical area will outline a 3-5year plan in which intermediate objectives from the Table 5 (vertical interventions)are sequentially introduced to guide focused improvement work in a selected ofdistricts.

l Introduction of QI skills and methods in pre-service training (with participation ofstudents in ongoing improvement projects to the extent possible).

l Strengthen monitoring of compliance to standards and guidelines e.g. medical audit.

l Establishment of improvement collaborative.

Phase 2

l Institutionalize formal recognition of performance and accreditation of hospitals

l Introduction of pay for performance at central and provincial hospital level


3


A more detailed operational plan for the horizontal dimension will be developed by theQA and QA directorate of the MoHCC in collaboration with stakeholders while the verticalinterventions will be developed by the specific program areas and incorporating relevantQI committees empowered by the MOHCC to ensure maximum engagement and buy-inas implementation begins. e imple-mentation of the QI strategy will utilise existingstructures and systems as far as possible. is will enable QI to take off with minimaladditional resources and encourage QI activities to be embedded and integrated withinthe normal operational environment of the MOHCC. It is anticipated that activities willoccur across the entire health system from community to quaternary levels, as well asincorporating the private sector. is is in line with the policy of Public Private Partnerships(PPPS) that the Government of Zimbabwe has embraced. In recognition of initiatives onQI in ART, PMTCT and Maternal Health, this strategy seeks to scale up these in anintegrated manner that supports an overall health systems strengthening approach.

Each MOHCC technical department will be given responsibility for working incollaboration with relevant professional associations and councils as well as the QualityAssurance Directorate within the MOHCC to define a 5-year operational improvementstrategy in their respective technical area, prioritising and sequencing improvement workthat are aligned to the strategic objectives outlined in Table 5. Individual technical workinggroups will develop a detailed operational plan that prioritises and sequences specificimprovement aims, indicators, training and supervisory support, for the high-burdenconditions in their technical area. is may be rolled out using an improvementcollaborative approach at a district or provincial level. Figure 9 illustrates the organisationalstructure for implementing the QI strategy.

Implementation of the QI Strategy3

Service Users Community committees

National QI Committee

Quality Assurance Department

Development Partners Professional Associations/Councils including private provider representatives Hospital Quality Committee (Central, Provincial, Local Authority, District, Mission, Private, Special e.g. armed forces)

Implementing partners

Civil Society Health Centre Committees/Hospital Boards/Councils

Primary Health Care Facilities (Public and Private)

Pre and in -service Training/Professional development and licensure Research, Knowledge Management, Quality Management Institutions e.g.

MOHCC Programs and Departments- AIDS & TB, Malaria, Epidemic and Disease Control, NCDs, Mental Health, Environmental Health, Nursing, Family Health

National Technical QI Working Group

Figure 8: Quality improvement Relationships

National Level

It is of paramount importance that a National Steering Committee with representationfrom senior management within the MOHCW as well as relevant stakeholders, overseeand guide the institutionalization of QA/QI processes to support health care servicedelivery in the country. Ideally this advisory group will be chaired by the Minister of Healthand Child Welfare or an appointed representative and will include key representatives fromother ministries such as higher education and finance, UN agencies, bilateral partners,health insurance representatives, professional associations, regulatory bodies, civil society,private sector and non-governmental organizations. e National QI Committee drivesquality improvement and ensures that QI becomes a nationwide continuous system wideapproach.

e National QI steering Committee has five main areas of responsibility:

1. Strategic Planning: prioritizing goals so that most critical areas are addressed first.

2. Overseeing Qi implementation: ensuring that all quality improvement activities aredone effectively in line with key quality priorities.

3. Providing guidance: overseeing activities to ensure that activities are on track andbeing responsive to staff, clients and partners during the improvement process.Support and encouragement to the provincial level is necessary to maintain themomentum built.

4. Resource mobilization: for building capacity for quality. e national QI committeewill be responsible for building sustainable infrastructure that fosters a culture ofquality service delivery.

5. enforcing accountability: tracking and reporting on implementation progress usinga set of agreed indicators and re-setting implementation course when necessary.

e QI committee will meet quarterly.

a National Qi Technical working Group will be established to provide technical supportto the QI committee on the five areas of responsibility outlined above. e group will meetquarterly.

Once the National Technical QI Working Group has been established, sub-groups will beformed to focus on specific goals or priorities. ese workgroups will include especiallypeople with expertise in the area of focus.

It is envisioned that there will be 7 working groups, each of which will define a detailedimplementation plan and annual targets with respect to their technical area:

1. MNCH:

2. HIV and AIDS, TB and other communicable diseases Neglected Diseases

3. NCDs and Mental health

4. Water and environment


Implementation of the QI Strategy 3


5. Information Systems

6. Commodities and supply chain, including laboratory and pharmacy

7. Client-centered care (with strong client/community representation)

Quality assurance Department

e Quality Assurance department is mandated to ensure that the quality of servicesprovided is within acceptable standards for the entire sector, both public and private healthservices. is is to be achieved through facilitating the establishment of internal qualityassurance and improvement capacity at all levels. ere is therefore need to provide human,material and financial capacity for this critical department to fulfil this mandate.

