Imagine you are a midwife in sub Saharan Africa who runs a community health center with a large population. In this health center, resources are severely restricted and there is a recurrent acute shortage of qualified staff in your team. Imagine that as the midwife you have poor problem-solving skills, have very little knowledge on expected standards of patient care and safety and knowledge deficit on how to be a leader and yet you are expected to act as one and lead a team effectively. Imagine that you are constantly under pressure to improve patient outcomes especially maternal and newborn outcomes despite all the issues mentioned above. Almost seems like you are being asked to perform miracles in the dark right? It is almost obvious the kind of outcomes one will have both for the patient and the staff who get frustrated and suffer from burnout.
This scenario is not unique to one nurse/midwife or primary healthcare unit but is easily copied and pasted across Africa. However, the attitude of the healthcare workers working under these circumstances is not something that can be replicated. Each individual chooses how to carry themselves and how to manage their patients. This is why human factors are now considered as part of standards in health systems accreditation. There is a lot of public outcry over the poor attitude of the nurses and very little about nurses who have a positive attitude despite all the issues mentioned above.
One such midwife who chooses to have a positive attitude and is composed, compassionate, self-driven and confident is Christiana Jillo Will, Midwife in-charge, Lunsah Community health Centre in Sierra Leone known for having one of the highest rates of maternal mortality in the world with huge lack of Maternal Health Care.
Within 6 months of training, mentorship and coaching on basic improvement methods, she rose to become one of six healthcare workers who were recognized for their efforts in achieving and sustaining gains in their health centers. I must acknowledge as a facilitator and mentor that the attitude of the team mentored was a defining factor.
During our chat recently this is what she had to say about what drives her and vision for nursing:
” Learning how to use data to identify gaps in my maternity unit and using the model for improvement has empowered my team and I to develop solutions for gaps within our control. This automatically changed our attitude as we felt in control of our situation most of the time.
For example, ever since I learnt to use the partograph correctly during mentorship, I feel empowered to monitor my patients and make the necessary decisions in a timely manner. This has greatly improved my maternal and neonatal outcomes, patient satisfaction feedback and my team and I have developed confidence to work in the labor ward.”
She concluded to say; ”I look forward to having platforms where I can share my knowledge with other nurses to empower them as well to help change their attitude towards patient care.’’
If you are a medic you might be thinking the use of a partograph is something basic, but when you have been on the ground and seen the reality you will know that availability of patient care standards in the midst of complex health systems is not equivalent to the use and compliance to them.
As much as there are a lot of challenges in the already complex health system, the reality is that the leadership cannot be on the ground every day to solve all the emerging issues. Majority of the staff in the health system are nurses and midwives, empowering them with problem solving skills automatically improves patient outcomes, their attitude and eventually transforms the health system.
Ultimately, the attitude of the healthcare worker across the healthcare system remains a defining factor.
Christiana Jillo Will, we at Nurses In Africa  celebrate you in a big way.


Pediatric Nurse Winnie Kubai, Kenyatta National Hospital seizing an opportunity to mentor her colleagues at work.

It takes a special person to be a nurse but it takes an extra special person to be a pediatric nurse who is passionate about her calling.  One such nurse is Winnie Kubai, pediatric Nurse who works at The Kenyatta National Hospital, Kenya’s largest public referral hospital situated in Nairobi. You would be amazed to hear the reviews I got about her from the larger nursing community who share a learning platform on social media! I contacted her and we had a conversation and this is the story behind what drives her.

This is what she had to say:  I am a registered Nurse with a specialty in pediatrics and my heart belongs to children.  I grew up loving children and on my first posting, I was fortunate to be deployed to the Maternity wards. My passion for children grew even stronger after I took one year of specialization course in pediatrics and began to associate their every action with what’s in their mind, according to their developmental stage. This enables me to handle each child differently including adolescents who are not ‘’small adults’’.

I seize every opportunity to promote health to the community and preventive measures on common illnesses that affect children. Opportunities such as: social gatherings, meetings, church, at work and one time in the bus on my way to work. My deepest desire is for children to seldom get sick and those who do to get well with minimum or no sequel at all. Its always a heart wrenching experience to see them suffer when sick and the pain it brings their families.

