title: Improving quality in resource poor settings: observational study from rural Rwanda.
abstract: OBJECTIVE
  Hospitals in rural Africa, such as in Rwanda, often lack electricity, supplies, and staff. In our setting, basic care processes, such monitoring vital signs, giving drugs, and laboratory testing, were performed unreliably, resulting in delays in treatment owing to lack of information needed for clinical decision making.
  
  
  METHODS
  Simple quality improvement tools, including plan-do-study-act cycles and process maps, were used to improve system level processes in a stepwise fashion; resources were augmented where necessary.
  
  
  METHODS
  50 bed district hospital in rural Rwanda. MEASUREMENT OF IMPROVEMENT: Three key indicators (percentage of vital signs taken by 9 am, drugs given as prescribed, and laboratory tests performed and documented) were tracked daily. Data were collected from a random sample of 25 charts from six inpatient wards.
  
  
  METHODS
  Our intervention had two components: staff education on quality improvement and routine care processes, and stepwise implementation of system level interventions. Real time performance data were reported to staff daily, with a goal of 95% performance for each indicator within two weeks. A Rwandan quality improvement team was trained to run the hospital's quality improvement initiatives. EFFECTS OF CHANGES: Within two weeks, all indicators achieved the 95% goal. The data for the three objectives were analysed by using time series analysis. Progress was compared against time by using run chart rules for statistical significance of improvement, showing significant improvement for all indicators. Doctors and nurses subjectively reported improved patient care and higher staff morale.
  
  
  CONCLUSIONS
  Four lessons are highlighted: making data visible and using them to inform subsequent interventions can promote change in resource poor settings; improvements can be made in advance of resource inputs, but sustained change in resource poor settings requires additional resources; local leadership is essential for success; and early successes were crucial for encouraging staff and motivating buy-in.
authors.affiliation: Partners In Health, 888 Commonwealth Avenue, Third Floor, Boston, MA 02215, USA. mkotagal@post.harvard.edu
authors.forename: Meera
authors.initials: M
authors.lastname: Kotagal
authors.forename: Patrick
authors.initials: P
authors.lastname: Lee
authors.forename: Caste
authors.initials: C
authors.lastname: Habiyakare
authors.forename: Raymond
authors.initials: R
authors.lastname: Dusabe
authors.forename: Philibert
authors.initials: P
authors.lastname: Kanama
authors.forename: Henry M
authors.initials: HM
authors.lastname: Epino
authors.forename: Michael L
authors.initials: ML
authors.lastname: Rich
authors.forename: Paul E
authors.initials: PE
authors.lastname: Farmer
mesh_terms: D002983:Clinical Competence / Q000592:standards; D003625:Data Collection; D019937:Diagnostic Techniques and Procedures / Q000706:statistics & numerical data; D006282:Health Personnel / Q000193:education; D006295:Health Resources / Q000600:supply & distribution; D006767:Hospitals, District / Q000592:standards*; D006801:Humans; D007857:Leadership; D010043:Outcome and Process Assessment, Health Care; D011787:Quality of Health Care; D019035:Rural Health Services / Q000592:standards*; D012432:Rwanda