More specifically the Quality Assurance department is tasked to:

1. Provide overall operational oversight and coordination for QI.

2. Consolidate Quality Management Plans and oversee implementation.

3. Support QI teams developing and disseminating standards and guidelines on QI.

4. Establish data collection systems for performance measurement of QI

5. Provide support to the provincial level for QI through training and provision oftechnical assistance.

6. Coordinate the planning and resource mobilisation efforts for QI.

7. Work with training institutions and other MOHCC departments to develop andimplement the national QI training curriculum and materials.

8. Document quality improvement best practices and identify platforms forinformation sharing among healthcare facilities and with other interestedstakeholders.

9. Act as secretariat for the National QI Committee and lead the QI TWG.

10. To recognise the best performing Province

Other levels

Quality Improvement Committees shall be established at each hospital level. e provincialQI committee will provide overall monitoring and supporting of quality in the respectivedistricts. e Provincial QI teams would be responsible for consolidating all the initiativesfrom both hospitals and the district QI committees for then sharing to the national. edistrict QI committee will monitor and support quality at health facility level. Similarstructures will be used to monitor quality in the provision of healthcare from urbanfacilities. Central hospitals will receive oversight of QI from QAD with support from theQITWG. e roles of the QI committees’ will include:

1. Guiding implementation of QI Activities

2. Development of local QI implementation plans and budgets, integrating QI plansinto broader work plans to the extent possible (e.g. district health plan; facilityhealth plan)


3. Active role in capacity building and learning activities

4. Supervision, mentoring and coaching

5. Monitoring and evaluation of performance of subordinate QI teams

6. Identify best practices to be rewarded and recognized

e Provincial and District Quality focal persons will be secretariat for the QI Committees.e focal persons will be part of a management team where their central position is clearwithin the organizational structure. ey will be involved in the strategic planning processfor QI. e quality manager serves as the subject matter expert in quality. In order for theQI focal person to be proactive the QAD will put in place a programme to capacitate themwith the necessary change management, knowledge management and communicationskills. e QI focal person will also be incorporated in the planning and implementationof QI activities in specific technical areas. e QI focal person with support from the QI Committee will be responsible for checking to ensure that the quality of services meetclient expectations.

Roles and Responsibilities of Stakeholders

Government

e MOHCC will provide overall leadership and oversee planning, implementation,monitoring and evaluation of standards on QA/QI in the health sector. Other functionswill include:

l Formulate enabling legislation for QA and QI initiatives in the health sector.

l Provide technical guidelines and protocols in support for QA and QI processes.

l Provision of high quality services and maintenance of infrastructure and equipmentat all levels of care.

l Create a conductive environment for continuous learning through training andeffective mentoring.

l Identify and disseminate indicators and data collection tools on QA and QI.

l Promote operations research that informs policy implementation of QA and QIprocesses.

Private for Profit Sector (Private providers from different sectors including privatehospitals, surgeries, laboratories, pharmacies)

l Complement government efforts in the provision of accessible, affordable and qualityhealth care in line with agreed national standards and guidelines.

l Mobilize and allocate resources to QA/QI approaches in the provision of healthservices in the workplace.

l Participate in national monitoring and evaluation on QA/QI processes.

l Promote networking among private companies and developing mechanisms of peerreview on QA/QI approaches.




l Involve communities in QA/QI processes in the context of social responsibilityprogrammes.

l Assist government leverage on technical expertise such as setting of qualitymanagement systems.

Development partners

l Provide technical and financial support for sustainable QA/QI initiatives.

l Advocate for increased global and national commitment to QA/QI processes in thehealth sector.

l Support operations research on QA/QI approaches.

Community Representatives, Civil Society, Non-governmental Organisations

l Advocate for the rights of the population with respect to equitable access to qualityhealth care services.

l Act as watchdogs to improve accountability to providing quality health services in thecountry.

l Forge partnerships that promote a culture that demands quality for services providedin communities.

l Implement community based strategies that promote healthy behaviours as well astimely health seeking behavior.

l Articulate community needs and influencing quality policy and the way healthservices are provided to them.

l Complement government efforts in the provision of quality health care.

Professional associations

l Self-regulation of individual and institutional standards of practice.

l Contribute to clinical guidelines development.

l Provision of professional recognition of good performance.

