“Quality is possible here”

QI Leadership Institute

The QI Institute gave her the energy to do the things she needs to do, said Aniceta Kiriga from Kenya, center. She’s working here with Modestine Etoy from the Democratic Republic of Congo and UW-Madison doctoral candidate Jackson Musuuza.

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A father’s story

Dr. Balkachew Nigatu knows firsthand the anguish of a new father waiting for word from the delivery room. “When your wife is in labor, you want to be updated,” he said, remembering the fear and the pressure when he didn’t know what was happening.

About 7,000 babies are delivered each year at St. Paul Hospital in Addis Ababa, Ethiopia. Women are taken to the

Balkachew Nigatu and Kidest Hailu work together on a plan to improve communication between mothers in labor and their families in the hospital waiting room.
Kidest Hailu, right, saw so many good results from previous QI Institutes that she needed to attend to learn more. She’s shown here with Balkachew Nigatu, also from Ethiopia.

labor room. Families are directed to a waiting room 150 meters away. Fathers have no idea if there are problems in the delivery room; mothers have no way to ask their families for help making decisions about procedures.

“As a father, I can understand the pain,” said Nigatu, an obstetrician and gynecologist and family residency program director at St. Paul Hospital Millennium Medical College. “Families have a right to know the status of their relative in the labor ward,” he said. “We need to design a system to get information to families.”

Improving communication with mothers in labor, reducing breast cancer, empowering girls, managing medical equipment and educating volunteer health workers were among the challenges addressed by medical and public health leaders representing nine countries and low resource settings in Wisconsin. They gathered for the 2014 Quality Improvement Leadership Institute hosted by the University of Wisconsin-Madison Global Health Institute (GHI).

During the week-long institute, participants worked with UW faculty, staff, students, and each other, learning the basics of quality improvement (QI)—a way to strengthen health care systems through measurable steps.

The right to health

From left, QI participants XXXXXXXX and XXXXXXX visit with QI Director Lori DiPrete Brown.
Mozambique QI participants Dr. Sandra Mavale, left, and Dr. Paula Santos-Ritchie, meet with GHI Associate Director Lori DiPrete Brown, who is also director of the QI Leadership Institute.

“Everyone has the right to the highest attainable standard of health,” said Lori DiPrete Brown, GHI associate director for education and engagement and director of the QI Institute. “Quality improvement is a tool for realizing these rights.” QI provides the tools to define a problem, develop indicators, monitor what happens and improve quality. It helps eliminate waste, reduce error and improve outcomes.

Creating a culture of quality is essential, DiPrete Brown told the group, as she challenged them with questions and urged them to develop plans of action.

“How can you get everybody believing that quality care is possible in low-resource settings? That may seem like a low bar, but it is not easy to achieve. How can you lead in a way that moves people from thinking ‘I’m not sure quality care is possible with the constraints I face’ to ‘I’m part of a team and we can do this’?”—Lori DiPrete Brown, QI Institute director

For a week, physicians, pharmacists and other health care providers, engineers and project managers learned how to tackle complex problems by breaking them into doable pieces. They learned to how to lead and develop specific criteria to tackle immediate challenges. “Small changes are big,” DiPrete Brown said often throughout the worshop. “When you’re in a chaotic situation, starting with something feasible and doing it is the only thing that makes sense. When you change one thing, you have moved the frontier of what is possible, and you have more power as an advocate and may advocate for further improvements.”

Improving care in rural South Africa


The dominant image of the Western Cape of South Africa is that of a tourist mecca with metropolitan élan. Yet in low-income townships, about 8,000 rural, often elderly, villagers rely on a non-governmental organization, which works out of a shipping container-turned-office, for home-based care. Volunteer health care workers, who have little health care training, walk to the homes of patients with chronic diseases such as HIV/AIDS and tuberculosis.

Pharmacist Renier Coetzee, a senior lecturer at the University of the Western Cape School of Pharmacy and a clinical facilitator for UW-Madison’s School of Pharmacy, left the QI Institute with a plan to develop teaching

South African pharmacist Renier Coetzee is working to establish clinical pharmacy as a trusted health care partner in his country.
South African pharmacist Renier Coetzee is working to establish clinical pharmacy as a trusted health care partner in his country.

materials for the volunteers who, mostly, have not completed high school. Spending one month in training on each of five major diseases, the volunteers will be empowered to care for their patients and will know when to refer someone for more treatment before it’s too late.

