It was Aristotle who said that quality is not an act; it’s a habit. I have a feeling that Aristotle probably said a lot of stuff like that – wise words that you know are true, but can be difficult to live by. According to him, once this habit is established, it becomes an easier way of doing things than by acting ad-hoc to fix your problems. I agree. However, how do you build habits in people? How do you convince them that these habits will benefit them in the long run?
When I first started my Fellowship, I was told that I needed to build continuous quality improvement habits across two hospitals, 40 members of staff, and numerous medical faculties. I kind wished I were Aristotle right about then. There were all sorts of problems with varying perceptions of importance based on whom you were talking to about them. I realized that building habits required inputs, and a lot of them. In order to build a comprehensive system that would not only fix the problems that people presented me with, but would prevent them from happening again, I needed a well-designed system that was actionable and relevant to the people using it, buy-in and political support from management, human resources who could re-train staff based on the new system, and an action plan on how to affect behavior change amongst all levels of staff. Needless to say, the prospect of doing this for every problem that was gracing my doorstep was a tad overwhelming.
What my team and I ended up doing was doing an overall assessment of all the problems in the hospitals and prioritizing them based on the central objectives of the hospital. We decided that we would design a system that would have direct positive benefits to some of our most important services, obstetric care and delivery, but would have indirect positive benefits to other aspects of the hospitals. We sought guidance from LifeSpring Hospitals, a very successful model of low-cost, high-quality maternal health services based in Hyderabad, to design a system that would aim to increase the number of women accessing our antenatal care services who then choose to deliver in our hospitals. Finally, we created Key Performance Indicators around the primary factors that would be critical in compelling women to deliver in our hospitals – Clinical quality, marketing, and internal operations. We included a broad array of staff in our workshops on designing processes, monitoring and evaluation systems, checklists, audit schedules, supporting documents, and operational dashboards around these three focus areas. It was a lot of work, but three months after the entire system was designed and staff was trained, we have seen a 20% increase in planned deliveries in our hospitals and dramatic increases in adherence to process.
Of course, this system hasn’t operated free of challenge. Despite our improved clinical quality, we still operate in a low-cost model, meaning that top-of-the-range ultrasounds are out of the question for the time being. Despite a more comprehensive marketing strategy, it is still a difficult task to convince women to deliver institutionally, and despite improvements to our internal operations, it’s not to say that we operate 100% efficiently all the time. However, the fact that we regularly collect data that shows us exactly where we need to improve convinces me that we’ve lived up to Aristotle’s ideal of quality as a habit, rather than a one-time act.