Quality improvement in emergency units in low resource settings: a qualitative assessment for understanding challenges and delivering solutions
Indrakantha Welgama, Daniel Lange, Gerard O’Reilly, Aurore Nishimwe, Agnieszka Ignatowicz, Justine DaviesObjective
This study aimed to identify the barriers and facilitators for quality improvement (QI) in emergency units (EUs) in low- or middle-income countries (LMICs) and to understand the prioritisation of care quality domains to inform the development of EU-specific guidance for QI across all World Health Organisation (WHO quality domains for LMICs.
Methods
We conducted in-depth interviews (IDIs) with specialist emergency physicians from LMICs and convened a workshop with global technical experts in emergency care. A structured topic guide was used for the IDIs. Interviews were conducted virtually, transcribed and thematically analysed using the WHO quality domains and the WHO Health Systems Framework. Data collection and analysis continued until saturation was reached. The 2-day workshop included presentations, discussions and interactive ranking exercises to assess measurements for QI and prioritise WHO quality domains for guidance development. Findings from both components were synthesised to generate key insights.
Findings
Eleven IDIs were conducted and 26 experts participated at the workshop. QI efforts in LMIC EUs primarily focused on quality domains of effectiveness, timeliness, safety and occasionally patient-centredness. Key barriers to QI included high patient turnover, a lack of skilled staff, limited funds and resources and prioritising patient care quantity over quality. Facilitators included the availability of QI guidance, training, initiating small-scale projects, enhancing documentation and communication and supportive hospital management. Safety and effectiveness were considered the most feasible domains for QI, although all domains were considered important. Variability in how participants defined these domains highlighted the need for clear guidance on definitions, their relative importance and appropriate measures for each.
Conclusions
EUs are complex, high-pressure environments managing time-critical health conditions and require development of specific tools and guidance for QI. Addressing the barriers and leveraging facilitators identified in this study can inform the development of effective QI strategies for LMIC EUs.