Overview: National Patient Safety Survey

1. Kenya National Patient Safety Standards SurveyIFC-WHOTechnical advice of SafeCare/ PharmAccess FoundationSupport from the Ministries of Health, Kenya.

2. Overview: National Patient Safety Survey • Intended as a baseline survey to gauge state of patient safety standards in health facilities of all types in the country • Wide stakeholder participation on the study: • A collaboration between the World Bank Group’s Health in Africa Initiative (HIA) and the World Health Organization (co-funders) • Technical advice of PharmAccess/ Safecare • Support of the Ministries of Health • SafeCare Essentials Checklist adapted as study tool • A total of 493 facilities in both private and public sectors sampled in 29 counties across the country • Public and private sector facilities comparable in terms of facility size

3. Key Messages • Patient safety remains an area for critical improvement within the wider issue of quality of care for both public and private sectors • Facilities want to know more & need training • Patients must be a central part of the picture • There is much scope for targeted interventions: information, guidelines and support • Action must be collaborative, taking into account support and enforcement, and both private and public sector facilities

4. Overview Why Patient Safety in Kenya? 1 Overview: National Patient Safety Survey and Methodology 2 Overview of Initial Findings from the Survey and Recommendations 3

5. Why Patient Safety? • Resource-constrained health systems in the developing world present multiple challenges that require urgent attention: • Provider and service constraints • Human resource capacity limitations • What is patient safety? Process-based, Participatory, a Public Good • Populations with critical health needs means that focusing attention on Preventive, Promotive, and Proactive action is key • Risk mitigation and quality assurance of key areas • Coordinated leadership of staff and systematized management in facilities • Mitigation of health care associated infections and risks • Safe surgery and specialist services • Safe management of environmental risks • Patient-centered care

6. The Private Sector and Quality of Care • The need for effective collaboration with the private sector in SSA to meet unmet demand and improve effectiveness, access, and equity of care (IFC 2007). • Concerns remain over the variability of quality in a diverse and under-regulated private sector with a variety of health care providers (Mills et al. 2002; Barnes et al. 2010). FINDINGS OF THE BUSINESS OF HEALTH IN AFRICA REPORT • The private sector already plays a significant role in delivering and financing health care in Africa: it delivers 50 percent of health care and 60 percent of the financing coming from private sources. • Private providers (including for-profit and not-for-profit) serve all income levels and have broad geographic reach, not just the rich and elite in Africa.

7. Patient Safety as a Regional Issue: Evidence from the Literature • The problem: Healthcare-associated infections: • WHO estimates that the risk of health care-associated infection in some developing countries is as much as 20 times higher than in developed countries. Safe Surgery and safe specialist services: • Anesthesia-related mortality remains an issue with published mortality rates between 1 : 150 and 1 : 3000 • Mortality rates in major surgical procedures run between 5-10% due to surgical complications • What can be done? • Evidence that relatively simple interventions may have marked effects • Effective interventions are often process-based • Documentation and systematization of risk-mitigation needs to be emphasized in facility management and care processes

8. Process Based Changes are FeasibleExample : WHO’s ‘Safe Surgery Saves Lives’ Checklist

9. Overview Why Patient Safety in Kenya? 1 2 Overview: National Patient Safety Survey and Methodology Overview of Initial Findings from the Survey and Recommendations 3

10. Methodology: Sample design • 8 Geographic clusters selected for sampling • Stratified Cluster sample in 29 counties • N. Eastern province was not included in the sampling frame due to security and logistical constraints with the study • Survey conducted by IPSOS using trained personnel with a nursing background • Mean SafeCare scores computed with SPSS

11. Sampling: Overview of Facilities surveyed • Roughly equal numbers of Public (247) and Private (246) Facilities surveyed, with a total of 493 facilities retained out of an original sample of 500 • Greater number of rural facilities surveyed overall, with comparable numbers of urban and peri-urban facilities recorded.

12. Sampling: Facility Size The majority of institutions sampled were smaller health facilities (KEPH 2, with less than 10 staff)

13. Complementary approaches: The SafeCare Essentials and The Kenya Quality Model for Health (KQMH)

14. Survey Study Instrument: SafeCare Essentials Checklist • The Essentials may be used as a rapid screening tool, as a self-evaluation strategy for facilities wanting to embark upon a quality improvement journey, but also as a basis for Governments to help develop an inspectorate system for public and private facilities. • The Essentials Checklist uses 5 main areas of risk and 41 sub-categories to determine the achievement level of individual facilities in each area: • 1.0 LEADERSHIP PROCESS & ACCOUNTABILITY • 2.0 COMPETENT AND CAPABLE WORKFORCE • 3.0 SAFE ENVIRONMENT FOR STAFF & PATIENTS • 4.0 CLINICAL CARE OF PATIENTS • 5.0 IMPROVEMENT OF QUALITY & SAFETY

15. Survey Instrument: SafeCare Essentials Toolkit (PharmAccess Foundation) adapted for use

16. SafeCare Essentials: Scoring Guide • The SafeCare Essentials Checklist is scored on a graded ‘Levels of Effort’ from 0-3, representing progressive achievement in risk reduction over the five areas identified in the Checklist: • Level 0: The desired activity is absent, or there is mostly ad hoc activity related to risk reduction • Level 1: The structure of more uniform risk-reduction activity begins to emerge • Level 2: The processes are in place for consistent and effective risk-reduction activities • Level 3: There are data to confirm successful risk-reduction strategies and continue improvement

17. Simple questions form the basis of objective scores given: A total of about 250 simple “Yes/No” questions were defined by the research team and should ensure replicability of scoring method. • Emphasizing documentation: In many cases, safety-related activities of health facilities had to be documented in order to be considered as “existing”. Questionnaire methodology: Determining Scoring

18. Overview Why Patient Safety in Kenya? 1 2 Overview: National Patient Safety Survey and Methodology 3 Overview of Initial Findings from the Survey and Recommendations

19. Results: Key messages • Low scores overall: most mean scores were less than 1 on the SafeCare scoring scale • Larger facilities tended to perform better in most subcategories • Smaller facilities exhibited varying levels of performance, with scores frequently below 0.5 • Statistically significant differences in performance between public and private sectors in several areas

20. Results Summary: Overall areas of strength and weakness • Particular weakness was demonstrated in these areas (mean scored performance on risk areas <0.5):

21. Leadership Process & Accountability Better performance in average scores for two subcategories:‘Leadership for Quality and Safety’ & ‘Oversight of Contracts’

22. Overall average scores were below 1, with particular areas of weakness in subcategories relating to staff management and orientation to their jobs Competent & Capable Workforce

23. In a risk area of weakness for both sectors, statistically significant differences favoring the private sector were confirmed in the following Safe Environment for Staff and Patients

24. Patients do not appear to be receiving sufficient information from providers Clinical Care of Patients

25. Informed consent was a general area of weakness in performance Focus on 4.2: Informed Consent

26. All the facilities scored low in this category, however statistically significant differences observed in the areas of monitoring of patient satisfaction which was better in the private sector. Improvement of Quality and Safety

27. Key messages from the analysis of the Survey

28. Recommendations for Next steps

29. Concluding Messages • Focus on designing effective interventions: The findings of the National Patient Safety Standards Survey can help in the process of setting priorities, as well as the subsequent design of interventions. • A repeat survey will show which interventions have been most effective.

30. Thank you.For more information, please visit www.wbginvestmentclimate.org/healthwww.who.intwww.safe-care.org