Skip to 0 minutes and 5 seconds I’m Mike English. I’ve worked in Kenya for about 20 years as part of the Kemri Welcome Trust research programme. So, I helped initiate Clinical Information Network by winning grant funding for it. It’s on the basis of long term work we’ve been doing in the country. But it brought together a set of ideas and a set of people that we’ve actually worked with for a while as well. I helped bring it all together. So the Clinical Information Network was set up for a number of reasons. One primary one is to try and understand what goes on inside hospitals and what care is being provided.
Skip to 0 minutes and 43 seconds The quality of that care, refer here to quality as really being whether people are using evidence-based practices, and also then to determine the outcomes, because even very basic information in Kenya about what happens in hospitals, and whether children live or die has largely been missing previously. But then we use the information to feed back to the hospitals to try and get them to improve, so it’s a form of improvement collaborative as well. But we’re also trying to understand what kind of things we could do better and maybe move on to testing those things. So actually working with the clinicians on the ground to test new ways of providing care or new interventions potentially.
Skip to 1 minute and 26 seconds So that’s a lot of its formal purpose. There was a broader purpose, which was really to bring clinicians in what is sometimes relatively rural parts of the country together so they felt more connected, more engaged with the paediatric community, and get them to think about the way they are providing care, not just their particular role as a clinical specialist who might diagnose and plan a treatment course for a child. So the word network is important in this. Because, in the environment we work in, clinicians often quite young or early in their career in these more rural areas and are fairly isolated. They work alone as a specialist with a more junior clinical team.
Skip to 2 minutes and 11 seconds And it often does become a little bit boring because of the lack of resources that they have. And they often feel that they’re not doing a worthwhile job. So part of the network was to get people to think about the fact that they are doing a useful job, and that they can foster improvements, but to link them up with a peer group that hopefully would support them. My name is Grace Irimu. I’m a field professor in the Department of Pediatrics and Child Health in University of Nairobi. I am also a paediatric nephrologist, so I’m an honorary consultant in Kenyatta National Hospital, which is a teaching hospital for Nairobi University.
Skip to 2 minutes and 58 seconds We have a project which is ongoing since year 2013, which we call Clinical Information Network project. It aims at improving documentation practices in hospitals, because we felt good data cannot be good to know where we are. And that data, we’ll only be able to get it if there’s good documentation practices. Problems we actually have, or challenges, is that use of evidence-based care. And evidence-based care in Kenya, what we have done, we have put it in guidelines in the Basic Paediatric Protocol, like the one I have. So use of evidence-based care is a challenge. The problem is we can have the guidelines, but have people using the guidelines in the care of the children.
Skip to 3 minutes and 48 seconds And even when they use the guidelines, the question now which we’d probably be asking, to what extent have we, have we changed practice? And that’s a big question because without good documentation practices of what has been done, then you cannot tell people to what extent the practice has changed. So the Clinical Information Network helps in improving documentation practices so that we can use the routine data to monitor the use of guidelines, or to monitor the kind of care given to patients. For most of the patients who die in most developing countries, we have the data from Kenya, they die of common illnesses with simple solutions. Common illnesses including diarrhoea, including pneumonia, severe malnutrition, malaria, meningitis.
Skip to 4 minutes and 42 seconds These illnesses that are common, they are evidence-based practices which have been tested over years and have been shown to work and can save lives. But you find that compliance to the best practice is the issue. And let me just also add, although we do a lot of work in hospital practice, these same conditions can actually be presented by simple diversions in the community, can be prevented. So for us we are dealing with identification of cases and treatment, but we are just seeing that they can actually be prevented even from occurring.
Skip to 5 minutes and 18 seconds But now when they occur, they come to the hospital, we are trying to see whether they can be managed the best way, because we can save lives by doing that. Sometimes for some hospitals that can develop and catch it, we also complain of resources. But for example, like focus of diarrhoea, patient will die because oral rehydration salt has not been given. Now worse cases are somehow gone, because people are using the ORS well when the patient come to the hospital. Most of those patients then who go to ICU, that can be discepted. The process can be discepted of going to ICU by good care of that simple condition.
Skip to 6 minutes and 0 seconds Now, changing practice is not just a matter of reading gauges or giving people guidelines, or giving people a paediatric care admission record form. Changing behaviour is beyond that. It’s more than that.
