Learning from the End of the Public-Private Partnership for Lesotho’s National Referral Hospital Network

I. Protocols, monitoring, and quality improvement

1. Use of clinical protocols led to higher quality care

a) “Patient outcomes—they’re incredible. When you have standard operating procedures, you basically have a map of how you are going to care for patients.” – QMMH staff, clinical roleb)

b) “The most important change is quality care (…) [By] having guidelines and policies, one knows what to do and how [to do it]. Hence, in the end, we have quality care.” – QMMH higher management, clinical role

2. Routine internal and external monitoring as driver of performance

c) “We monitor the performance of the clinicians and the nurses. We do clinical audits to see whether they are conforming to the protocols and the clinical pathways (…) [We] come up with quality improvement projects that will improve from where we are and eliminate gaps that were identified.” – QMMH higher management, clinical roled)

d) “For every department we do a risk assessment, risk rating, and monitoring (…) They report the near misses, the incidents, the adverse events, and the sentinel events. (…) The policy is that if there has been any sentinel or adverse event, within five days we should have done a root cause analysis and, within 20 days, advise the management on what to do.” – QMMH staff, non-clinical rolee)

e) “It’s all about meeting goals and having this independent monitor to come and check that things are being dealt in accordance to what has been requested by the contract. It puts everyone on their toes (…) There is an evaluator [who comes to] check your work functions, evaluate [you] and give you a penalty if you are not performing well. This positive change in performance [is] because there is an evaluation and monitoring process.” – QMMH higher management, non-clinical rolef)

f) “Because we try to adhere to COHSASA, our standards are much higher. We get evaluated so I think our services are a lot better than the previous hospital.” – QMMH higher management, non-clinical role

3. A dedicated office of quality and risk led staff actions to address gaps and improve quality

g) “QMMH doesn’t joke, if there is a loss of life we have to sit down (…) to see what went wrong. The fish bone [diagram] is really scrutinized. And the people [then] know that, yes, I could have changed the outcome. And next time we [see] this case, I am not going to miss that. (…) [It is] the most important change.” – Clinic higher management, clinical role

h) “[If] we meet certain obstacles, we come up with quality improvement projects (…) because we have a quality office here and they really ensure that in all aspects everything is on point.” – QMMH staff, clinical role

II. Accountability and discipline

4. Accountability started with clear roles, responsibilities, and polices

i) “What happens is on day-to-day, employees know what is expected of them because they have their job descriptions.” – QMMH higher management, non-clinical rolej)

j) “We know what time we have to be in at work and what time to knockoff. Things with the PPP have been going so well, compared to where I was working before, because I would leave [early] at 1: 00pm and nobody will ask me anything. Here I know that even if nobody asks me anything, there are things I should follow. I have to come at a specific time. I have to do [specific work]. There are guidelines, policies.” – QMMH higher management, clinical role

5. Individual performance assessed using a balanced scorecard

k) “Before I can assess the employee, we need to fill out the balance scorecard so that they can know which issues I am going to assess them on (…) [The balanced scorecards] have helped in a positive way. People don’t want to make any mistakes (…) [and] if they have made mistakes (…) we can rectify.” – QMMH higher management, non-clinical rolel)

l) “Even me, I have a balance scorecard (…) my goals are this: to decrease morbidity in the department, to decrease neonatal deaths. Every quarter I have to translate to where we left and where we are in this quarter. Do we see a decrease? And then be accountable to say what measures am I going to implement in the department to ensure that we achieve what reflected in the score card. (…) It is really well structured. Hence why a doctor who is not used to that gets frustrated. They get to a point where they are monitored, monthly, weekly, quarterly to say: ‘but you are not performing.’ So it really helps to keep the performance standards.” – QMMH higher management, clinical role

6. Disciplinary actions taken to help ensure quality

m) “If you don’t perform or you are found guilty of mismanagement of patients, steps are taken about such individuals. Some of them had to be sacked because of those reasons, and you hardly find that happening in a government setup. These things make people stand on their toes (…) I think this is [a] positive change.” – QMMH higher management, clinical rolen)

n) “A receipt is given to every single service that has been done. Stickers and receipts are verified. We had discrepancies where we found that the clinics, their payments were done but were not dropped in the safe. And a whole lot of employees were fired and disciplinary [meetings] were held (…) They are very particular in checking. Yes, there will be loopholes, [but] when we find them, we do something about it.” – QMMH staff, non-clinical role

