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Applying a Performance Improvement Approach to Infection Prevention 
Human Resources Development Division, Ministry of Health, Ghana

10 April 2000

Following is the summary of a meeting held in Ghana to address poor infection prevention (IP) practices in the country. The Ministry of Health, along with other key stakeholders, had voiced frustration that, while much effort had been put forth to improve IP practices, including training, IP practices remained far from desirable in most parts of the country.

JHPIEGO offered to co-facilitate a meeting with the Ministry of Health to try to get at the root causes behind these poor IP practices so that a more coordinated, more effective approach could be taken to improve them. The performance improvement process was used as a framework for guiding the meeting. The model below was prominently displayed during the meeting and participants were informed that focus of the meeting would be on Performance Analysis, Root Cause Analysis and Intervention Selection.

The Performance and Quality Improvement Division (PQI) of the LPS office has drafted some discussion guides to be used in conducting a performance and root cause analysis. These draft tools are on file in the PQI Division for further reference.

AGENDA

Meeting on a Performance Improvement Approach to Infection Prevention

10 April 2000, HRDD

Participation

Twenty two individuals attended the meeting (see list of participants). In addition, the following from JHPIEGO were in attendance: Susi Wyss, Sue Brechin, Barbara Jones, and Abigail Kyei. The meeting was facilitated by Nancy Caiola of JHPIEGO and Said Al-Hussein of HRDD, MOH. The meeting started at approximately 10:15 and ended at approximately 1:45. Participants were engaged throughout and there was much lively discussion.

Objectives and Expectations

The following objectives were set forth for the meeting:

• Describe the infection prevention performance gap:

Whose performance?
What performance?
Where is the problem?

• Identify root causes of poor infection prevention practices
• Outline steps for working jointly to close the gap

The following expectations were elicited from the participants

• Identify framework to improve IP sector-wide
• Develop strategies to improve IP practice in Ghana
• Standardize bleach used in the system
• Incorporate IP into UCMS program
• Identify strategies to adopt
• Develop uniform KAP for training
• Improve and maintain standards in IP practice
• Retrain those trained
• Find out what is new in IP and standardization
• Maintain IP practice
• Learn from others
• Standardize process and terms

Nancy then described the performance improvement framework within which the meeting would be conducted. The PI process was described and displayed on a poster and on hand outs. It was explained that due to the limited time available, the meeting would focus on root cause analysis and preliminary identification of solutions or interventions. It was decided beforehand to limit discussion of desired performance as considerable effort had recently been devoted to writing IP guidelines which define desired IP practices. Key performance factors were then reviewed. (Very few participants had heard the PRIME 2 presentation on performance improvement but this did not seem to hinder their ability to quickly grasp the basic key concepts of the PI process.)

To illustrate the concepts of PI practically, a large group exercise was conducted whereby an IP scenario was presented (see attached) and participants were asked why, in this scenario, IP practices were still poor, even after some training had taken place. Following are the reasons given by the participants:

• shortage of gloves
• not enough chlorine
• bleach strength not indicated
• gloves were viewed as protection for staff - not as protection for patients
• it takes time to change habits
• information not disseminated
• forgot how - no job aid
• support not available from supervisors
• gloves wrong size -> didn’t use/too heavy, cumbersome
• colleagues not trained and therefore discouraged correct practice
• lack of clean water
• complacency
• want to finish early - too much work
• not sure who supervises laborers
• laborers don’t know
• wrong people trained
• no disincentive for poor performance
• procurement orders wrong supplies
• training did not take into consideration local resources
• no thought to change management
• training follow-up conducted too late

Gap Analysis

The large group was then asked to describe the performance gap in terms of who, what and where. When asked whose performance was at issue the following groups of people were identified. Those in bold were identified by the group as the most important:

service providers
administrators
trainers in IP
supervisors
cleaning staff
suppliers/manufacturers

When asked what practices were at issue, the following practices were identified as being equally important:

wearing protective gear correctly
handwashing
decontamination
waste disposal (how) and sites (where)
disposal of sharps
managements of pricks
general cleaning
storage of supplies

When asked where was the focal point of these practices the group agreed that service delivery sites in general should be the focus of the discussion.

Cause Analysis and Preliminary Identification of Interventions

The large group was then divided into three small groups. Each group was assigned two performance factors and were asked to do the following:

1. Describe how each performance factor affected IP practices
2. Identify priority, realistic solutions which should be further pursued, identifying who needed to be involved.

Group 1 considered job expectations and performance feedback

Group 2 considered knowledge and skills and motivation.

Group 3 considered management systems and leadership along with facilities, equipment and supplies.

The groups reported back as follows:

Group 1

Performance Factor: Job Expectations

How does it affect IP practices?

• Some knowledge of expectations exists but it is not necessarily adequate
• In some cases people know what they are to do but not all
• Training, observation, posters, reading but limited job aids, little dissemination (??)
• Guidelines limited only to RH
• No official job descriptions in place
• Existing job descriptions do not identify IP practices

Solutions:

• Analyze obstacles to supervision
• Put in place effective supervisory system

Performance Factor: Performance Feedback

How does it affect IP practices?