3.1 PERFOMANCE MEASUREMENT IN QUALITY

Measurement is a core principle underpinning all improvement and an important tool fordriving large-scale improvements in quality of care. An important role of the technicalworking groups will be to review current indicators tracked in the national HMIS systemand as part of existing QI initiatives, make recommendations about specific quality of careand outcome indicators that should be tracked by RHCs, hospitals and as part of the routineHealth Management and Information Systems to permit regular tracking and analysis ofpriority quality of care indicators and facilitate results-based action at all levels of the health


system. Scientifically valid and clinically relevant performance measures have the potentialto significantly improve the quality and efficiency of patient care across Zimbabwe. egoal in assessing performance is to create a system that promotes the best clinical standardsand ensures the highest quality of patient care through transparency, accountability, andcredibility. Unfortunately, the nation is in its infancy of formulating a coordinated strategyfor collecting and combining performance data, and thus, lacks an effective method forpinpointing gaps in quality and efficiency across the country. is section of the strategicplan outlines ways of bridging this gap.

Creating systems that collect and use data to improve performance is essential todemonstratingvalue and providing consistent, evidence-based care. Incorporatingmeasurement into daily practice highlights strengths and weaknesses, identifiesopportunities to improve delivery of care, and provides insight into whether changesactually lead to improvement. It is recognised that different stakeholders in a system mayneed information tailored to the specific functions for which they are responsible.Performance measures will be categorized into three basic types: structure e.g. midwife tonumber of women of child bearing age ratio, process e.g. correct use of partograph, andoutcomes e.g. still birth rate.

Quality assessment indicators

e following list of specific areas under the domains mentioned above shall guide thedevelopment of quality indicators with guidance from the Quality Assurance Department.

Structural indicators

l Accessibility to health care- geographical coverage and location, distance and time tothe health facility, continuity of services, financial etc;

l Availability of trained and competent health workers

l Availability of diagnostic equipment, medicines and supplies

l Work environment organisation

l Logistics management

l Data management, use and dissemination

Process indicators

l Availability and use of up to date standards, treatment guidelines and protocols

l Organisational management for implementing QI

l Safety to service providers and users

l Infection prevention and control practices

l Testing and documentation of changes

l Client involvement

l Staff engagement, responsiveness and attitude to work




Outcome indicators

l Health outcomes (e.g. mortality, incidence of complications)

l Equitable health care to reduce outcome variations across the population divide

l Waiting time and crowding at service points

l Adverse events reporting

l Responsiveness in the institution health care system

l Community participation

l Level of initial and continuous utilization of services

l Extent to which health care is delivered in a manner which maximizes resourcesand avoids waste

l Indicators for standardization

l Indicators for sustainability

l Client and community satisfaction

Sources of Data

Both routine and periodic data collected from facilities and communities will be used tomonitor quality of service provided. e nature and detail of the data will depend on agreedperformance measures and indicators that will facilitate monitoring, evaluation, researchinto QI and evidence based decision making for specific interventions.

l Health Facility Data - data will be collected routinely using the existing data collectiontools and transmission mechanisms using an integrated approach as far as possible.

l It is recognised that in some (many) facilities, established records and registers donot capture necessary information to permit reliable calculation of quality of caremeasures. In such cases, there may be a need for modest adaptation of records andregisters to permit capture of essential data. Indeed, improving quality of facility dataand the capacity of facility staff and MOHCC staff to collect aggregate and analysequality of care data in real time will be a central objective of the national qualityimprovement strategy.

l administrative data will provide information on health infrastructure, supervision,management meetings, logistics management, human resource profiles, financialresource flows and expenditures at the different levels of the health sector.

l Vital Statistics will provide critical information on births, deaths and cause of death.

l Population based Surveys such as the Zimbabwe Demographic and Health Surveywill incorporate questions that seek to measure quality of care.

l Periodic assessments of quality of facility health care services – in general, there islimited available information about the quality of care of specific services inZimbabwe. In order to deepen understanding of critical quality of care gaps to helpprioritize improvement aims and design of improvement work and to develop a multi-


year operational strategy, individual technical working groups may recommend a one-time assessment of quality of care in a representative number of facilities if resourcespermit. For neglected diseases and NCDs, in particular, there is scarce high qualitydata related to quality of health care and prevalence and epidemiology of specificconditions (e.g. for heart failure). Better baseline data may be necessary to informdevelopment of the most rationale operational improvement plan for certain technicalareas.

3.2 MONITORING AND EVALUATION

e M&E framework will be streamlined to ensure that maximum value is obtained fromthe investment on data collection and compilation.

Progress towards the quality objectives will be assessed nationally by reference to QualityOutcome Measures. ese measures will be based on a combination of patient and staffreported experiences and outcomes as well as measures of patient safety and clinicaleffectiveness. Indicators may be selected in line with agreed areas for specific acceleratedimprovement for each year. A few indicators of quality should be incorporated into thebasic health information system. Examples of indicators that may be easy to report onroutinely include case fatality rates for major conditions such as pneumonia, head injuryand general hospital mortality rates, accuracy and timeliness of reporting. Otherconsiderations include comments on quality of care appearing in the press andparliamentary debates.

