Improving Care at the Most Remote Clinics in Liberia

In southeast Liberia, a small Partners In Health team of nurse trainers has been driving to some of the most remote health clinics in the world. In trucks and on motorcycles they bounce for hours over rolling grassland, cross flooded rivers, and squeeze through cuts in massive fallen trees.

The four-wheeling isn’t for fun. The rugged commutes are to help increase the quality of health care at some two dozen small rural clinics. Starting in 2015, the Liberian Ministry of Health began rebuilding the country’s health system, which was devastated by the civil war that ended in 2003 and again by the Ebola epidemic of 2014 and 2015. The government is creating health care guidelines, training staff in hospitals, and much more. But improvements in the hard-to-reach rural clinics are a ways off yet. In the meantime, the handful of staff in these single-story cement buildings are often the first to see patients and the last to receive training.

A clinical mentor on the way to Juduken Clinic. Photo by Ezra Patrick Lugemwa / Partners In Health

So beginning in April 2016, PIH, along with local health officials, created a program called the Integrated Clinical Mentorship and Improvement Collaborative. The design of the program borrowed liberally from various models, including the program that PIH, Harvard Medical School, and Rwanda’s Ministry of Health invented to mentor rural nurses in Rwanda seven years ago, called MESH-QI. Taking a cue from the Liberian Ministry of Health’s nationwide priorities, the goal of the Collaborative was to boost services for mothers and children, and improve infection control for everyone, by sharpening up the skills of clinicians in these remote facilities.

“We want to build sustainable, country-driven, and evidence-based solutions,” says Anatole Manzi, PIH director of clinical practice and quality improvement.

For two months, PIH master coaches Nurse Gilbert Lekakeny Nkodedia and Nurse Irene Awino Ogongo each led three other nurses in rolling out the project. They measured the 19 clinics’ performance in eight areas key to preventing the spread of disease and improving the health of women and children. They gathered baseline data on how often nurses washed their hands during births, for example, and how many clinicians routinely tested pregnant women for syphilis.

Once the observation period was over, the fun began. “Traditionally, the solution is, ‘Let’s see how they are performing and have the directors correct them by writing you should do X instead of Y,’” says Manzi. Instead, the master coaches and other PIHers hosted county health officials, clinic staff, and community representatives in something like a design sprint.

The agenda was shared. Challenges were presented and agreed on. Sticky notes were deployed. And participants spent hours sharing possible root causes of poor staff performance and brainstorming potential solutions. An example? One of the causes of poor hygiene might be a lack of motivation. One of the solutions could be a talking faucet, a small stereo recording that plays at handwashing stations and reminds staff, in English and the local dialect, of the importance of scrubbing in.

The next day, they winnowed the list to the few ideas that seemed most promising. These solutions were a bit more conservative, including, for example, establishing a buffer stock of essential hand hygiene supplies. At the end of the second day, everyone dispersed to the county level office to review and share ideas that were to be tested, knowing that they would be able to refine or abandon them in subsequent sessions every two months.

Was all that really necessary? How difficult can it be to encourage clinicians to wash their hands?

Manzi answers with the story of Ignaz Semmelweis, a Hungarian doctor who practiced medicine in Vienna, Austria, in the 1840s, the dawn of modern medicine.

Many pregnancies in one maternity ward of the hospital where Semmelweis worked went well, while in another maternity ward, 1 in 5 expectant mothers died. Semmelweis wanted to find out why and used the technique of objective experimentation. He had women give birth on their sides instead of their backs (no effect). He rerouted a bell-ringing priest known to frighten women (also no effect). After months of trying out various theories, he finally arrived at the answer.

Doctors in the dangerous ward weren’t washing their hands. They were performing autopsies and heading straight to the delivery room, and the women were getting infected and dying of sepsis.

All should have been well from then on, but finding the answer proved to be only half the solution. Semmelweis lectured his peers on the importance of chlorine. He fought with powerful colleagues. He berated the stubborn. And he grew ever-crankier, suffered a mental breakdown, and died (of sepsis, likely contracted while having a wound treated in a hospital) a full three decades before most of the world would embrace his ideas about antiseptic.

“So when we talk about quality improvement and infection control in Liberia,” says Manzi, “we don’t want to be like Semmelweis.”

And they weren’t. Clinicians created solutions for themselves, such as a calendar with pictures of the best hand washers of the month. And patients contributed, for example, by proposing a patient-staff buddy system, in which each inspects the other’s hand washing.

How did it turn out? “Small ideas lead to great improvements,” says Manzi. An analysis in April will reveal year-end results, but between March and December 2016, at least, the improvements were dramatic.

The percent of clinicians who used a childbirth checklist and monitoring tool during deliveries, known as a partograph, increased from 24 to 71.

Testing pregnant women for syphilis increased from 0 to 24 percent.

The percent of women giving birth at clinics increased from 41 to 56.

Other results showed no improvement. And the percentage of women tested for HIV actually decreased 16 percent, due to some clinics’ difficulty in finding and paying for HIV test kits.  

Manzi and others are pleased with the improvements. The solutions that failed will be replaced by new ideas, which they will test and hopefully prove valuable.

“It’s a cycle,” says Manzi. “It’s a new way to accelerate and push. Most importantly, the clinicians feel like they own their health system. In my experience working with country teams to design and implement quality improvement interventions, the role of leadership has been critical. PIH/Liberia’s leaders played a critical role throughout this program. They are both leaders and key players—inspiring, informing, supporting, and acknowledging change agents as they generate creative ideas.”

And the number of clinicians who washed their hands correctly? It increased from 37 percent to 72 percent. If only Semmelweis had tried a “Handwashing Champion” calendar.