A Quality Improvement Training Programme For Health Professionals In The Ministry Of Health And Social Services In Namibia

ABSTRACT

A quality improvement training programme is important to address the challenges that the health professionals are facing in their quest for quality health care delivery. In Namibia, most health care facilities have not been yielding good results in response to patients’ health care needs. Health care dynamics are complex and inundated with several factors; among others new methods, speed of improving medical science and technology, as well as increasing demands of the clients to address emerging and re-emerging diseases. Health professionals are often criticised for unsatisfactory results due to several challenges sometimes beyond their capacity and knowledge to mitigate and manage. The difficulties experienced cannot be ignored, since there is no specific quality improvement / management training programme to prepare health professionals. Without appropriate training and empowerment of health professionals, health care delivery would continue to yield unsatisfactory results. Thus quality improvement training programme seeks to empower health professionals with knowledge, skills, and aptitudes with the aim of enhancing quality health care delivery.

The nature of this study required a clear paradigmatic perspective thus constructivism and interpretivism approaches were adopted. Assumptions such as ontological, epistemological, axiological, methodological and rhetorical were used. Further Practice theory of Dickoff (1968), programme development by Van Niekerk; Kolb’s theory of experiential learning, Deming’s model of quality improvement, quality improvement management policy of the MoHSS and Centre for disease control (CDC) framework for programme evaluation in public health formed a theoretical basis of the study. The research process was carried out in five phases: Phase 1: A mixed method which is a quantitative, qualitative, exploratory, descriptive, and contextual was used. This was done to achieve the objective one (1) and two (2) as part of situational analysis (phase 1).

Objective 1: A checklist was used in order determine the present situation of quality health care / service delivery at health care facilities. The target population were the managers in leadership positions, such as deputy permanent secretary, undersecretary, directors, pharmacist, medical superintends, principle medical officers, health programme officers, matron senior officers and others. A total of twenty-one (n = 21) participants which purposively selected comprised of managers in leadership (n = 6) from the MoHSS head office, while (n = 15) were drawn from the health facilities in the Khomas, Kunene, Erongo and Omusati regional health directorates. A part from the demographic data, participants were given opportunity to rate themselves on Likert’s scale with scores ranged from strongly disagree; disagree, agree and do not know on the following variables such policies and guidelines; leadership; human, physical, material and financial resources; patient safety, information as well as monitoring and evaluation. Further participants were given a statements of “yes”, “no” and don’t know on research ethics and utilization of data. SPSS software was as used tool for data analysis. Data were presented in percentage, figures and tables. To ensure reliability, items in the checklist were tested using the Cronbach alpha coefficient for multiple items measured on the Likert’s scale. It was indicated that the items from 1-40 provided a value of 0.95 while the rest of items (measures) was 0.88. For validity, content, criterion and construct were used. The findings of this objective revealed some ambiguities in the availability of policies and guidelines, leadership to facilitate

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care delivery, health system infrastructure, patient safety, as well as research and information to facilitate quality health delivery.

Objective 2: Concentrated on the exploration and description of the experiences of managers in leadership positions and health professionals with regard to quality health care / service delivery at health care facilities. Individual interviews (n = 12) from twenty-one managers in leadership position, as well as focused group discussions (n = 5) that consisted of eight participants for each FGD were implemented. In addition, field notes were conducted. Participants in the FGDs were 40 from health facilities in the above four regional health directorates as indicated above. The regions were selected based geographical location, population density and services delivery namely referral, intermediate and district hospital. Participants were purposively selected. To achieve that exclusion and inclusion criteria were used. Both individual and FGD data were collected until saturation. Data from the transcription of the recorded audiotapes and field notes were analysed using Tech’ steps methods. Independent coder assisted with coding of the results. Various reasoning strategies such inductive, deductive, inferences, reflective and bracketing not only in this objective were used. Five themes and 13 sub- themes were identified that were a basis for the development of the educational programme for health professionals. The themes revealed that the participants’ experienced unavailability of guidelines and structure to facilitate QI and QA; inadequate management of resources; inadequate interpersonal relationships amongst the health workers; an inadequate understanding of QI and QA; as well as poor research and information, monitoring and evaluation, and indicators of monitoring and evaluation. Phase 2: The Practice Oriented Theory of Dickoff (1968) was used as practical guidelines to develop the conceptual framework. This framework was employed during the research and the educational programme development process. During the research process, the agent was the researcher; recipients (Managers / leadership and health professionals); the context (MoHSS head office and healthcare facilities); dynamics (findings for objective one and two); Procedure (research process) and terminus (foundations for development of educational programme). For the educational programme developing process, agent (quality specialist), recipients (health professional), context (health facilities), procedure (training programme for health professionals), dynamics, (challenges hampering successful implementation of the programme) and the terminus (knowledge, skills and abilities acquired through the training programme). Phase 3: During the development of the quality improvement training programme, an adopted version of two main theories was used. The most prominent one was a model by Meyer and Van Niekerk (2008), which was adapted to guide the process of developing the training programme. While Demining’s PDSA model of quality improvements well as quality improvement policy of the MoHSS focused on the content to enhance the findings. Further, Kolb’s experiential and Knowles adult learning theories were used to facilitate the teaching and learning process. The educational programme included the name, purpose / aim, objectives, structure / design, facilitation process, implementation process, and evaluation of the programme this was done inline n with Namibia Qualification Authority (NQA) framework. Phase 4: This phase, focused on developing the guidelines for implementing based on UNFPA while the evaluating the training programme were done in line with CDC framework. These guidelines outlined the process, activities, and elements required for implementing as well evaluating the educational programme for health professionals in Namibia.

The study achieved trustworthiness by applying the criteria of dependability, transferability confirmability and credibility (Guba & Lincoln, 1994; Babbie, 2008; Lincoln & Guba 1986; Schwandt, Lincoln, & Guba 2007).

Based on the study findings, it was clear that a need existed for a quality improvement training programme to empower health professionals with knowledge, skills, and aptitudes (KSAs) in quality assurance standards and quality improvement processes to facilitate quality health care delivery at the health care facilities (MoHSS). Specific recommendations of the study were highlighted with reference to the responsibilities and roles of different stakeholders for the successful implementation of the programme, as well as the purpose of improving quality health care goals in the MoHSS. The management, health professionals, education, profession of quality improvement, and research have vital roles in contributing to the sustainability of the training programme.