Skip to 0 minutes and 5 seconds I’ve thought a lot during these years I’ve interacted with hospitals, for the last 12 years or so, doing this kind of quality improvement work. But the solutions come from people, they need to come from the people. And once you build their capacity to just maybe think of more of the best practices, that answer will tell you how they’re going to be implemented, and they do a fantastic job. I cannot impose the method of implementation to a hospital. I tell them the standards of care, and we discuss with them, they understand and then we identify problems in the care with them, and we identify solutions, because we don’t have a shoe… we don’t have a one size shoe for everyone.
Skip to 0 minutes and 55 seconds Solutions lies with the people. Listen to them. Give them time. Create forum for them to discuss relationship, for them to discuss what processes. Creating that forum it makes them be able to discuss issues because some times we’re finding hospitals, they don’t have meetings. So they go for quite some time having meetings other than the which is maybe called for another reason other than improving clinical care. So bringing them together, it gets solutions and improves teamwork. I think lessons for others who wants to similar things is start with the people you’re going to be working with, don’t impose a solution on them.
Skip to 1 minute and 44 seconds You have to have an idea of a common agreement on what comprises good quality basic care, because that’s what you are measuring. And it helps when those people have taken part in developing that consensus about what comprises good care. And recognising that it’s probably not the first thing that - when people wake up in the morning they don’t - it’s not the first thing they worry about, is this network, so you have to engage with them, prompt them, but accept that there’s some of the things they can’t or won’t do because they’ve got other priorities. While you still keep things trying to move forwards.
Skip to 2 minutes and 26 seconds So really try to engage the people you’re working with and involve them in process Yeah I think that… …in difficult situations. That level of… the engagement and we… these are quite spread out, these facilities we work with, but we do try and meet people face to face three times a year as a network. And that’s I think important to building some cohesion, some sense of a group.
Fostering ownership and engagement in clinical networks: lessons from the clinical information network in Kenya
Here we look at how developing effective MCNs is not a simple, mechanistic quick fix. Rather, it is a process that requires effort to engage with front-line health professionals to develop ownership of network activities. To explore this topic, we return to the example of the Clinical Information Network (CIN) in Kenya, introduced in an earlier step. Please watch the short video clip and read through the written summary that follows.
As noted earlier, CIN has made significant improvements in the quality of healthcare provided to Kenyan children by introducing and normalising the use of evidence-based standards and clinical audit in district hospitals. One important reason for CIN’s success is its leaders have developed ownership of the network and its activities. Thus, rather than simply being asked to implement external standards and collect data for others, CIN participants volunteer to make changes which they regard as beneficial to patients.
The CIN is led by two doctors with experience of the challenges of working on the ‘front line’ in the Kenyan health system. Both have helped to develop national evidence-based guidelines and have taught paediatrics at the University of Nairobi’s School of Medicine. Consequently, they have credibility among network participants both as paediatric clinical experts and people knowledgeable of day-to-day realities in Kenyan hospitals. In many ways, CIN’s leaders are role models of good practice ‘at the coal face’, demonstrating how to improve services and are therefore trusted by rank-and-file network members.
Developing ownership of network activities
The CIN successfully introduced clinical guidelines, clinical audit and targets for improvement in 14 paediatric departments involved in the network. Crucially, before doing so, the CIN engaged in dialogue with the paediatric departments involved, to ensure there was consensus that the guidelines and targets were relevant and feasible in local contexts. This consensual approach helped to minimise the risk that new goals, standards and data collection requirements were rejected or ignored by clinicians on the front line.
As we saw in an earlier step, routine data collection on processes of care is rare in the Kenyan health system. While Kenyan clinicians were expected to record information few took this process seriously, regarding it as an administrative burden imposed by the Kenyan ministry of health. As a consequence, much of the data held centrally was inaccurate. By contrast, the CIN helped to demonstrate to network participants how collecting clinical data on the processes of care could be used to improve the services they provided. By presenting these data in a positive and constructive (rather than punitive) way, showing the opportunity for improvement, the CIN convinced network members to take clinical audit seriously and use it to make changes for the better.
A further outcome of CIN was to generate ‘healthy competition’ between participating paediatric departments, over who might provide the best services and make the greatest improvements. By seeing incremental improvements in the provision of their care, doctors and nurses develop a sense of professional and departmental pride and motivation to maintain and raise standards of care.
Professor Mike English and colleagues note that ‘successful adoption of best practices…appeared where the implementing team, hospital management, and facilitator together provided leadership and supported a shift in organisational culture and commitment that helped motivate health workers and change their individual behaviours’. Thus, ownership of the CIN was built from the ground up, through collaboration between users and generators of data.
Because of this, the CIN might be described as a form of professional movement. By meeting regularly face-to-face, it has helped to break down traditional status hierarchies which stood in the way of service improvement in the past. By promoting open discussion of evidence and standards, clinical audit and improvement techniques, the CIN also provides an opportunity for the paediatric doctors and nurses to improve their own and wider sub-specialisms’ professional status within Kenyan healthcare. This provides further motivation to engage in network activities. Indeed, CIN participants describe a sense of pride in the way the quality of paediatric care was improving and how their colleagues in other non-paediatric departments wanted to establish similar networks.
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