Applying QuAlity improvement ApproAches to humAn resources for heAlth

Around the world, the scarcity of trained health workers undermines

efforts to address skyrocketing HIV/AIDS infection rates as well as other infectious diseases, and provide basic health care to mothers and children. Over-loaded health workers and understaffed facilities are struggling to care for rising patient loads. Many of these health care providers lack motivation and a sense of control over their work which lowers their productivity and the quality of care their patients receive. Improving the capacity and engagement of health workers is essential for improving health care in USAID-assisted countries.

hci’s strategy to engage and retain health WorkersThe USAID Health Care Improvement (HCI) Project supports countries in applying quality improvement methods to strengthen processes and outcomes of health care. Quality improvement (QI) involves mobilizing provider teams to: 1) identify and overcome problems affecting care quality, 2) test interventions, and 3) spread successful changes through shared learning and collaboration among multiple teams. This process encourages creativity and shared decision-making, measures changes frequently to ensure improvement, and provides a platform for exponential sharing of lessons learned and adoption of best practices.

HCI’s health workforce strategy adapts this improvement approach to strengthen and improve human resource systems by engaging health care workers, their communities, supervisors, and decision-makers in developing, testing, and implementing practical and sustainable solutions. The project applies QI

approaches to solve human resources problems faced by developing country health systems, especially at the facility and district levels. QI approaches are especially appropriate for strengthening human resources at the peripheral level, since experience shows that QI work empowers health workers to make changes to improve care and increases health workers’ sense of professionalism and job satisfaction.

HCI uses employee engagement to measure and improve health worker performance. Engaged employees – according to research and practice in many private sector organizations – work harder, produce more and stay longer in their jobs. Engaging employees requires that employees value their organization and

their jobs, believe they can succeed, feel valued, and perceive they have a substantial role to play in the organization and in shaping their futures.

As teamwork, collaboration, and empowerment are key elements in engagement, using working teams to empower health workers to solve problems, providing recognition and support for accomplishments, and empowering workers with approaches such as self-assessment, peer coaching, and peer support for flexible work times, can have dramatic effects on the engagement and productivity of workers. Teams can provide a shared mission, clarity in roles and responsibilities, feedback on performance, reward and recognition, and allow individuals to influence the work

A health worker’s belief in her ability to succeed in her job and good relations with her supervisor are among the key drivers of employee engagement. Photo by Steve Harvey.

may 2009

The USAID Health Care Improvement (HCI) Project seeks to develop the capacity of host country health systems to apply modern quality improvement approaches to make essential services better meet the needs of underserved populations, improve the efficiency of service delivery, reduce the costs of poor quality, and improve health worker capacity, motivation, and retention. The work of the HCI Project is supported by the American people through the United States Agency for International Development (USAID) and its Bureau for Global Health, Office of Health, Infectious Diseases and Nutrition. The project is managed by University Research Co., LLC (URC) under the terms of Contract No. GHN-I-01-07-00003-00.

strategies, and facilitate spreading successful practices to other sites.

The figure below depicts the relationships between performance management, quality improvement, employee engagement, and the desired outcomes of increased retention, increased productivity, and improved quality of care. By addressing drivers of employee engagement and productivity, HCI is meeting country-specific needs while expanding the evidence base for applying QI approaches to human resources management.

current hci Activities in Workforce Developmentn Niger – HCI is working with the

Ministry of Health and Regional Health Directorate to implement a Human Resources Collaborative in the Tahoua Region to improve health worker engagement, productivity, and retention. Improvement activities focus on strengthening performance management through QI teams and increasing employee engagement.

HCI measured the engagement of health workers with an instrument that adapted current best practices in Employee

university research co., llc • 5404 Wisconsin Ave. • �hevy �hase, maryland 20815-4811 • usA • 301-654-8338The contractor team for the USAID Health Care Improvement Project includes prime contractor URC, EnCompass LLC, Family Health International, Initiatives Inc., Johns Hopkins University Center for Communication Programs, and Management Systems International. Initiatives Inc. is HCI’s lead partner in the area of human resources management. For more information on HCI’s work in human resources management, please contact Ms. Lauren Crigler, HCI Director of Health Workforce Development, at lcrigler@urc-chs.com. For more information on the work of the USAID Health Care Improvement Project, please visit www.hciproject.org.

they do. Team participants feel part of a whole larger than themselves, working with others towards the same end. Engagement strategies can also challenge health care workers to support each other, rather than wait for supervisors and managers to solve a problem.

Increasing health worker engagement also requires consistent performance management support. Performance management ensures that workers have achievable workloads and clear expectations. Health workers need feedback on performance, fair evaluations, recognition and rewards for performing well, and career development opportunities. Although this process is ideally delivered by managers through consistent supervision, elements can be supplemented through quality improvement teams, worker-focused initiatives, and peer groups. Teams can address gaps such as clarifying job expectations by analyzing work processes and rationalizing provider skills with required jobs and tasks. Using the improvement collaborative approach, multiple teams can work on common problem areas, share successful change

the effects of performance support and Quality improvement on employee engagement, Quality of care, productivity, and retention of health care Workers

performance systems

1. higher quality services

2. improved productivity of health workers

3. greater retention of staff

health Worker engagement

Belief in job/organization

Belief in ability to succeed

Good relations with supervisor

and/or team

Professional advancement

Recognition/reward

Influence in decision-making

Setting objectives

Feedback

Incentives

Capacity building

Evaluation

Professional advancement

Environmental safety

Process of care

Quality of care

performance management

Quality improvement

Engagement to the Nigerien context. All heath workers, including non-literate ones, completed a confidential 26-item questionnaire with a 5-point agreement scale. Teams of health workers are using the results of the engagement questionnaire, along with other baseline results, to solve some of the issues that are most serious to health workers, such as rewards, career advancement, and safety on the job. Employees will complete the same questionnaire on a quarterly basis, and QI teams and facility, district and regional managers will meet regularly with groups of employees to continue analyzing and solving problems that mean the most to them.

n Uganda – The Ministry of Health and HCI are applying the improvement collaborative approach to engage district management teams in coaching facility-based quality improvement teams as a long-term strategy to improve performance management and institutionalize a continuous quality improvement function at the district level.

n Benin – Together with the PISAF Project, HCI is conducting research to evaluate the effectiveness of a task-shifting intervention that uses job aids to enable lower cadre health workers to achieve proficient performance of maternal and newborn care tasks.

n Namibia – HCI is supporting the Ministry of Health and Social Services to expand its Workplace Program to provide training for health care providers on abstinence-be faithful-condoms, de-stigmatization of HIV, stress management, and bereavement.

n Global – In partnership with USAID, HCI has developed a rapid assessment tool to measure community health worker programs, as part of USAID’s strategy to address the human resources crisis for maternal and child health services. Field testing of the tool begins in June 2009 in Nepal. HCI is also evaluating HIV/AIDS training programs for health workers in selected USAID-assisted countries.