GHANA HEALTH SERVICE

SWISS RED CROSS

GHANA RED CROSS SOCIETY

QUALITY IMPROVEMENT
IN EYE CARE

K ARL BLANCHET, DR MARIA HAGAN, DR PETER O SEI -B ONSU, DR CYNTHIA B ANNERMAN,

DR FELIX AHORSU, DR K ENNETH A SUBONTENG, DR S ETH WANYE

ACCRA, G HANA
August 2005
 The Authors

Karl Blanchet works as a consultant in public health for the Swiss Red Cross. Karl is also a
research fellow at the London School of Hygiene and Tropical Medicine.

Dr Maria Hagan is the Head of the national Eye Care Unit of the Ghana Health Service.

Dr Peter Osei-Bonsu is ophthalmologist for the Brong Ahafo Region and is based at the
Sunyani Regional Hospital.

Dr Cynthia Bannerman is the Head of Quality Assurance Unit of the Ghana Health
Service.

Dr Felix Ahorsu is ophthalmologist for the Upper West Region based at the Wa Regional
Hospital.

Dr Kenneth Asubonteng is ophthalmologist for the Brong Ahafo Region and is based at
the Sunyani Regional Hospital.

Dr Seth Wanye is ophthalmologist for the Northern Region and is based at the Tamale
Regional Hospital.

For comments and questions please contact:

Dr Maria Hagan Mr Seth Addae-Kyereme

Eye Care Unit Country Representative
Ghana Health Service Swiss Red Cross
Ministries 3rd Floor Mobil House
Accra, Ghana Liberia Road Accra
Phone: ++233-21-666850 P.O. Box 835, Accra
E-mail: hagan_maria@yahoo.co.uk Phone: ++233-21-667226
E-mail: srceye@nas.com.gh

Mr Josef Kasper
Programme Coordinator
Swiss Red Cross/Int. Cooperation
Rainmattstrasse 10
CH-3001 Berne, Switzerland
Phone: ++41 (0) 31 387 72 85
E-mail: josef.kasper@redcross.ch

2
 Table of content
Acronyms ____________________________________________________________ 4
1. Introduction ________________________________________________________ 5
2. What is quality?________________________________ ______________________ 6
A. Definition of Quality ________________________________ ___________________________ 7
1. Technical Competence ________________________________________________________8
2. Access to Services____________________________________________________________8
3. Effectiveness _______________________________________________________________ 9
4. Interpersonal Relations ________________________________________________________9
5. Efficiency__________________________________________________________________9
6. Continuity _________________________________________________________________9
7. Safety_____________________________________________________________________ 9
8. Physical aspects _____________________________________________________________ 9
B. Perspectives on the Meaning of Quality_____________________________________________10
The Patient _________________________________________________________________11
Medical Staff ________________________________________________________________11
The Health Care Manager _______________________________________________________11
C. Proven Strategies _____________________________________________________________11
3. How to set up a Quality Improvement system? _____________________________ 12
Step 1: Identify the key quality dimensions_____________________________________________12
Step 2: Define quality standards ____________________________________________________12
Step 3: Define indicators of quality __________________________________________________13
Step 4: Planning Monitoring Processes _______________________________________________13
Step 5: Compile and Analyze the Data ________________________________________________14
The Quality Monitoring Table ______________________________________________________15
4. The Monitoring Process ______________________________________________ 17
Technical competence and effectiveness ______________________________________________17
Access to services _______________________________________________________________17
Interpersonal relations ___________________________________________________________17
Efficiency ____________________________________________________________________17
Continuity ____________________________________________________________________18
Safety _______________________________________________________________________18
Physical Aspects________________________________________________________________18
5. Implementing Change _______________________________________________ 19
Appendix ___________________________________________________________ 21

3
 Acronyms

QI Quality Improvement

QA Quality Assurance

GHS Ghana Health Service

GRCS Ghana Red Cross Society

SRC Swiss Red Cross

WHO World Health Organisation

4
1. Introduction

Improving the quality of care is not an easy task. It has nevertheless been seen as a great
incentive both for staff and patients. High-quality health services attract more clients and
improve staff motivation. Improving quality means giving more initiative to health staff and
authorising better involvement of patients in health service delivery. This may not be always
possible when accountability lines and administrative procedures are complex and unclear.
Comprehensive quality improvement processes can nevertheless facilitate relationships
between health professionals and community members.

The objective of the present document is to describe an appropriate strategy for improving
the quality of care in eye care services in Ghana . The document will serve as a guide for all
eye care professionals involved in the Vision First Programme. A comprehensive literature
review of public health and eye care literature was carried out covering diverse aspects such
as the definitions of quality of care, quality assurance strategies and the perceptions of
patients on quality. Quality monitoring tools were also collected from various websites
(World Health Organisation, Vision 2020, Eye Care Hospitals and International Non-
Governmental Organisations).

Quality Improvement (QI) or Quality Assurance (QA) is a strategy that has been developed
to improve the quality of care. QI is a systematic and planned approach to assessing,
monitoring and improving the quality of health services on a continuous basis.

