Ubuntu Village of Life is a medical clinic in the rural Mugamba Commune in Burundi, a small land-locked East African country. Ubuntu has become the heart of the community’s hope: providing local medical, ophthalmological and pharmaceutical care in addition to educational resources and local jobs. 

But this is only the beginning for Ubuntu’s mission. 

20 km away in the even more remote Kibezi, Ubuntu’s already building a satellite clinic with maternal and child health services. Across the Mugamba clinic there’s a huge pile of dirt — the construction zone for their future teaching hospital. 2 km away Ubtuntu’s planted hundreds of potato plants to support food security in the region. 

There’s a lot of ambition in their plans. How can we support it? 

This summer I worked with Madiro and Ubuntu Village of Life to establish Quality Improvement infrastructure so Ubuntu has the capacity to expand its operations while maintaining quality in their work. 

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What is Quality Improvement (QI)?
QI is the process of: 

• Analyzing health processes; 
• Identifying inefficiencies or gaps in care delivery;
• And implementing evidence-based strategies to optimize service delivery.

In the low-resource primary health context, some of the most crucial QI topics are infection prevention and control, maternal and child health, immunization coverage, malaria, HIV/AIDs and TB.

QI is a problem that will never fully be solved — there will always be ways to improve quality and react to new constraints. To do this effectively, health institutions need to have a QI team with a culture of continuous learning and adaptation. 

With this QI foundation in place, we believe clinics like Ubuntu can better manage ambitious expansions and make the most of their resources. 

The Ubuntu QI Project Framework

I worked with Madiro and UVL to define high standards for Quality Improvement (QI).

Using resources like the WHO Quality Toolkit and the Joint Commission international Primary Care Standards we created 5 core principles of QI:

1. A regular meeting discussion specifically dedicated to quality improvement (open to all staff, including cleaners)
2. Long-term and short-term goals clearly understood by all levels of staff
3. Regular assessments of QI components (e.g. infection prevention, maternal health, etc)
4. Personnel with dedicated time and responsibilities to focus on QI
5. Standard operating procedures integrated with care delivery

To bring these principles to action, the clinical team decided to pilot a QI team with an emphasis on Infection Prevention and Control (IPC) focused on the first 3 principles. Then, we created a 4-phase roll-out to incorporate all 5 principles while expanding the QI capacity beyond IPC.

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Field work for the pilot

After hundreds of hours with my head deep into the WHO’s QI recommendations, I headed on-ground to the clinic in Burundi to co-create with the local team.

The biggest emphasis for my fieldwork was getting to know the staff, their attitudes towards QI and IPC, and how the clinic standardizes its operations.

These activities really helped me understand the context to co-design QI at Ubuntu:

• Creating a digital record of the pharmacy: working with the pharmacy staff, I got to understand how their paper-based inventory functions while encountering intimate challenges like drug expiry management.
• Mapping medical inventory: I did a thorough walk-through of the clinic’s medical equipment and recorded a detailed photo diary. I also cross-referenced inventory records and had discussions with staff on the equipment’s use and functionality.
• QI attitude baseline: I interviewed the staff on how they define QI and their ideas for QI. Great empathy exercise!
• IPC attitude baseline: I interviewed all the staff on their definitions of IPC, status quo of IPC at the clinic and their ideas for improvement. I also asked the staff if they would benefit from a monthly IPC meeting to learn and discuss adaptations, and 100% of the staff said yes!
• IPC Assessment Framework (WHO IPCAF) and Hand Hygiene Self Assessment Framework (WHO HHSAF): I used these WHO tool to conduct a baseline of IPC at the clinic. I shared the data with everyone and got loads of second-opinions on all my inputs.

Towards the end of my 1-month field visit, we hosted the first official Quality Improvement Meeting (focused on IPC) where we discussed the data from these baselines!

There were a few key features for our first meeting:

1. Prior to the meeting the chief of medicine at the clinic appointed two champions of the project: the head of pharmacy to lead QI at the clinic and the head of nursing to lead IPC at the clinic.
2. The QI and IPC lead choose ~5 questions from the baselines that Ubuntu scored low on to focus on during the discussion.
3. From the beginning of the meeting, the leaders emphasized that our goal is to create 3 action-items with people responsible to complete them by next month’s meeting.
4. The QI lead took meeting notes and recorded the 3 action items at the end.
5. We put chairs in a circle to host the meeting to make it more discussion-style rather than lecture-style.

