title: A nationwide quality improvement project to accelerate Ghana's progress toward Millennium Development Goal Four: design and implementation progress.
abstract: OBJECTIVE
  The gap between evidence-based guidelines and practice of care is reflected, in low- and middle-income countries, by high rates of maternal and child mortality and limited effectiveness of large-scale programing to decrease those rates.
  
  
  METHODS
  We designed a phased, rapid, national scale-up quality improvement (QI) intervention to accelerate the achievement of Millennium Development Goal Four in Ghana. Our intervention promoted systems thinking, active participation of managers and frontline providers, generation and testing of local change ideas using iterative learning from transparent district and local data, local ownership and sustainability.
  
  
  METHODS
  After 50 months of implementation, we have completed two prototype learning phases and have begun regional spread phases to all health facilities in all 38 districts of the three northernmost regions and all 29 Catholic hospitals in the remaining regions of the country. To accelerate the spread of improvement, we developed 'change packages' of rigorously tested process changes along the continuum of care from pregnancy to age 5 in both inpatient and outpatient settings.
  
  
  CONCLUSIONS
  The primary successes for the project so far include broad and deep adoption of QI by local stakeholders for improving system performance, widespread capacitation of leaders, managers and frontline providers in QI methods, incorporation of local ideas into change packages and successful scale-up to approximately 25% of the country's districts in 3 years. Implementation challenges include variable leadership uptake and commitment at the district level, delays due to recruiting and scheduling barriers, weak data systems and repeated QI training due to high staff turnover.
authors.affiliation: Institute for Healthcare Improvement, Cambridge, MA 02138, USA.
authors.forename: Nana A Y
authors.initials: NA
authors.lastname: Twum-Danso
authors.forename: George B
authors.initials: GB
authors.lastname: Akanlu
authors.forename: Enoch
authors.initials: E
authors.lastname: Osafo
authors.forename: Sodzi
authors.initials: S
authors.lastname: Sodzi-Tettey
authors.forename: Richard O
authors.initials: RO
authors.lastname: Boadu
authors.forename: Solomon
authors.initials: S
authors.lastname: Atinbire
authors.forename: Ane
authors.initials: A
authors.lastname: Adondiwo
authors.forename: Isaac
authors.initials: I
authors.lastname: Amenga-Etego
authors.forename: Francis
authors.initials: F
authors.lastname: Ashagbley
authors.forename: Eric A
authors.initials: EA
authors.lastname: Boadu
authors.forename: Ireneous
authors.initials: I
authors.lastname: Dasoberi
authors.forename: Ernest
authors.initials: E
authors.lastname: Kanyoke
authors.forename: Elma
authors.initials: E
authors.lastname: Yabang
authors.forename: Ivan T
authors.initials: IT
authors.lastname: Essegbey
authors.forename: George A
authors.initials: GA
authors.lastname: Adjei
authors.forename: Gilbert B
authors.initials: GB
authors.lastname: Buckle
authors.forename: J Koku
authors.initials: JK
authors.lastname: Awoonor-Williams
authors.forename: Alexis
authors.initials: A
authors.lastname: Nang-Beifubah
authors.forename: Akwasi
authors.initials: A
authors.lastname: Twumasi
authors.forename: C Joseph
authors.initials: CJ
authors.lastname: McCannon
authors.forename: Pierre M
authors.initials: PM
authors.lastname: Barker
mesh_terms: D002662:Child Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D003299:Cooperative Behavior; D005869:Ghana; D006298:Health Services Administration; D006301:Health Services Needs and Demand; D006801:Humans; D007231:Infant, Newborn; D007373:Interinstitutional Relations; D008427:Maternal Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D010342:Patient Acceptance of Health Care; D058996:Quality Improvement / Q000458:organization & administration*