Priority QI initiatives will undergo evaluation to follow up on whether the intendedoutcomes are achieved. e type of evaluation to be planned for and conducted shouldreflect the nature and scope of the public investment. Evaluations will be conducted atbaseline, mid-term and at final phase. Impact evaluations will be prioritized to assess cost-effectiveness and determine whether or not the investment should be scaled up.

e QA department will work closely with respective programmes and institutions in theplanning and conduct of evaluations with a focus on using external or peer evaluators inorder to minimize the bias normally associated with self-evaluation. It is very importantthat the results of the evaluations are shared at widely as possible for example shared at theannual “MODO”, Provincial and District Health Team meetings. e MOHCC websitealso provides a wider platform for the dissemination of evaluation findings. At the highestlevel, inclusion of QI should be high on the agenda of the weekly Permanent Secretarymeetings.

Systematic Monitoring and Correction of Quality

Supervision and the checklists used to conduct systematic monitoring must include simpleelements of quality assessment based mostly on direct observation. Supervision should becarried out in a constructive, supportive and not demoralizing manner, recognizing thesensitivities and feelings of those supervised. A standardized quality supervision tool willbe developed by the Quality assurance department for all levels of care to assess the qualityof services and support them in improving the quality of service provided.




Data analysis and Reporting

All levels of the health system will be capacitated to undertake data analysis at local levelto enhance evidence based decision making. Performance indicators will be used in theanalysis framework in order to describe trends, divergence between planned activities andachieved results. Facilities, districts and provinces will be able to benchmark theirperformance against those of best performers.e following methods will be used

l Internal benchmarking will be used to identify to compare practices within theorganisation/health facility with accepted best practices as well assessing currentpractice over time. Visual aids such as line graphs and maps will be used to displaythis information. Simple statistical techniques will be employed to assess validity ofchanges noted.

l External benchmarking will be used to compare data between organisations/healthfacilities to judge performance and identify improvements that have proven to besuccessful in other organisations/ health facilities and learn from that experience.

Data Dissemination and Sharing

e Health Information and Surveillance Unit will act as the central repository and sourceof service delivery data at national level. Real-time district level data in the District HealthInformation System (DHIS) will be consolidated at provincial level and transmitted to thecentral level. is data will be used by QI teams in situation and problem analysis and


participatory SUPERVISION: observation of quality

INFORMATION on quality

IDENTIFICATION of quality issues

NOTIFICATION of problems

INITIATION OF ACTION:

IMPLEMENTATION and FOLLOW-UP

routinerecording andreporting system

other sources

organizationalmechanismsat district,provincial andnational level

training, reorganization of work, logistics,standards, information to the public,legislation, manpower policies, etc. W

HO

880

07

Figure 9: Support and Supervision for Quality improvement

planning QI activities. Other data from patient surveys for example will be collated byprovince and shared on the MOHCC website.

Data will need to be interpreted in the context of the internal and external operatingenvironment. Service delivery data shall be packaged and displayed at the various healthfacilities using the HMIS format to be provided for standardization purposes. e timingof information dissemination should fit in the planning cycles and needs of the users.Information will be available through platforms such as the Health Matters Magazine, theMOHCC website, press releases and through electronic and print media.

Client Satisfaction Surveys

Service providers, regulatory bodies such as the Health Professions Authority andprofessional associations will on a regular basis conduct client surveys to determine thequality of services from the service user’s perspective. Standardised tools will be developedby the Quality Assurance department for the different levels of care.

accreditation, Recognition and Reward

e following strategic approaches to regulation and accreditation of facilities will be used:

l Align regulatory focus with health sector priorities.

l Build on self-regulatory mechanisms for compliance.

l Reduce the costs of regulation via rational sampling, focused accreditation, and tieredinspection.

l Assess/accredit management and internal QA processes and structures.

l Minimize internal costs of response to inspection.

Role of Research in Quality Improvement

e Ministry of Health and Child Care (QAD) in partnership with Academic Institutionsand other relevant partners will dra a research agenda that tackles problems in deliveringquality of care. Formation of a task force to coordinate and support research is suggested.Potential institutional homes for such a task force include College of Health Sciences,National Institute of Health Research, Medicines Control Authority of Zimbabwe,Standards Association of Zimbabwe and others. is research will use proven scientificmethods leading to new or revised interventions as well informing policy relating to accessand delivery of health care. One deliberate strategy would be to steer more healthprofessionals in training institutions towards research focused at quality improvement atboth programmatic and service delivery point. e task force mentioned earlier will alsotake the lead in the formulating core sets of standardized performance measures whichwill guide researchers in evaluating quality in healthcare.

In some areas e.g. NCDs that have historically received fewer resources or attention, atargeted quality of care assessment must be prioritized. is assessment could be very usefulto help inform prioritization and sequencing of improvement aims based on leading qualityof gaps identified along the continuum of care.




Applied health services research should be expanded and should emphasize thedevelopment of knowledge, tools, and strategies that can support quality enhancement atdifferent levels of the health sector. To ensure better understanding and use of researchfindings a number of platforms will be used to present these. ese include district andprovincial team meetings, various research symposia such as the Annual Research Dayhosted by the College of Health Sciences, National Malaria Conference, Student Seminars,National AIDS conference as well the MOHCC website.