I want every caregiver to understand the simple, cost effective measures that will be used to protect the children from complications of current illness. Some practices like thorough history and clinical examination, even in the well child clinic, environmental hygiene, personal hygiene and infection prevention and control go a long way to ensure better outcomes for the little ones. Since it would be impossible to achieve this goal on my own, I decided to pass on my skills to others through intentional mentorship that way we would have a well-equipped team. I focus on nursing students on clinical rotations, healthcare providers during short courses pediatrics courses including ETAT+, Pediatric BLS, PALS, Newborn Resuscitation and Neonatal Standards of Care.

I look forward to the day healthcare providers will finally get the attention they seek from the ministry of health in Kenya to address recurrent issues that pose a challenge to offering the optimum care.

Pediatric Nurse Winnie Kubai, Kenyatta National Hospital [left] with her colleague at work all smiles!!
To my colleagues, I have this special request: Listen to the caregivers of the sick children. In the public hospital where I work, the mothers from low socioeconomic backgrounds have a lot to tell us that can affect the patient’s outcome and ultimately reduce hospitalization days. But due to huge workload, many a times we’re forced to postpone the session, as we have to attend to all the demands of the other patients and their caregivers. Some days we are assigned to over 30 children per nurse in a shift and it makes the delivery of service a huge challenge.

So, what keeps you going? Seeing a once unconscious child now play in the hallway, brightens my day especially when one is overwhelmed. Children don’t not how to pretend so when they feel better, they will be up and about. It makes my day!

At Nurses in Africa, we believe every nurse has a story and Winnie’s story is one to be celebrated. Through her, standards of care are communicated daily creating consistency which is a cornerstone of quality improvement. The nurturing environment she has created in her work environment to provide meaningful mentorship is an added advantage too after all quality improvement is not a microwave solution but a crock-pot solution.

In this already complex health system, sometimes all the staff need as motivation is recognition of their efforts by their leaders. A pat on the back from you makes a huge difference.

What keeps you going when the going gets tough?



Accreditation-The Gold star in Healthcare

I recently got a call from a potential client who was interested on quality improvement. The first consultation is always interesting as I try to find out what the motivation is behind striving for change. Apparently after the call for focus on quality by WHO most healthcare organizations are finally paying attention. As if that’s not enough, there is a new dynamic in town [ in Africa anyway] called accreditation and facilities that have achieved it are smiling all the way to the bank as they can prove publicly that they provide high quality of care. This is translating to patient numbers which means increased revenue. Of course, where there is mention of increased revenue and reduced costs, investors and owners of private entities sit upright.

My potential client had only one question in his mind? How fast can I get this accreditation so I can make it public to increase my visibility in the very competitive healthcare market? My question to him was also simple: Before we look at external evaluation to get accreditation, what are the internal standards, processes and procedures you have and how do you evaluate them?

Simply put, accreditation in healthcare is a form of external review that shows that a healthcare provider is meeting regulations and standards set by an external accreditation organization. In most developed countries, this process is not voluntary and each healthcare organization MUST adhere to the regulations or face massive penalties which include public announcements of non-compliance. Unfortunately, in Africa, most countries are still in the stage of developing their own internal standards and/or even more importantly evaluating themselves against these standards leave alone invite external parties to come and evaluate them. Some of the popular accreditation bodies are JCIA [ Joint commission of international accreditation], COHSASA [The Council for Health Service Accreditation of Southern Africa] among others. Of course, there is always the question of whether the standards meet the context of healthcare in Africa and that has led to development of simpler standards that are user friendly e.g. the SAFECARE standards.

In order for a healthcare organization to achieve accreditation, they must prove compliance with the standards. This usually involves a rigorous review process, in which industry experts survey the organization’s structures and policies to ascertain the degree to which the organization does what it says it does and the evidence to prove it. The standards cover everything from training materials, to data retention, to equipment maintenance. This usually cuts across all departments in the organizations i.e. Administration and finance, Human resources, patient care in different aspects, patient safety, infection control, security Etc.

To prepare for accreditation, organizations must do a comprehensive assessment of processes, policies, and procedures, and anything else related to accreditation standards. This allows them to identify any areas where there are gaps in compliance. The organization’s leaders can then make changes to ensure that the structures meet standards and regulations. Unfortunately, the process of accreditation is very expensive as it means structural changes among other things to meet the set standards. It is always advisable for the facility to initially adapt the set standards and work towards compliance internally before engaging external evaluators.

Once the organization is prepared, external surveyors will conduct an on-site survey to decide whether to approve the organization for accreditation.

To maintain accreditation, the organization will have to undergo review every few years to ensure continued compliance. This is normally the tricky part as most health organizations tend to relax after achieving accreditation leading to the danger of being de-accredited which is normally done in public the same way accreditation is announced.