“With the numbers (of patients out there), we have to do something,” Coetzee said. “The School of Pharmacy has a large number of students who can be involved assisting.”

Coetzee is dedicated to establishing clinical pharmacy in South Africa. “It has been proven that pharmacists improve patient outcomes and safety,” he said. Pharmacists are experts in medications, and Coetzee knows his work has reduced the cost of medications, increased proper use of drugs and avoided patient harm.

QI needed more than ever

During the past four years, in partnership with the American International Health Alliance (AIHA), the UW Medical Foundation, and the UW School of Medicine and Public Health, the GHI Quality Improvement Leadership Institute has welcomed participants from 15 countries, who have returned home to improve health and well-being and save lives by developing teams and making measurable changes. Quality improvement is more important than ever for several reasons, DiPrete Brown said:

  • Disparities in health and the availability of care are increasing in countries rich and poor.
  • Caring for chronic conditions requires a new model of ongoing care.
  • Emerging and re-emerging infectious diseases demand an effective response.
  • Complex emergencies—including war, natural disasters and climate change—tax health systems.
  • The growing availability of medical information and technology may provide additional capacity but also leads to more errors.

The QI Leadership Institute brings learning from settings all over the world and the United States together in one classroom, creating a space for two-way learning across these settings.

“QI empowers you; you can improve on what you have.”—Professor Girma Tefera, UW-Madison

“QI empowers you; you can improve on what you have,” said Girma Tefera, a UW-Madison professor of vascular surgery and key to the university’s Twinning Partnership with

"If you make a change, believe me, others will notice, Dr. Girma Tefera, a vascular surgeon and GHI special advisor, told QI participants.
“If you make a change, believe me, others will notice, Dr. Girma Tefera, a vascular surgeon and GHI special advisor, told QI participants.

Addis Ababa University. He began his work in Ethiopia, which is his homeland, believing he knew what was needed—and learned he was wrong. So he went back to the drawing board, asking this time, “What do you need?”

“Sometimes when people come with goodwill and intention to help, you also need to express your priority,” he told the QI participants. “It is so important not to feel you are just receiving. You are giving a lot. … Think about the equally important things you are going to bring to the table, to share and to teach.”

The emergency medicine program Tefera established in Addis Ababa has resulted in more than a dozen active QI projects plus leadership training. Partners have made dramatic improvements in infection control, triage, and various aspects of clinical care. “When you leave Madison, think about whether you’re ready to change and change your environment, no matter what others will say,” Tefera said. “Make sure you are convinced and you want to do this and you want to change this. If you make a change, believe me, others will notice.”

Kidest Hailu, the AIHA country director for Ethiopia, has watched several of AIHA’s partners make significant changes after attending the QI Leadership Institute. Addis Ababa University reduced infection rates by 65 percent, she said. Debre Berhan Hospital, in one of the coldest areas of the country, significantly reduced its neonatal death rate with $1,000 in area heaters and rice heated in a microwave to fill heating pads that keep the babies warm.

“When I saw that, it motivated me to be part of it, to be able to advocate for more small projects, to walk the walk and talk the talk,” Hailu said. She plans to document QI projects in Ethiopia and bring participants together at least once a year to create a network and avoid duplication.

From left, Judy XXXXXXXX, UW-Madison graduate student xxxxxxx and Lodestone Etoy wrestle with XXXXXXXXXXX.
From left, Judy Anderson, executive director of ACT for Congo, UW-Madison graduate student Allison Sambo and Modestine Etoy from DR Congo wrestle with how to better empower girls and women.

Empowering women and girls

Modestine Etoy from the Democratic Republic of Congo and Aniceta Kiriga from Kenya know that outsiders, though they mean well, often cannot make a difference when local culture and tradition marginalizes girls and women.

For Etoy that means mobilizing groups within communities to help teenage mothers—victims of rape and incest—become self sufficient. “In my society, they are rejected and have problems,” Etoy said. She organizes teams who go to villages and talk about reducing violence and how the girls can contribute to communities. She collaborates with government and local partners to provide health and occupational education.