Communication and Knowledge Management

Communication is a key component of the Quality Improvement Strategy, not just in termsof raising awareness about goals and objectives, but as a major driver to motivate andinspire everyone across Zimbabwe to take appropriate action to make their contributionto achieving the shared vision for high quality healthcare services. e key aims ofcommunication are:

l To raise awareness both internally and externally of the Government of Zimbabwe’svision for the MOHCC to ensure the delivery of high quality healthcare services atboth public and private institutions.

l Inspire staff and the public to appreciate and understand the role they play indelivering the Quality Improvement Strategy’s vision.

l Highlight national and local programmes and services which are helping deliverquality healthcare

e following approaches will be used to achieve these communication aims:

l Position and frame the Quality Improvement Strategy’s purpose and vision in throughpress releases and the electronic media. is will provide more meaning andunderstanding to the general public of Zimbabwe.

l Use all available approaches (events, publications, campaigns and media) to engagewith all stakeholders throughout Zimbabwe at a national and local level informingthem of the vision for quality improvement and their role in the achievement of thisgoal.

l Motivate, inspire, equip and support the people working in the health and relatedsectors with information about what they can do to help the MOHCC and its partnersbecome a world leader in delivering quality healthcare.

Promoting regular shared learning for rapid uptake and dissemination of emerging bestpractices will be a high priority for the QI improvement strategy. e provincial quarterlyreview meetings are an ideal platform to implement this. e Principal Director, Policy,Planning, Monitoring and Evaluation though the Quality Assurance Department (QAD)will arrange platforms that allow and promote regular shared learning acrossprovinces/districts working on similar technical areas. e MOHCC – QAD incollaboration with research institutions, programme managers will oversee theimplementation of national level research activities, communication and knowledgemanagement. Provincial and City Medical Directors will be responsible for follow-up ofinstitutional and district based activities.


ANNEXESANNEX A:QUALITY IMPROVEMENT METHODOLOGIES

5-S Method5S is a management tool which originated in the Japanese manufacturing sector. It is usedas a basic, fundamental, systematic approach for productivity, quality, and safetyimprovement in all types of organisations. Although 5S originated in the manufacturingenvironment, it translates well to other work situations including hospitals, general offices,telecommunication companies, etc. e 5S are abbreviations of the Japanese words Seiri,Seiton, Seiso, Seiketsu, and Shitsuke. In English, the 5S are translated as Sort, Set, Shine,Standardise, and Sustain.

5-S seeks to create a neat, clean and orderly work environment that allows for the provisionof effective, efficient, acceptable and safe health care. It is the initial step andfoundation/gateway towards establishing Continuous quality Improvement (CQI or Kaizenin Japanese)-Total Quality Management (TQM) programs.

1. SORT (S1)Focuses on eliminating unnecessary items from the workplace. is is achievedthrough categorization of the different items in the working place into three categoriesi.e. necessary, not necessary and may be necessary. is exercise will also help toaddress the ‘’just in case’’ attitude.

2. SeT (S2)Organizing everything needed in proper order for easy operation matching the workflow. It should be done based on finding efficient and effective storage of necessaryitem and can be applied using “Can see, Can take out, and can return” philosophy.is will save time and energy spent to look for required items..

3. SHiNe (S3)Cleaning up one’s workplace daily so that there is no dust on floors, machines orequipment, etc. to maintain a high standard of cleanness. It creates ownership andbuild pride in the workers.

4. STaNDaRDiSe (S4)Maintaining an environment where S1 to S3 are implemented in the same mannerthroughout the organization. It gives opportunities to employees to take active partin the development of these standards. It can be achieved by developing and usingstandard operating procedures, work instructions, checklists and symbols among others.

5. SUSTaiN (S5) Maintaining S1-S4 through discipline, commitment and empowerment. It focuses ondefining a new mind set and a standard in workplace. It can be facilitated throughregular progress reporting; refresher training; periodic evaluation of the 5S program;appreciation; recognition; awarding and putting a reminder system using 5S cornerand newsletter.



MODEL FOR IMPROVEMENT – PLAN-DO-STUDY- ACT MODEL

e Model for improvement is a strategy to manage change for improvement that stemsfrom the work of William Edwards Deming. e model, as depicted in Figure 8, includesthree basic questions to help structure improvement, which can be addressed in anyorder:

1. what are we trying to accomplish?

2. How will we know that a change is an improvement?

3. what changes can we make that will result in improvement?