In the end, achieving accreditation in healthcare comes with many important benefits for your organization: This include:

  • Achieving accreditation requires holding staff to high standards for patient care which in turn improves the overall quality of care in healthcare facilities.
  • In certain specialty areas, accreditation programs even improve patient outcomes.
  • Standardized processes decrease variations in the ways different staff members and departments care for patients therefore maintaining quality of care throughout.

Yes, I acknowledge the fact that in Africa we still have a long way to get there but I do know that each healthcare organization can start the process on their own to achieve internal benefits which will ultimately benefit the patient who remains the focus of this whole exercise. The right leadership in place makes or breaks the outcome of the process on establishing standards of patient care even in the smallest unit of healthcare.

The beauty of the whole thing is that you don’t even have to think about the standards as they are already available. As someone who has worked in both contexts of standards and lack of them, I can tell you for free that as a healthcare worker, the presence of standards makes our work much easier with less burnout.




Root cause analysis: Focus on the CAUSE not the PROBLEM.

The beauty of quality improvement is that the teams get to meet regularly to review their progress against the process indicators they are tracking. That said, this is not always all happy and cordial. Sometimes it gets to a point of confrontation especially when the teams are just beginning their improvement journey. 

A few weeks back I had to sit through a quality improvement meeting with a team in one hospital just beginning their Improvement work. A documentation audit review indicated that there was a steady decline in the monitoring of vital signs for patients therefore poor clinical outcomes. Upon random review of one file, the patient in question had been discharged without a recheck of their vital signs and the last reading had shown extremely elevated blood pressure reading. Of course, at this point, everyone in the meeting understood the repercussions of the incident based on the medical history of the patient. Naturally what followed was everyone trying to pass the blame around from the doctor who discharged the patient, the nurses on duty, the leadership and therefore provided a very good forum to perform a root cause analysis to identify the real cause.

Getting to the heart of a problem – locating the roots – is sometimes a difficult task especially in a health system with more than one challenge. In quality improvement, we advocate for it nevertheless because every time we solve the problem and not the cause of it, it happens again, and a vicious cycle is created.

 In this case, it was easy to use the five why’s technique to get to the real cause of the problem at hand which was poor monitoring of vital signs leading to poor clinical outcomes. i.e.:

Patient discharged with elevated blood pressure from last reading [why]

Vital signs monitoring not done that day [why]

Lack of blood pressure machine and thermometer in the ward [why]

Nurse in charge refused to supply the ward with more vital signs monitoring equipment[why]

The equipment has been disappearing from the ward within a month of supplying from the store [why]

Handing over of equipment is not consistent in the ward especially over the weekend, [why]

root cause analysis- RCA

There is no formal process in place, therefore, no accountability. [why?]

If we were to solve the problem and not the cause of it, the traditional way would have been to punish the doctor and the nurses on duty when the incident occurred. Contrary to the traditional way, the team ended up developing an SOP on handing over and an implementation schedule that would ensure the problem never occurred again.

Whether you conduct a root cause analysis using a method that involves asking a series of “why” questions or you rely on a method that uses tree charts or cause and effect diagrams is not important. What matters most is that you have a reliable process and use it to analyse information so you can identify both the cause of problems and solutions to those problems at the most fundamental level.

I am very sure that when you look around our health systems, the challenges identified and how the solutions are derived you would agree that we are constantly attempting to solve the problem and not the cause and that’s why the health indicators being tracked have little if no improvement at all. From the recruitment of more health workers to one-off training and purchase of numerous equipment to handle quality issues instead of addressing at the point of care.

Bottom line is, the whole quality improvement team should participate in this exercise if the real cause is to be defined for corrective action. The key is to avoid assumptions and encourage the team to keep drilling down to the real root cause. If you try to fix the problem too quickly, you may be dealing with the symptoms, not the problem, so use five whys to ensure that you are addressing the cause of the problem. Remember, if you don’t ask the right questions, you won’t get the right answers.

Root cause analysis (RCA) helps quality improvement teams retrospectively study events where patient harm or undesired outcomes occurred to identify and address the root causes. By understanding the root cause of an event, we can improve patient safety by preventing future harm. A good root cause analysis allows for the design and implementation of a solution that addresses the failure at its source.

On a lighter note, root cause analysis can be used in any aspect of our lives and not only the clinical one. Go ahead and try it.

In my experience, often the causes of the problems are process failures and not people failure.