When no one in her Kenyan community addressed female genital mutilation (FGM), Kiriga knew she must take action and address the FGM from a traditional perspective or nothing would change. “Most of what happens to girls is about culture, and culture does not disappear,” said Kiriga, the founder of the Tharaka Women’s Welfare Project that educates girls about the risks of FGM and offers an alternative rite of passage. “This is what people who come (from the outside) may not understand.”

She wants Kenyans to understand that girls’ health suffers because they’ve been cut, that sometimes they must be taken to the hospital because the bleeding doesn’t stop. She works with traditional women, hopes to empower girls, mothers, boys and fathers to make different choices and is seeing results as the rate of FGM has fallen from 94 percent to 55 percent.

The QI training gave the women a new sense of leadership and a chance to re-evaluate their programs. Etoy has new tools to improve her team. Kiriga will develop better training manuals for the alternate rite of passage and to enable community participation in the empowerment of girls and women.

“It has given me new energy to do the things I need to do,” Kiriga said of the QI Leadership Institute.

Face the facts but never give up hope

“Face the brutal facts but never give up hope,” Dr. Jeff Thompson, CEO of Gundersen Health System, told participants during an afternoon session. “Sometimes you have the opportunity for incremental improvement, incremental change.”

Thompson has worked in Madagascar and Kenya, and Gundersen Health collaborates with partners in Nicaragua, Ethiopia and Pine Ridge, South Dakota, to build health care capacity. He encouraged QI participants to ask their staffs what can be done differently to improve care. Find what will pull people in and get them excited, and measure the results, he said.

“You measure results because you can see progress and develop a rhythm,” Thompson said. “You build up a portfolio. You get some momentum, and you get so much credibility if you can marry data, competency, outcomes for patients and patient stories.”

QI Institute participants went home with specific plans to engage their colleagues and begin making changes that will improve the lives of men, women and children.

  • In Nicaragua, where 70 percent of breast cancer is diagnosed at Stage 3, a team including Gundersen Health, UW-Madison students and local partners, plans to increase the rate of breast exams. They’ll train health care workers to notice problems, recruit local women to train others in self-exams and establish screening as a priority for mid-level providers.
  •  At St. Paul’s in Addis Ababa, Nigatu will convene a team to communicate with the hospital director, develop protocols for allowing communication with women in the labor room, test it and train personnel. In six months, he hopes to see 25 percent improvement, with 50 percent in a year.
  • In southwestern Ethiopia, a team including health care workers, biomedical engineers, technicians and support staff will establish an inventory system for
    Ethiopian biomedical engineers XXXXXXXX, left, and XXXXXXX wrestle with steps to improve equipment handling at Jima University Referral Hospital.
    Ethiopian biomedical engineers Esayas Alemayehu, left, and Getachew Alemu Tesema wrestle with steps to improve equipment handling to improve health care for children at Jima University Referral Hospital.

    medical equipment in the pediatric ward at the Jimma University Referral Hospital, the only referral hospital in southwestern Ethiopia and southern Sudan. About 70 percent of medical implements in sub-Saharan Africa are not functional, and equipment may be 50 years old with no parts available for repair and missing manuals. “Improving medical equipment management will definitely improve the quality of health care delivery,” said Esayas Alemayeho, an associate professor of water supply and environmental engineering at the Jimma Institute of Technology.

  • In Mozambique, about 25 percent of children in the pediatric intensive care unit die. Parents often wait too long to bring children to the hospital, taking them first to traditional healers. The team returned home with a plan to train families to bring children to the hospital sooner and reduce deaths to 18 percent in two years.

During a week with UW-Madison experts, QI participants heard about infection control, leadership, infectious disease, palliative care and strategies to improve quality. They learned about the power of checklists and inter-professional collaboration and worked in small groups to develop plans for change.

“My favorite part of the (QI) week is when we all talk about what we’re going to do when we get home,” DiPrete Brown said. “Our hope is that in addition to doing your QI project, you’ll also be able to motivate and share these tools with your teams.”

For participants including South Africa’s Coetzee, the training made a difference.

“I’ve got the (QI) skills now,” he said. “When I go back, we’ll make them work for us. We just need to start somewhere.”—Renier Coetzee, South African pharmacist and senior lecturer

The Global Health Institute, supported by public and private funds, is dedicated to equitable and sustainable health for people, animals and ecosystems—across Wisconsin and around the world. To learn more or to make a gift, visit ghi.wisc.edu.

By Ann Grauvogl/ Nov. 24, 2014