All improvement begins with clear aim(s) as depicted in the model for improvement(what are we trying to accomplish?). Defining measurable improvement aim(s) andindicators to measure progress against aims is essential for supporting the work of localimprovement teams (whether a facility-based team or a District Health ManagementTeam). In turn, developing the capacity of managers and providers at all system levels todefine meaningful and measurable improvement aims focused on important quality gapsfor high-burden conditions linked to regular testing of changes and tracking of qualitymeasures (e.g. monthly run charts) is essential for building a system capable ofcontinuous improvement.

e Plan, Do, Study Act (PDSA) cycle is shorthand for testing a change in the real worksetting—by planning it, trying it, observing the results and acting on what is learnt. isis the scientific method used for action oriented learning.

e 3 questions in the model for improvement help to guide subsequent PDSA cycles:

l What are we trying to accomplish? - is question helps to guide and focus theefforts of the healthcare improvement team to work toward a clear and measurableimprovement aim. It is important that there is consensus in this team that a problemexists and needs fixing and hence that there is clarity about the aim of theimprovement. Information/evidence to support the existence and extent of theproblem must be collected, analysed and shared by relevant parties.

l How will we know that a change is an improvement? Improvement toward a definedaim can only be confirmed if clear measures have been established and resultsdemonstrate progress over time; erefore the team must define clear measures toascertain whether or not improvement work is achieving (or not achieving) thedefined aim.

ANNEX A: Quality Improvement Methodologies

Sort (S1)

Standardize (S4) Set (S2)

Shine (S3)

Sustain (S5)

DiagrammaticPresentation of the 5S’s:

l What changes can we make that will result in an improvement? is questioninvolves an improvement team brainstorming and testing incremental small tests ofchange to usual work processes to try to achieve the aim. Successful changes areadopted or adapted; unsuccessful changes are discarded.

Teams new to improvement need ongoing support to identify and test changes toprocesses of care to improve adherence with best practices. Ideally, team support includesintegrated clinical, QI and data-management capacity-building over time. Improvementteams are typically made up of managers, front-line health care workers and staff whopossess the necessary deep knowledge of their local systems to be able to identify andtest feasible and sustainable changes to “usual processes” to improve care in their localsetting.

Aer testing a change on a small scale, learning from each test and refining the changethrough several PDSA cycles, the team can implement the change on a broader scale—for example, for an entire pilot population or on an entire unit. Successful implementationof a change or package of changes for a pilot population or an entire unit can permit theteam or managers to spread the changes to other parts of the organisation or in otherorganisations.



Figure 10: Model for Improvement

Act Plan

Study Do

What are we trying to accomplish?

How will we know that a change is an

improvement?

What changes can we make that will result

in improvement?

Establishing MeasuresTeams use quantitative measures to determine if a speci�c change actually leads to an improvement.

Setting AimsImprovement requires setting aims. the aim should be time-speci�c and measurable; it should also de�ne the speci�c population of patients that will be a!ected.

Selecting ChangesAll improvement requires making changes, but not all changes result in improvement. Organizations therefore must identify the changes that are most likely to result in improvement.

Testing Changes"e Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting - by planning it, trying it, observing the results, and acting on what is learned. "is is the scienti�c method used for action-oriented learning.

Figure 10: Model for improvement

A key tenet of improvement is that making care better always requires change, althoughnot all change necessarily leads to improvement. Without “change” every system willcontinue to produce the same results it has always produced. Or, in the words of Deming,“every system is perfectly designed to get the results it gets”.

Managing change is central to improvement efforts whether or not such efforts areprospective (e.g. defining aims and proactively testing changes to processes of care to tryto reach the aim) or retrospective (e.g. auditing and examining adverse events to identifyand correct root problems contributing to poor quality).


While context has a strong influence on which changes may be most feasible and effectivefor overcoming gaps in a specific setting, categories of quality and system gaps andeffective changes (solutions) are oen common across settings. Diverse settings can learnfrom each other to overcome common quality and system gaps. Increasingly, manyimprovement approaches (e.g. Improvement Collaborative) mobilize teams to worktogether across health system levels and geographic sites to identify, test and sharesuccessful changes for overcoming important quality and system gaps, e.g., weeklysimulated resuscitation practice using structured peer to peer observation to maintainprovider competence. Promoting regular shared learning among teams helps to accelerateand scale up improvement efforts.

CLINICAL PRACTICE IMPROVEMENT (CPI)

CPI methodology has been widely used by health-care professionals to improve thequality and safety of health care. It does this through a detailed scrutiny of the processesand outcomes in clinical care. e success of a CPI approach depends on the teamcovering each of the following five phases.

Project phase: e team needs to ask themselves what it is they wish to fix or achieve.ey do this by developing a mission statement or objective that describes what it is theywish to do in a few sentences. is is the time to select the team members who should beselected on the basis of their knowledge about the problem. It is important that patientsshould always be considered as appropriate members of the team at this initial stage.

Diagnostic phase: e team needs to ask if the problem they have identified is worthsolving. e team should establish the full extent of the problem by gathering as muchinformation about the problem as possible. A brainstorming exercise by the team willgenerate possible changes that could lead to an improvement. A decision about how tomeasure the improvement needs to be resolved during this phase. During this phase theteam collects and analyses quantitative and qualitative data of the process beinginvestigated to establish causes of and potential solutions.

intervention Phase: Each of the solutions have to be tested through a trial and errorprocess by using the PDSA cycles to test changes, observe them and keep the bits thatwork.

impact and implementation Phase: is is the time to measure and record the resultsof the trials of the interventions. Did they make any difference? All changes are requiredto be measured for impact so that the change can be said to truly have made a differencerather than a coincidence or a one-off effect. e goal is to introduce a change that hassustained improvement.