It wasn’t a perfect meeting, but what’s important is we got the ball rolling! Afterwards I shared some suggestions for improving the flow for the next meeting. Remember: continuous learning and adaptation!

Key Insight: Loop Local Staff into the Vision 🔑

While much of my fieldwork was about data collection, interviews and supporting the QI team launch, arguably the most important part was getting all the staff’s buy-in.

I started by having many discussions trying to understand their feelings. Through them, I learned that QI is a pretty new term. When asked about quality improvement, they answered with the day-to-day activities they do that are high-quality. For example, hand washing, referring patients to the doctor, monitoring blood pressure, etc. Everyday, routine, short-term goals.‍

💡 Most staff have not been offered opportunities to think long-term. Their jobs are routine and without encouragement, they will stick to the short term.

To implement QI, we must look to the future. For example, it’s not effective in the short-term to organize and label all the clinic’s closets. That time could be spent serving patients! But, the accumulation of minutes or budget saved because of increased organization, in the long-run, is effective.

Empowering staff to contribute to QI was the highest ROI activity we did. By the end of the field work, people were energetic to be part of an expanding vision at Ubuntu! Here are some of the empowerment activities we did:

1. Identifying champions (the QI and IPC leaders mentioned before)
2. Introducing them to JCI through printed and translated materials. They were SO excited to strive for United States’ Accreditation, even if it’s 10 years out.
3. Almost daily <10 minute interactions asking them questions or seeking their advice for the long-term vision. First, their perspectives are crucial. But second, it is important they feel that their perspectives are crucial; asking them for advice starts to set that precedent.

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What’s Next for QI at Ubuntu? 

We’ve created a 4-phase plan to roll out QI over the next 2 years. At a high level, here are the phases and their priorities: 

Phase 1: Establishing the QI Team pilot with IPC 

1. Establish a team with monthly meetings and a QI resource centre. We created a dedicated shelf in the reception with printed QI materials. Things like the French edition to the WHO’s tool for water, sanitation and hygiene. A library for anyone to access and learn!  
2. Discuss IPC baseline results as a team  (HHSAF and IPCAF) 
3. Cultivate a culture where everyone feels like they are part of the improvement efforts 

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Phase 2: Increase the capacity of IPC-QI 

1.  As a team, conduct a new baseline assessment (suggestion: WASHFIT) 
2. Conduct an IPC training for all staff (including cleaners) 
3. Create an annual objectives list with SMART goals 

During this phase, we hope that co-creating Standard Operating Procedures (SOPs) can be part of the annual goals. 

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Phase 3: Reach ‘Full’ IPC Capacity 

1. Create comprehensive Standard Operating Procedures (SOPs) for all primary health IPC processes as defined by WHO’s minimum IPC requirements
2. Have functioning monthly meeting minutes and quarterly reporting on IPC/QI 
3. Introduce an IPC support person to the team ie. someone to support the IPC lead on things like data collection and tracking implementation. 

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Phase 4: Expanding QI 

1. Integrate a process of mortality reviews and reporting (including appointing a lead to this expansion)
2. Have 4 regular annual assessments: 3 IPC assessments (WASHFIT, IPCAF and HHSAF) and 1 whole-clinic assessment: Star Rating Assessment
3. Empower the on-ground team to build up QI capacity for phases beyond 4! Phase 4 is about adding mortality-reviews (a crucial component to reducing preventable deaths!). But after this phase, QI isn’t complete! Phase 4 is about practicing expanding QI beyond IPC, but there is still work to do later on.

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Let’s build infrastructure for the community!

Ultimately, the goal of this project was to create a customized Quality Improvement plan for Ubuntu Village of Life.

During my internship I got to see the impact Ubuntu’s had on the community in Burundi — from providing safe birthing places to giving people glasses to see — and I hope QI gives them the foundation to keep expanding their work!

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