7. Accountability systems, such as biometric clocking and employee numbers, promoted professionalism and discipline which led to increased quality

o) “You account for every minute of your time. We do a biometric clocking system. Those are things that don’t exist in the [public] health sector. This culture in the private sector makes a difference in terms of outputs.” – QMMH higher management, non-clinical rolep)

p) “The cashiers use [an] employment number which they enter in the [accounts] system. During lunch time when they are being relieved, they have to balance their money, drop it in the safe, and then go for lunch. Whoever is coming in, she also is going to use her employment number so there is not going to be any mixed ups.” – QMMH higher management, non-clinical role

q) “We are disciplined because of the kind of management we have. You won’t arrive at work at 10:00 when you are supposed to arrive at 7:00. That means services are going to run on time. People don’t steal the medications from the pharmacy (…) Even as staff [when I am sick], I know I have to consult with a doctor, pay the 15 Rand, get my medication. [This] is not the case in those other facilities. (…) This is why I said I can advocate for another PPP facility.” – QMMH staff, clinical roler)

r) “They [management] has their eyes on the staff. They know what is happening where. Who is performing and who is not performing. We are [more] closely monitored than at many other places. I think that is the good thing that is happening. [However], I know there is also some dissatisfaction in certain ways [with this close monitoring].” – QMMH higher management, clinical role

III. Infrastructure, core systems, workflows, and internal referral network

8. High quality and maintenance of physical infrastructure including facilities and equipment

s) “It’s the infrastructure. It’s new and improved. People have access to a well-maintained facility.” – QMMH higher management, non-clinical rolet)

t) “In the wards there are cubicles, there are curtains where the patients are seen and you draw them. All our consultation rooms are private. (…) Patients are given the privacy they need.” – QMMH higher management, clinical roleu)

u) “Having access to clinical services that didn’t exist before, that’s a big deal for me. Because for instance, the MRI machine didn’t exist before, it [allows for] better diagnosis.” – QMMH higher management, non-clinical rolev)

v) “If I report that my ultrasound machine is out of function, it’s going to be repaired immediately. [Conversely] sometimes at Queen Elizabeth II, six months down the line you find the X-ray machine is still broken (…) So patient satisfaction goes with that, [at QMMH] you will not have to come several times and still find [equipment that is] not functional and be returned.” – QMMH higher management, clinical role

9. Strong core systems, including pharmacy and laboratory, and hospital workflows

w) “The difference between us and the government is that we don’t do long term procurement. We buy more regularly (…) so we don’t necessarily experience long-term stockouts [at QMMH]. If it is an essential medication, it is categorized into E, VI, HV - Essential, Very Important, and High Volume. You make your assessment. If it’s something you feel a week is too long, you can’t survive, [but that medication isn’t available from the government stock,] we immediately outsource it from elsewhere.” – QMMH higher management, non-clinical rolex)

x) “[QMMH is] incredible compared to Queen Elizabeth II, where you would have to run around and go look if you have got [laboratory] results [back]. Here its digital (…) An ABG (arterial blood gas) you are going to get results in five minutes time. So when it comes to the lab, it’s really effective. We even have a way of tracking the specimens.” – QMMH staff, clinical role

10. Efficient internal referrals and collaboration across network

y) “The [internal] system of a collaboration between the [filter] clinics and hospital is perfect. Because (…) there is all this collaboration, at a high level with the heads of departments [passing] down all the information to the [staff] of the department. And the referral system, it’s really well strategized (…) Among the audits I do in a regular basis, I [evaluate] to find out how many patients were referred. What was the outcome? What was the condition of the patient? Was it a delay in referring [the] patient? So all this we monitor on a regular basis. There has been a tremendous improvement.” – Clinic higher management, clinical rolez)

z) “The network really helps because I don’t see one [facility] working alone in isolation. An example [is] exchanging of drugs, as in borrowing, maybe those that are due to expire. (…) They [patients] will be put on a particular medication that really improves their lives. So when they [patients] go back to their original places, they need the same medications, and sometimes those people there don’t have that medicine, it is only at the referral hospital. So, we said okay, the recipient hospital will borrow this much for the patient until they get theirs.” – QMMH higher management, clinical role