Sustaining and improvement phase: e final phase requires the team to develop andagree upon a monitoring process and plans for continuous improvement. Improvementsmade now will become failures in the future if there are no plans to sustain theimprovements.


is will involve:

l Standardization of existing processes and systems for undertaking work activities

l Documentation of relevant policies procedures protocols and guidelines

l Measurement and review to enable the change to become routine

l Training and education of staff

ROOT CAUSE ANALYSIS

A root cause analysis is a defined process that seeks to explore all of the possible factorsassociated with an incident by asking what happened, why it occurred and what can bedone to prevent it from happening again. is applies especially to severe adverse eventssuch as avoidable deaths.

Root cause analysis will be used to determine the underlying causes of adverse events,incidents or situations. A root cause analysis may be used for example aer an incidenthas occurred to uncover the primary possible causes. As such, it focuses on the particularincident and the circumstances surrounding it. ere are many lessons to be gained fromthis retrospective process that may prevent similar incidents in the future if this isconducted in a systematic way. Techniques such as problem trees, driver diagrams andthe 5 Whys technique will be applied in conducting root cause analysis.

Health-care workers will receive instruction in this method as part of QI training at bothpre and in-service levels.

For effective root cause analysis the following components are critical:

l Multidisciplinary team which includes community representatives particularlythose that may bring out a patient perspective

l Composed of people who can add value because of their knowledge, position inthe organisation or unique perspective they bring

l Committed persons trained in root cause analysis

QUALITY IMPROVEMENT COLLABORATIVE

e improvement collaborative is a structured improvement approach that organizes alarge number of teams or sites to work together for a 12 to 24 month period to achievesignificant improvements in a specific area of care. e collaborative approach combinestraditional QI methods of team work, process analysis, and introduction of standards,measurement of quality indicators, training, job aides, and coaching. e collaborativeorganises regular sharing of results among teams through learning sessions in whichteams learn from each other about which changes have been successful and which werenot. is results in a dynamic improvement strategy in which many teams working onrelated problem areas can learn from each other in a way that facilitates rapid




dissemination of successful practices. In its emphasis on spread and scale-up ofimprovements, the improvement collaborative model offers a powerful new tool for QI.

e following elements are key to successful collaboratives:

l Clear improvement objectives

l Organisational structure

l Change package and clear dissemination plan

l Qualified and functional quality improvement teams

l Monitoring systems for quality of processes and results

l Regular coaching support to quality improvement teams

l Opportunities to share experiences and results obtained from changes made

improvement Collaborative Phase

e improvement collaborative will typically will go through the following phases:

Preparation: A situation analysis of current quality standards with a focus on identifyingroot causes of the discrepancy between expected standards and what is obtaining is thefirst task of the collaborative. Involvement of key stakeholders is critical during this phase.e organisational structure of the collaborative is established as well as the capacity andresource needs. Aer selection of initial sites a spread and communication strategy andcollaborative implementation plan is laid out. is process will take 6 to 8 months.

implementation: A collaborative will focus on one technical area (e.g. malaria, ART, TB,newborn care etc.). Interventions may also focus on issues of health systemsstrengthening (safety, health worker responsiveness and performance). e model forimprovement will incorporate 4 key elements:

l Specific and measurable aims

l Measurements of improvement that are tracked over time

l Key changes that will result in the desired improvement

l Series of parallel testing plan-do-study-act (PDSA) cycles. PDSA cycles shouldbe short but significant, testing a big change idea in a short timeframe so that ateam can identify ways to improve or change the idea.

ese stages involve the organisation of content and methods of learning sessions andaction periods as well as determine when to synthesise best practices and dissemination.

Learning sessions will typically be a national or provincial / regional workshop for teamsto share experiences and learn from one another, learn QI as well as clinical content.Attendees will comprise team representatives from each facility, provincial, district andnational stakeholders and trainers.


Documentation of improvement changes or best practices will assist in motivating teamsto sustain gains. e implementation stage will last 18-24 months. Aer completion anddemonstration of significant improvements the team may then focus on another technicalarea.

a spread strategy is a crucial feature of a collaborative. A spread strategy defines howone plans to gets to escalate or disseminate improvements made as a result of a testedand proven change package. In this phase the more experienced initial teams providesupport and mentorship to new teams.

e success of collaborative will hinge on qualified, functional and committed qualityimprovement teams. rough teamwork they will strive to understand their clients,analyse management processes, monitor results, and plan, implement and study changesor innovations to improve performance. ese teams are expected to come together atdefined intervals as a network with other teams to share results, innovations, and issues,and to learn from one another.