• Supervision exists but not standardized nor systematic
• Supervisors don’t necessarily know IP
• Supervision mainly fault-finding, inspection oriented, not supportive

Solutions:

• Peer supervision
• Supervision tools needed which specifically look at IP practices
• Site-level supervision

Group 2

Performance Factor: Knowledge and Skills

How does it affect IP practices?

• Some people know how to perform as desired, some don’t. Even those who do, don’t always perform in the desired manner.
• Attitudes are poor. In some cases there is lack of training. Some need constant reminders to perform as desired but there is lack of support to do so, supervision is weak, information sharing on importance of correct IP practices is lacking.

Solutions

• Standard protocol needed (there are many currently)
• Sensitize managers
• Dissemination of protocols (next month)
• IP course must be part of inservice training
• Training needs assessment and inservice training plan development
• Keep information on IP training and practice

Performance Factor: Motivation

How does it affect IP practices?

• Little appreciation for practicing desired performance
• Rewards/incentives are rare
• Disincentives are rare

Solutions

• Integrate IP into preservice training to promote appreciation for the need for correct practices
• Institute awards such as certificates, invitation to conferences, award credit points to teams, use exemplary performers as resource people
• Supervisors must do correct follow-up (verbal, written) and provide retraining indicated
• No compromise in IP practice: Facilities must use their USER fees (IGF) to promote IP practice
• Training participants need to conduct dissemination seminars after training
• Involve the private sector: What support? What incentives?

Administrators, supervisors and service providers all need to be involved in these solutions.

Group 3

Performance Factor: Facilities, Equipment and Supplies

Performance Factor: Management Systems and Leadership (factors considered jointly)

How do they affect IP practices?

• Inadequate supplies and equipment at all levels but worst at the peripheries
• Inappropriateness of the supplies and equipment (e.g. using running tap water instead of container water)
• Managers and administrators are not informed, aware of the importance of IP

 Solutions:

• Develop strategy to ensure adequate supplies at the peripheries
• Managers must be made to attach greater importance to IP, infection control
• Monitoring/supervision system should address IP
• Review Cash and Carry Policy and its implications on IP (procurement of expendable supplies) - through MOH Senior Managers
• Put up appropriate signs at vantage points as reminders to service providers

Recommendations

At the end of the meeting the priority strategies were summarized. There was discussion about the availability of resources to carry out the recommended actions. It was agreed that:

• HRD and JHPIEGO would summarize the meeting and develop a detailed action plan including resources needed and proposed time frame for implementation;
• HRD would call a meeting of the same group with one month to present an action plan for approval and implementation. Additional resources needed will be defined and committed at that time.

Infection Prevention Scenario - What is going on here?

Two nurses from a district hospital were trained in a regional workshop on infection prevention. Topics covered during the training included hand washing, proper use of gloves, decontamination of instruments, proper disposal of sharps, and waste disposal.

Two months after training was completed, a regional supervisor visited the hospital and found the following:

• Nurses wore the same pair of gloves and examined several patients before changing them.
• Used syringes were accumulating in an open basin for eventual disposal.

Laborers were disposing of waste using no protective hand covering.

• The decontamination solution was not being mixed according to infection prevention guidelines.

Why do you think that these practices were occurring despite the training that the nurses received?

Meeting on a Performance Improvement Approach to Infection Prevention

10 April 2000, HRDD

Participants

Name Organization Contact Address

Mrs. Vida Elorm Doe Inservice Education Unit, Korle Bu Korle-Bu Teaching Hospital, P.O. Box 77, Korle-Bu

Mr. Said Al-Hussein HRDD

Dr. Kwame Adogboba ICD, MOH ICD, MOH, Box M-44, Accra

Dr. Glena Quansah Asare Reproductive & Child Health Unit, MOH

Dr. E. Yao Kwamukume Dept. OBGYN, Korle Bu Dept. OBGYN, UGMS Korle-Bu, Accra

Mary Osae-Addae HRDD, MOH

Evelyn ? -Achew MOH RHA, MOH, Box 175 ??

Veronica Damha Nurses and Midwives Council Box M44, Accra

Ruth Gyang Nurses and Midwives Council Box M44, Accra

Florence Q?? G.R.M.A. P.O. Box 147, Accra

Henrietta Odoi- MOH (RCH) P.O. Box 44, Accra

Dr. N. S. Kanlisi AVSC International PMB KIA, Accra

Toshiko Oshita JICA (HIST Projects) P.O. Box 6402, Accra

Toshio Akiba Team Leader for HIST Project P.O. Box 6402, Accra

Gladys Kankam MTS, Korle-Bu P.O. Box KB81, Korle-Bu

Mary Dampson PHN School, Korle-Bu P.O. Box KB84, Korle-Bu

Charles A. Acquah CHAG P.O. Box 7316, Accra-North

Seth D. Acquah HRD/MOH P.O. Box 44 Ministries

Dr. Ken Sagoe HRD/MOH P.O. Box 44 Ministries

Dr. Joseph Amuzu USAID

Gladys Nana Kusi-Yeboah Maternity Unit, Korle Bu P.O. Box KB81, Korle-Bu

Dr. J. Taylor Korforidua General Hospital

 

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