I. Human Resource Management Challenges

1. Poor salaries and working conditions impact on recruitment and retention

a) “A big factor driving change in performance is salary. The biggest tool you have in a hospital is the staff. It’s very difficult to keep the staff if other ministerial departments pay more.” – QMMH higher management, non-clinical role

b) “As for these shifts we are working, most people like them. They are used to working 12 hours shifts, while in government people are working 8 [or] 9-hour shifts. They say they are fine with the shifts. They only complain about money.” – QMMH staff, clinical role

c) “For a tertiary hospital we should have people who are more experienced, but that’s the opposite because of issues of salaries we usually get. So [that is] quite challenging. We have newly graduated nurses coming to work here (…) we need people with skills that are mature.” QMMH higher management, clinical role

2. Limited staff and clinical specialists

d) “We feel we are understaffed (…) the nurse-patient ratio is one nurse to ten patients. But given the work that we are doing here and the quality of work that we provide to our patients (…) [and] the type of patients that we treat here - those that could not be treated anywhere else (…) we feel we are severely understaffed.” – QMMH staff, clinical role

e) “There are no ICU specialists; [nor] emergency specialist.” – QMMH higher management, clinical role

3. Insufficient focus on training

f) “The hospital, from what we understood at the beginning, was to reduce referrals and to train people. Train doctors, specifically local doctors, so that they then care for most of the patients locally. That is not happening as expected (…) There has to be a lot more effort with regards to developing the doctors (…) We don’t have a well-organized training program which should be there.” – QMMH higher management, clinical role

g) “Queen Mamohato [is] not really empowering the [rest of the health] system (…) [The] job description talks about external capacitation, [via] internal and external interaction. But most of the time, the current system is not flexible enough to allow external participation.” – QMMH higher management, clinical role

II. Limitations of Structure and Function of larger Health System and Referral Network

4. Perceived lack of capacity at district hospitals increasing patient load at QMMH

i) “QMMH is a symptom of what is broken in the system. Patients are flooding QMMH because it’s the only place that they feel they can get help. So QMMH ended up doubling [it’s expected] numbers of patients (…) some of these patients, maybe caesarian section for fetal distress, could have been done at a district hospital but they say they don’t have oxygen, so patients are referred (…) The entire health system needs to be strengthened.” – Clinic staff, clinical role

j) “There are no resources in government institutions. (…) You tell [patients] to go to a hospital [and] they cry, they don’t want to go (…) the entire service delivery in government institutions is not functioning as one would expect it to (…) You walk into a [public] clinic and maybe there is only one nurse working there. It’s very difficult. People queue for very long time. I think it’s easier for people to trust Queen ‘Mamahato rather than the government institutions.” – QMMH staff, clinical role

5. Inappropriate referrals from outside facilities leading to QMMH not functioning at intended level

k) “Patients will be referred here [at QMMH] who don’t need to be here (…) there was no linen at the district hospitals so they could not do a caesarian-section (…) We can have a better functioning system. [That is] our challenge. We get unnecessary referrals.” – QMMH higher management, clinical role

l) “[The existence of QMMH] has decreased the quality of care provided by the district hospitals because now if you go to the district hospital, people will just refer something that they could have treated locally. Refer. But we don’t see that from the filter clinics (…) I think [the presence of QMMH] has taken away the clinical skills of people [working in the districts].” – QMMH higher management, clinical role

m) “Patients are coming late, they are referred late, and therefore the outcome is bad. So we can’t blame the hospital [QMMH] for the poor outcome of the patients. (…) Providers will waste time in the in private clinics up until it’s late, they will send a patient to QMMH when it’s late.” – Clinic higher management, clinical role

n) “The closing of Queen Elizabeth II caused a lot of havoc in the whole [health] system, because Maseru did not have a district hospital. Only recently Queen Elizabeth II was opened [again] and only the outpatient department. Now you find that QMMH has literally becomes the district hospital [and] the referral hospital. (…) Service provision has been affected by trying to share resources between managing primary cases and high-risk cases. And the bulk of patients that come here are primary care patients.” – QMMH higher management, clinical role

Perspectives on transition of QMMH-IN after PPP

1. Concern over management transition

a) “Just see how the government hospitals are managed. How the services are in the government hospital. So if the hospital is given back to the same management, all of this [at QMMH] will fall. That is my personal opinion.” – QMMH higher management, clinical role

