- The ACQUIRE Theory of Change
ACQUIRE’s BIG IDEA: HEALTHCARE WITHOUT QUALITY IS UNSAFE
Frontline healthcare workers learning from
data on their patients and processes
is the key to saving lives in Africa
ACQUIRE believes that the key differentiator between the poor/low healthcare practice in SSA and the relatively higher/stronger healthcare practice in the US, Europe, or even India is the science of Quality Improvement (QI). The Quality Chasm was big news 25 years ago. In SSA, it is just starting to be news.
Patients do not trust healthcare because there is so much direct evidence of it not working—from healthcare strikes to a lack of drugs to errors—the everyday examples of poor-quality care are easy to find.
Example from Kenya: Public hospitals offer metformin for free for type 2 diabetes, but if the government-funded facility is out of stock, the diabetic patient is stuck. Drug stockouts that lead to many diabetes fatalities would quickly be resolved by healthcare workers learning from their routine process data through the science of Quality Improvement (QI). Such an easily avoidable procurement challenge would never happen in the US and Europe, which have been practicing QI for 25+ years.
Getting to the Critical Mass Tipping Point: When small multi-disciplinary teams learn together, their learning can drive improvement within their departments. When these learning projects are repeated and scaled within the same setting, there is now a sufficient number of healthcare workers within the hospital facility who understand how to drive quality changes. Quality improvement can now become the lens that management uses to determine progress and success. Moreover, their patients are assured of repeated high-quality health services, leading to positive patient outcomes. Finally, the evidence of Quality Improvement efforts and their stories of success is enough to build champions that influence systems-level change within the hospital and national government/policy framework.
An enabling environment for quality approvement moves from exposure to experience, expertise, and sustaining.
PROBLEM
Three in every five preventable deaths are due to poor quality of care at health facilities in low- and middle-income countries in sub-Saharan Africa.
SOLUTION
- Build the capacity of frontline health workers in QI
- Create an enabling environment for evidence-based QI practice within their institutions
- Foster a community to drive uptake of QI practice
ACTION
- LEARNING: Virtual theory training courses in patient safety and quality improvement
- DOING: Facility-based experiential peer-learning by doing QI projects:
- Government healthcare management
- Hospital C-suite leadership
- Healthcare workers
- Quality Improvement coaches
- SHARING: Annual academic scientific conference and a community of practice
- SUSTAINING: Developing a QI pre-service and continuing professional curriculum
HOW ACQUIRE is applying the people-driven, systems change frameworks to the improvement of Africa’s healthcare systems
ACQUIRE’s approach unleashes intrinsic motivation by utilizing a peer-to-peer approach to drive learning from their process/patient data and inspire possibility-thinking. For example, the virtual theory training takes place in hospital-based teams of six nested in WhatsApp groups of up to 30 healthcare institutions. Both the individual healthcare workers and their teams are applauded and publicly celebrated. They respond by encouraging each other to complete the courses and demonstrate learning. For example, ACQUIRE uses leaderboards posted in weekly WhatsApp check-in sessions to show which teams have completed the most lessons in a theory course.
In experiential learning, the teams practically apply the science and methods of QI from the theory course. These hospital-based teams, together with coaching support, identify a local problem they want to address. In applying the science and methods of QI, teams listen to each other, commit to a common goal, and analyze the data to identify and test solutions. Real learning happens as teams document their progress, utilizing simple tools like run charts and process maps, and reflect on what has occurred. The reflection allows teams to adapt in action and to celebrate success. Bi-weekly check-ins where multiple teams share their progress within a community of other teams at the same learning stage combine peer learning. It supports the sharing of success. The peer learning process is enhanced as teams demonstrate success and share how they overcame challenges.
Thirdly, ACQUIRE believes that change in the healthcare system also requires government-level policy interventions and a curriculum that teaches pre- and continuing learners the principles of quality improvement.
A LITERARY PERSPECTIVE
ACQUIRE’s theory of change leans on two change management frameworks that we discuss briefly below.
- Framework One: Activate healthcare workers’ agency, and they will change the more extensive health system
The Psychology of Change framework looks primarily at the human factor, the people, and individual healthcare workers, and what they need to do to change.
Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston: Institute for Healthcare Improvement; 2018. (Available at ihi.org)
- Framework two: Apply a systems approach to organizing healthcare institutions
Edward Demmings’ System of Profound Knowledge addresses the “messiness” or complexity of problems at the systems level. Healthcare institutions have complex problems; therefore, change requires a deeper understanding of the system, not just individual agency. Systems thinking is not routinely taught to healthcare workers but is fundamental to the science and methods of healthcare quality improvement. The system needs to change to create an enabling environment. The paradigm moves from making it possible to do the right thing to an approach that makes it very difficult to do the wrong thing for a patient. This systems approach promotes patient safety. It requires institutions to commit to building an environment or culture that will support and sustain change for the patient’s good.
- Source: Kazzaz Y. The Lens of Profound Knowledge. Glob J Qual Saf Healthc. 2023 Aug 24;6(3):96-98. doi: 10.36401/JQSH-23-X3. PMID: 38405326; PMCID: PMC10887482.Source: Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care. 2007 Feb;16(1):2-3. doi: 10.1136/qshc.2006.022046. PMID: 17301192; PMCID: PMC2464920.
