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. 2019 Mar 1;8(1):e000408.
doi: 10.1136/bmjoq-2018-000408. eCollection 2019.

Implementing a quality improvement initiative for the management of chronic obstructive pulmonary disease in rural Nepal

Stephen Mehanni #  1   2   3 , Dhiraj Jha #  1   4 , Anirudh Kumar  1   5 , Nandini Choudhury  1 , Binod Dangal  1 , Grace Deukmedjian  1   2   6 , Santosh Kumar Dhungana  1 , Bikash Gauchan  1   2 , Tula Krishna Gupta  1 , Scott Halliday  1   7 , S P Kalaunee  1   8 , Ramesh Mahar  1 , Sanjaya Poudel  1 , Anant Raut  1 , Ryan Schwarz  1   9   10   11 , Dipendra Raman Singh  12 , Aradhana Thapa  1 , Roshan Thapa  1 , Lena Wong  1   2   13 , Duncan Maru #  1   5   14   15   16 , Dan Schwarz #  1   9   10   17   18
Affiliations

Implementing a quality improvement initiative for the management of chronic obstructive pulmonary disease in rural Nepal

Stephen Mehanni et al. BMJ Open Qual. .

Abstract

Background: Chronic obstructive pulmonary disease accounts for a significant portion of the world's morbidity and mortality, and disproportionately affects low/middle-income countries. Chronic obstructive pulmonary disease management in low-resource settings is suboptimal with diagnostics, medications and high-quality, evidence-based care largely unavailable or unaffordable for most people. In early 2016, we aimed to improve the quality of chronic obstructive pulmonary disease management at Bayalpata Hospital in rural Achham, Nepal. Given that quality improvement infrastructure is limited in our setting, we also aimed to model the use of an electronic health record system for quality improvement, and to build local quality improvement capacity.

Design: Using international chronic obstructive pulmonary disease guidelines, the quality improvement team designed a locally adapted chronic obstructive pulmonary disease protocol which was subsequently converted into an electronic health record template. Over several Plan-Do-Study-Act cycles, the team rolled out a multifaceted intervention including educational sessions, reminders, as well as audits and feedback.

Results: The rate of oral corticosteroid prescriptions for acute exacerbations of chronic obstructive pulmonary disease increased from 14% at baseline to >60% by month 7, with the mean monthly rate maintained above this level for the remainder of the initiative. The process measure of chronic obstructive pulmonary disease template completion rate increased from 44% at baseline to >60% by month 2 and remained between 50% and 70% for the remainder of the initiative.

Conclusion: This case study demonstrates the feasibility of robust quality improvement programmes in rural settings and the essential role of capacity building in ensuring sustainability. It also highlights how individual quality improvement initiatives can catalyse systems-level improvements, which in turn create a stronger foundation for continuous quality improvement and healthcare system strengthening.

Keywords: PDSA; chronic disease management; continuous quality improvement; decision support, computerised; evidence-based medicine.

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Conflict of interest statement

Competing interests: SM, AK, GD, RS, LW, DM and DS work in partnership with and DJ, NC, BD, SKD, BG, TKG, SH, SK, RM, SP, AR and AT are employed by a non-profit healthcare company (Possible) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic and private foundation sources. At the time of initiative implementation, RT was employed by Possible. SM, GD, BG and LW are academic fellows affiliated to a bidirectional fellowship programme (Health, Equity, Action, Leadership Initiative Fellows) that is affiliated with a public medical school (University of California San Francisco). DJ and DRS are employed by the Government of Nepal. AK is an academic fellow at and DM is a faculty member at a private medical school (Icahn School of Medicine at Mount Sinai). GD is employed part time at a public medical centre (Natividad Medical Center). SH is employed part time at a public university (University of Washington). SK is a graduate student at a private university (Eastern University). RS and DS are faculty members at an academic medical centre (Brigham and Women’s Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. RS and DS are faculty members at a private university (Harvard Medical School). RS is employed at an academic medical centre (Massachusetts General Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. LW is employed by a medical centre (Tuba City Regional Health Care) that is managed using public sector funding through the Indian Health Services. DM is a non-voting member on Possible’s board of directors but receives no compensation. DS is employed at an academic medical centre (Beth Israel Deaconess Medical Center) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. DS is employed at an academic research centre (Ariadne Labs) that is jointly supported by an academic medical centre (Brigham and Women’s Hospital) and a private university (Harvard TH Chan School of Public Health) via public sector research funding and private philanthropy. All authors have read and understood BMJ Open Quality’s policy on competing interests and declare that we have no competing financial interests. The authors do, however, believe strongly that healthcare is a public good, not a private commodity.

Figures

Figure 1
Figure 1
Mean corticosteroid prescription rate based on per cent of chronic obstructive pulmonary disease (COPD) exacerbations prescribed prednisolone by week.
Figure 2
Figure 2
Mean template chronic obstructive pulmonary disease (COPD) completion rate by week.
See this image and copyright information in PMC

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