Background: Quality improvement (QI) efforts in which providers from various
health facilities, with support from coaches, work together to implement innovations for
improving health care are rapidly spreading from high-income settings to resource-poor
settings. However, limited research exists regarding the factors that drive teams to
succeed or fail, spread, and sustain best practices. The purpose of this study was to
understand the factors facilitating or inhibiting the performance of QI teams of maternal
and child health (MCH) service delivery in resource-poor settings.
Methods: A qualitative multi-site case study was conducted in northern Ghana to
determine the views and beliefs of QI teams, coaches, and beneficiaries of Project Fives
Alive (PFA) about the application of QI to MCH service delivery. Using key informant
interviews, document review, and group interviews, the study elicited information about:
1) the factors that affect QI team success and failure when implementing QI methods
designed to improve MCH service delivery; 2) the interplay of factors that facilitate or
inhibit the spread of best practices among QI teams in northern Ghana; and 3) steps being
taken by stakeholders to sustain these best practices. Grounded theory processes were
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used to identify themes from the data.
Results: Testing of changes using Plan-Do-Study-Act (PDSA) cycles and
adoption of a client-centered model to the delivery of services has helped teams to
identify the felt needs of clients, resulting in perceived increased uptake of MCH
services. Key contributory factors to successes were: availability and accessibility of
midwives, training of QI teams, incentive packages for providers and clients, community
support groups, and PFA partners. Key challenges inhibiting success were: staff turnover,
inadequate supervision, cultural practices, and inadequate infrastructure. Some of the key
factors that shaped successes have dissipated, threatening sustainability of QI efforts two
years after PFA ended.
Conclusion: The presence of a midwife, providing leadership for organizing team
members and implementing PDSA cycles, can facilitate success. Project staff support is
important, but teams and coaches need space and time to drive the QI process
independently and practice QI methods in ways that foster continuity beyond donor
support.