Monitoring is a vital feature of any collaborative. Quality improvement teams shall usea common agreed set of process and outcome indicators to measure quality. Whereverpossible, data should come from existing sources and not from a separate data collectionsystem. Occasionally, existing health information collection systems may be slightlymodified to capture essential information e.g. waiting time.

It is essential, that the quality improvement teams receive regular support throughcoaching. A coach will be an experienced person in quality improvement who will inturn help build the capacity of the local team in the collaborative process towards beingself-sufficient in QI.

Collaboratives have as their overall goal to provide an improved set of norms, models ofcare and/or best practices in an organisation for carrying out norms that can be rapidlyspread to other sites. Collaboratives provide a mechanism for resolving the operationalbarriers or obstacles around implementing any set of norms. us, a key feature of acollaborative is to arrive at a tested and refined “change package” and/or a set of bestpractices related to its implementation.

National, Provincial and District Quality improvement workshops

e National, Provincial and District Health Executives will facilitate inter-facilitylearning sessions where QI teams will share their experiences on the methods they usedto improve quality, results and lessons learnt. ese workshops will include cases studies,interactive illustrated presentations, discussion of common themes, and walk throughposter gallery through various team presentations. It is recommended that health careproviders in implementing facilities attend these workshops and that a verifiable methodof feedback to their facilities is put in place. A suggested frequency of a least bi-annualmeeting is suggested. It is important that leadership demonstrates commitment to qualityso as to motivate healthcare providers. Recognition and awards for performance shouldbe made at such platforms to help build a culture of quality improvement.




Annex B: LIST OF PARTICIPANTS IN STRATEGY PLAN FORMULATION

ANNEX B: Listof Participants in Strategy Plan Formulation

NaMe DeSiGNaTiON ORGaNiSaTiON 1. Dr. Dhlakama Principal Director PPM&E MOHCC2. J. Z. Chiware Director Quality Assurance MOHCC3. Gerald Shambira Consultant UZ/DCM4. Joseph Murungu Deputy ATP Coordinator MOHCC5. Charles Chiku QA Officer NMRL MOHCC6. Lawrence Mhatiwa Radiation Office MOHCC HQ7. M. L. Musiyambiri Director Gvt Analyst MOHCC8. Boniface Machingauta Provincial Analyst MOHCC9. Sibongile Zimuto Executive Director ZINQAP TRUST

10. Paula Zindi Deputy Director G Analyst11. Nyasha Masuka PMD Mat North MOHCC12. Lydia K. Madyira Data Quality Officer MOHCC13. Janeth Chinyadza Hospital &Projects MOHCC14. Fabian Mashingaidze Medical Superintendent Gweru MOHCC15. Joshua Mavambe Deputy Director Admin Health Service Board16. Gwati Gwati Planning & Donor Coordination MOHCC17. Slyvia Kudakwashe HRO - MOHCC MOHCC18. Lyness Majonga Admin Education DNS MOHCC19. Bernedette Sobuthana Health Consultant World Bank20. Leonad Mabandi Director Finance MOHCC21. Eva Muronda Quality Manager ZINQAP TRUST22. Prosper Shumba Quality Assurance Officer NIHR23. Joan Marembo PNO Midlands MOHCC24. Eneti Siyame Mental Health Manager MOHCC25. Dr. S. N. Zichawo Treasurer CPCDZ26. Rose Kambarami Country Director MCHIP27. Margaret Tawodzera A/food Safety Manager MOHCC28. Petunia Deda Human Resources Officer MOHCC29. More Mungati Epidemiologist MOHCC ATP30. Blessing Mutede PI, MEO EGPAF31. Bekezela B. Khabo QI, AIDS &TB Unit MOHCC32. J. Javangwe SNR Registrar Pathology - MOHCC33. V. Makanganise Nutrition Logistics MOHCC34. Arjanne Rietsema Country Director CORdaid35. Forward Mudzimu36. Hilary Chiguvare Technical Director MCHIP37. Kathleen Hill Consultant World Bank38. Gwati Gwati Planning & Donor Coordinator MOHCC39. Tendayi Jubenkanda Project Cordinator ZIPCOP/BRTI40. Jo Keating Technical Advisor USAID41. Bernard Madzima Director, Family Health Services MOHCC42. Margaret Nyandoro Deputy Director, Reproductive Health MOHCC43. Stephen Banda D/Director, Policy and Planning MOHCC44. Clemenciana Bakasa Deputy Director, NCDs MOHCC45. Rueben Musarandega SCE Manager EGPAF46. Joyce Hightower Patient Safety Officer WHO47. Stanley Midzi Professional Officer WHO48. Lovemore Marufu A/Director, Conditions of Service HSB49. Agnes Makoni Programme Analyst UNFPA50. Petros N. Ndanga Quality Manager MCAZ 51. Reggie Mutsindiri Senior Inspector HPA52. Alice T. Mazarura Save the Children53. Rachel Gondo M&E CWGH 54. Edgar Mutasa HL CWGH

zimbabwe quality assurance and quality improvement

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