Skip to 6 minutes and 16 seconds We treat not in training, but we build capacity for the team leaders on how to change practice in a complex system.
Using Managed Clinical Networks to implement evidence based practice: paediatric care in Kenya
Now we will look at the example of how managed clinical networks (MCNs) can have a potentially transformational impact on changing practice and raising standards.
As we saw earlier, MCNs were originally developed to communicate best-practice, evidence and expertise across organisational and professional boundaries and facilitate shared learning. Most research on MCNs has taken place in high-income countries. However, MCNs have also been adopted in low and middle-income countries (LMICs) which face very distinct challenges in terms of resources, clinical staff training and morale. In what follows we look at an example of an MCN in Kenya. Please now read the case description that follows and watch the short video clip relating to this case.
The Clinical Information Network
The Clinical Information Network (CIN) is a Kenyan paediatric MCN, spanning 14 public district hospitals. It is funded by the Wellcome Trust and operated under the auspices of the Kenyan Medical Research Institute (KEMRI) in collaboration with the Kenyan Ministry of Health and Kenyan Paediatric Association. CIN aims to improve healthcare and reduce mortality for Kenyan children. As detailed by the CIN leader, Professor Mike English (English et al., 2017), the CIN’s specific intervention activities are as follow.
- Developing consensual agreements on feasible and appropriate service priorities and goals for hospitals given available resources. This is important because goals imposed top-down may be poorly presented and rejected at the level of practice.
- Working with government to develop hospital information systems and then collating, analysing and regularly feeding back these data to hospitals as a tool for improvement (rather than being judgmental).
- Providing training in leadership, team-working, quality improvement, problem-solving and mentorship. CIN also provides a forum for mid-level clinical clinician/nurse managers to share their experiences and try to address common challenges.
- Identifying, disseminating and testing successful strategies for service improvement.
- Recognising and making visible the CIN’s and related hospitals’ achievements within the network and to policymakers.
Introducing and normalising evidence-based guidelines and clinical audit
In many developing countries, common illnesses which can be easily prevented and treated, such as diarrhoea, pneumonia, malnutrition and malaria, account for a majority of deaths among children. Providing evidence-based guidance about diagnosis and treatment for these common illnesses could, therefore, have a major (and very rapid) impact on child mortality. Leading CIN members played key roles in developing evidence-based paediatric and neo-natal guidelines at Kenyan national level, adapting WHO guidelines to suit the local context. Yet simply making clinical guidelines available does not ensure they are used. For this reason, the CIN also trains and motivates doctors and nurses to use paediatric guidelines in practice.
While clinical audit and data collection are routine in health systems in high-income countries, in Kenya and many other LMICs, reliable data about health services or outcomes simply does not exist. Another aim of the CIN has therefore been to improve capabilities in this area. This has been achieved through the introduction of clinical audit and the collection of routine information on how Kenyan children are diagnosed and treated and with what outcomes.
Making transparent whether and how healthcare organisations record, diagnose and treat patients (and the consequent effect on clinical outcomes) also plays a powerful role in motivating changes to clinical practice within the CIN. Every two to three months the CIN provides participating hospitals in the network with a written report on their performance, feedback on how to understand and interpret results positively and constructively and advice on how to use data to address problems and improve practices and clinical outcomes. ‘Harnessing data as a disciplinary force’ has led to significant improvements in the provision of paediatric health care within the hospitals involved (English et al., 2017).
The CIN also provides a support network for Kenyan doctors in the 14 hospitals affiliated to it. These doctors are often posted to remote district hospitals, where they may be put in charge of departments with little support or training. Many new doctors find this difficult, particularly when they are without the resources required to provide high standards of care. Consequently, loss of motivation and burnout are common among Kenya doctors. To address this problem, the CIN aims to create a networked community of paediatric doctors and nurses. The network provides both physical and online spaces for clinicians to support each other and share learning about how to address problems and improve the provision of healthcare. Through this support, the CIN has been able to engage with paediatricians and nurses at all levels, who might otherwise feel isolated and burnt out.
English, M., Ayieko, P., Nyamai, R., Were, F., Githanga, D., & Irimu, G. (2017) What do we think we are doing? How might a clinical information network be promoting implementation of recommended paediatric care practices in Kenyan hospitals? Health Research Policy and Systems, 15 (4): 1-12.
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