The COVID-19 pandemic is impacting the availability of essential health services – especially services for pregnant women, newborns and children – that cannot be delayed or shifted to other settings. In many lower middle-income countries, maternal and child mortality remain high, and hard-won gains could falter without continued attention. Practitioners are already voicing such concerns.
Countries around the world are facing the challenge of increased demand for care of people with COVID-19, compounded by fear, misinformation and movement limitations that disrupt the delivery of health care services. Similarly, health facilities are facing several challenges to provide quality health care – a care that is safe, timely, equitable, effective, efficient, and patient-centered.
Placing quality of care at the heart of global efforts is indispensable to strengthen health systems for equitable primary health care. Closing the quality gap in health care, especially during the intra-partum period, can save 4 million lives (maternal deaths, still births and neonatal deaths) by 2035 (Lancet, Every Newborn 2014). The findings of three landmark reports – The Lancet Commission on Quality of Care, Delivering quality health services and Crossing the Global Quality Chasm: Improving Health Care Worldwide – provide ample evidence to support the assertion that “providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical”.
Virtual quality improvement workshop
The training was organized in coordination with the Ministry of Health Kenya, and Nairobi county. The workshop, jointly supported by UNICEF, WHO, and UNFPA, was held via Zoom from 29th June – 3rd July 2020. Seventy participants (trainees and observers) attended the 3-hour daily training over the five-day period.
The main goal for organizing the training workshop was to prepare and equip a pool of resource personnel for effective implementation of the Quality Improvement (QI) agenda at the national, county and health facility level.
1. To understand practical steps necessary to improve the quality of maternal, newborn and child health (MNCH) care including infection prevention and control (IPC)
⁻ Identify quality challenges related to MNCH/IPC
⁻ Strengthen quality improvement teams and develop aim statements for quality improvement
⁻ Develop and test change ideas to learn what works
⁻ Embed successful changes into health facility systems to sustain improvements
2. Initiate/coach a QI project to improve quality of care in various settings
3. Provide tools to support self-learning and capacity building for quality improvement
4. Acquire skills to conduct trainings using virtual platforms
This training is unique because it utilizes a blended learning approach. The figure below summarizes the various phases of the training.
Pertinent features of the training
– Participants from all levels (sub national and health facilities) of the health sector in Kenya attended the training.
– Participants included a variety of cadres – midwives, nurses, doctors, managers etc.
– Training focused on applying QI strategies to improve infection prevention practices in the context of MNCH.
– By the end of the training, participants had a draft of their QI projects – which they are to develop further with the support of their health facility QI teams during the post-workshop “Knowledge into Practice” phase.
– Participants from Ethiopia, Tanzania, Malawi, Namibia were also present as observers, with the aim of replicating similar workshops in their respective countries and to generate interest.
1) Preparation is key!
a. Decide focus area – QI principles apply to all areas of health care. For starting teams and participants, it helps to give practical examples that relate to the area of work that needs improvement. Identify a focus area that is of current interest to participants & stakeholders.
b. It is essential to have one person who takes the lead in organizing – this must be someone based in the country and is familiar with the participants. The person can also help decide how to group participants for breakout rooms
c. Decide the meeting ‘host’ and ‘co-hosts’ for Zoom or similar virtual platform
d. Google forms were used for pre-test, post-test and evaluation forms
e. Two shared google drive folders were prepared for facilitators and meeting participants
f. Two WhatsApp groups were created to ensure ease of communication during the workshop
g. Polls were set up in Zoom daily to assess participants knowledge and opinions
2) A technology briefing is critical. A planning session to familiarize all facilitators and participants with the technology interface was conducted prior to the workshop. This helped teach participants how to use various zoom features such as share screen, raise hand, mute/unmute, breakout rooms, polls, whiteboard etc. A poll conducted during the session showed approximately 50% of participants were using Zoom for the first time
3) Incorporate energizers – Identify simple and creative ways to keep the participants engaged. Several videos and intermittent polls were used to keep participants engaged. Even a simple act of ‘taking photos’ helped energized the participants
4) The importance of attending all workshop sessions need to be emphasized to participants
5) For facility level participants, it helps to ensure a team of 3-4 people attend. This will help implementation, otherwise it becomes challenging for one person to provide in-facility support and apply QI methods
6) Things take longer online! Our one-day agenda spilled into two days, we had to compensate towards the end of the workshop. Lesson is to keep the objectives realistic and specific
7) Have a variety of presenters/facilitators to prevent monotony.
8) Encourage and appreciate participation consistently – Allow & encourage interruptions (within reason!) and consistently acknowledge participants who speak or type in the chat box. Appreciating any sort of engagement by participants will give the signal that you want them to be involved. Otherwise people will hesitate to interrupt and may lose interest
9) Daily briefing among organizers/facilitators is essential.
10) Be respectful of people’s time – always close on time even if you are running behind on the agenda.
11) Workplaces should allow participants to fully engage in the training as they would do for an in-person training.
12) Provide data bundles to participants – virtual meetings for several days will consume a lot of bandwidth, so this support is needed.
13) Share materials with participants in advance – Sometimes people have internet issues and may not be able to see the shared screen.
14) Have a post-workshop plan that is jointly agreed upon. For example, on the last day, participants developed a workplan to implement their quality improvement projects which included a training plan for health workers.
The way training workshops are usually conducted have been impacted due to travel restrictions imposed because of COVID-19 pandemic. Though technology is not a substitute for face-face meetings, it can be used to support health systems strengthening efforts – in this case, to build capacity and skills for quality improvement. It was a lot of fun for us to be part of this experience – the enthusiastic involvement and responsiveness of all participants during the workshop has boosted our confidence in virtual training methodologies.
We hope other countries and organizations globally will find this experience beneficial in conducting similar workshops for healthcare quality improvement.
Resources & materials used for the virtual QI training workshop
1. “Point of Care Quality Improvement” materials & resources
a. QI workbook – A self-paced online case-based course on QI for MNCH
b. PowerPoint slides for facilitators (encourage facilitators to adapt these slides to their convenience and style)
c. Introductory Lectures on the four step QI approach
2. Energizer video examples
a. WHO teams up with Minions and Gru to show how people can stay safe from COVID-19
b. A health worker dancing in PPE!
Participant Feedback & Evaluation – 37 responses received
More than 90% stated “strongly agree” or “agree” to the following statements –
“The instructors knew their subjects”
“I felt comfortable asking questions”
“The virtual training platform facilitated learning”
“I know how to continue building my QI skills”
“The course was organized well”
“The audiovisual presentations were easy to see and follow”
“I feel that I have the capacity to assist QI teams to improve QoC”
“I understand my responsibilities toward implementing the standards.”
“I feel confident about being able to carry out this QI Project”
“I will recommend this training to others”
About 31% of the participants felt the duration of the workshop was too short. Several participants felt more time should be allotted to the group work and breakout sessions.
Some sample feedback comments
“The hours could be increased so as to make it more interactive especially in breakout sessions”
“I think it may be useful at some point to put the national coaches in one group to chart the way forward in coaching the rest of the teams”
“Congratulations for excellent training”
“Increase the time to about 4 hours”
“It should end with the teams coming together in future”
“Sending training material prior to the training due to network errors during presentation”
“More story techniques”
“All the offices sending participants for training should support them for logistical purposes, like internet and also be off duty. Personally, I had hard time gambling with work and joining zoom at the same time sometimes missing hours, but am happy have managed”
“This was an excellent training in terms of content, very timely, content expertise was very good. Keep up the new normal, it worked. Let us follow up with teams on the end training plan to keep the momentum going.”