2. Insufficient preparation for transition

b) “I don’t think this infection control office, quality office and all of that will be functional. I think as soon as government takes over, things are going to deteriorate. Because if they were copying what QMMH is doing now, and trying to implement it at the district hospital, I would think they will be able to manage the hospital by then. But seeing that they have not even started [trying to learn what QMMH is doing], I am not convinced they will run this hospital to a level that it is at now.” – QMMH staff, clinical role

3. Poor receipt of quality standards at government facilities

c) “[There was a] pilot of the COHSASA standards [at] three institutions, [including] Christian Health Association of Lesotho institutions and government. The assessors of COHSASA said: [for] government institutions – this is an impossible task. [The institutions said] we will not be bothered; we don’t want this thing of yours. You can go away with your standards (…) You see, they [the government-run hospitals] are untouchable.” – QMMH staff, non-clinical role

II. Recommendations for transition of QMMH-IN post-PPP

4. Keep what works: culture of quality improvement, evidence-based practice, and well-functioning network systems

d) “Keep on doing the good things that you are doing. Learn about the new things that are coming up, and make sure that you improve and adhere to the new research and evidence-based practice.” – QMMH higher management, clinical role

e) “In regard [to the] availability of medications. We already [have] the strategies of how we make sure things are available (…) which should be maintained (…) Maintaining the camera-surveillance system will also save the budget of this country. I am even suggesting it can go to other areas [other hospitals] (…) I am able to see what our filter clinics have while I am sitting here. This can be an improvement for the country to have a centralized area with computers that is it able to locate where everything is.” – QMMH higher management, clinical role

f) “Botle, they’re a private [maintenance] company. If I were [the government], I would keep them (…) because they know everything. They have the floor plans, everything. So if you have somebody else they are going to [have to use] the first year try to figure out [what to do].” – QMMH staff, non-clinical position

5. Invest in management succession training

g) “The government must start by preparing management [staff] that will take care of this hospital (…) So let’s train people so that when take over here they know what to do.” – QMMH higher management, clinical role

h) “Make sure that you have at least a specialist in every department. Two in the big departments; have two surgeons, two physicians, two obstetricians, two pediatricians, two ophthalmology, maybe one ENT, dental one. If you have spread out the skills like that, you develop in every area. If that training program was there (…) by the time the government takes over, you have people who can head those departments.” – QMMH higher management, clinical role

i) “Other clinics around us are referring patients to us and then the staff start feeling that they are underpaid. And yet they have to do more work than their colleagues who are working in smaller health centres, but they are making more money than they are. It’s an issue of creating better job satisfaction [through better pay].” – Clinic staff, clinical role

6. Prioritize achieving adequate staffing levels and numbers of trained specialists by investing in employees through training, advancement opportunities, and appropriate salaries

j) “You’re handing this over a few years from now. There are contractual obligations that when you hand over equipment should be within its usable lifespan…I say start offering more trainings to people (…) The building, structural equipment should be intact when handed over. What about staff? Are they going to be here?” – QMMH staff, non-clinical role

k) “Do projects that are geared towards employees’ empowerment. We have people who need to go to school; (…) sponsor them to do part-time studies. That would help all other things, because if our human resources are not doing well then (…) dissatisfaction will arise. But if projects are geared towards their [staff] improvement and wellbeing, that would motivate staff. If you have motivated staff, then the output is good.” – QMMH staff, non-clinical role

7. Have QMMH be a training facility for the districts

l) “Doctors come from all over the world to Lesotho (…) Before they get dispersed into the other districts, they would sit at Queen Elizabeth II for six months for training. Which was excellent, because you know what they know, you know what they do not know, you put emphasis on developing them. (…) you have self-sufficient hospitals because you have appropriate doctors for that facility, but now we don’t have that. I don’t know [if] QMMH can help the country with that.” – QMMH higher management, clinical role

8. Invest in system strengthening and referral network improvements

m) “[We need] a functioning health system and a good referral system so that people are referred [only] if they qualify (…) As it is now, people who come [to QMMH] are people with basic things that need to be attended to at the district health hospitals.” – QMMH higher management, clinical role

n) “I think as a country as a whole, we need to try to have a network like [QMMH-IN] Where, there are levels of care: primary, secondary, tertiary level of care. We don’t want patients coming straight to casualty with cough and diarrhea whilst they could have been attended to at the clinic level.” – QMMH higher management, clinical role