In Ghana, QA started in 1990. The Ghana Health Service (GHS) developed in 2002 a
Quality Assurance policy 1. The policy defines directions for establishing and implementing
quality assurance processes. The objective is to ensure that quality assurance becomes a
routine activity for all health staff.

As stated in the GHS Quality Assurance policy, “the v ision of the Ghana Health Service is
to provide the best quality health care within available resources to the satisfaction of all
clients and providers.”

The following box summarises the four basic principles of QI.

1
Ghana Health Services, Ghana Health Service Quality Assurance Policy and Implementation Strategies, 2002, Ghana.

5
 The four principles of Quality Improvement

• QI is client-focused: QI aims to meet the needs and

expectations of clients and communities
• QI focuses on system s and processes: Providers need to
understand how processes work in order to improve them.
• QI is team-focused: QI reinforces teamwork to solve
problems and improve quality
• QI tests changes and uses data: QI is a change process
based on the analysis of information, the identification of
problems and the effects of changes on quality improvement

2. What is quality?
The simplest definition of quality is “Doing the right thing right, right away”. Quality of care
is at the intersection between providers’ performance and patients’ expectations.

Why does the Vision First Programme aim to improve the quality of care? The Vision First
Programme has been mainly focused on the reduction of the backlog of cataracts in Ghana.
The programme was primarily designed as an output-oriented intervention. In 2004, the
main partners identified the need for improving the quality of care. The main problem was
that no information was available about the level of quality of eye care in the three regions of
intervention: Upper West, Northern Region and Brong Ahafo.

The Quality Improvement strategy elaborated by the Vision First Programme is based on the
following assumption: the increase of the quality of eye care services delivered will increase
patients’ satisfaction2. Clients will then better utilise eye care services. The positive feedback
from clients will motivate health staff for maintaining and improving the level and quality of
outputs.

The following figure illustrates how better quality of care is supposed to generate more
satisfaction amongst patients. The recognition gained by eye care staff for their good services
may contribute to enhance the motivation of eye care teams.

2
Mathew J., Mathen M.M., Clinical practice module: Quality Assurance in cataract surgery, Aravind Eye Hospitals.

6
 The virtuous Quality Circle

Increase in quality
and quantity of eye
care services
delivered

Patients are more

Increase of staff
satisfied
motivation

Increase in eye
care facilities’
utilisation

A. Definition of Quality
Quality is a multidimensional and subjective concept. Quality means different things to
different people. We have adopted a comprehensive definition of quality that has been based
on literature and extensive consultation with health experts. This definition has been
developed and tested by the Quality Assurance Project3 in various fields and contexts in
developing countries.

The Quality Assurance Project defines eight dimensions of quality4. Their importance varies
from one context to another.

The eight dimensions are described as follows:

• Technical competence
• Access to services
• Effectiveness
• Interpersonal relations
• Efficiency
• Continuity
• Safety
• Amenities

3
See The Quality Assurance Project: http://www.qaproject.org/
4 Massoud, R., K. Askov, J. Reinke, L. M. Franco, T. Bornstein, E. Knebel, and C. MacAulay, A Modern Paradigm
for Improving Healthcare Quality. QA Monograph Series 1(1) Bethesda, MD: Published for the U.S. Agency for
International Development (USAID) by the Quality Assurance Project, 2001.

7
Defining quality in several dimensions presents the advantage of encompassing diverse areas
of intervention.

The multidimensional definition of quality also provides flexibility and choice for health
professionals. The importance of each dimension varies in function of the context and the
type of health intervention. Indeed, this definition requires from the actors to select the most
important and appropriate dimensions of quality that will fit with programme conditions.

The 8 Dimensions of
Quality

Technical Access to
Competence service

Effectiveness

Interpersonal Efficiency
relationships

Continuity

Safety Physical
aspects

We now propose to explore the different dimensions of quality.

1. Technical Competence
In healthcare, the technical competence of medical and non-medical staff is probably the
first key priority from a patient point of view. A lack of competence of health professionals
will lead to higher mortality and morbidity. Technical competence relates to the level of skills
and performance of health staff. This dimension also refers to the capacity of medical staff
to respect clinical guidelines and procedures in terms of prevention, diagnosis, treatment and
health education. It also concerns non medical staff and non clinical competences such as
management and relationships with patients.

2. Access to Services
Access issues refer to the capacity of the population to benefit from the services offered by
health facilities. Obstacles to access may be due to geographic, economic, social, cultural or

8
linguistic barriers. The geographic barriers may be the long distance between the health
centre and the residence or the unavailability of transport ation. High prices will restrain
patients to attend health services and will constitute economic barriers. Social, cultural and
linguistic access is determined by the level of acceptability of services in function of people’s
values, beliefs and dialects.

3. Effectiveness
The effectiveness of health services is defined as the capacity of staff to give the right
diagnosis and cure people. It also relates to the compliance with existing norms and
guidelines.

4. Interpersonal Relations
Patients have the right to be treated with respect by health staff. Good interpersonal
relationships between staff and clients will also improve patient attendance and health
seeking behaviour.

5. Efficiency
The efficiency of health services determines the availability and utilisation of health care
resources necessary for patients’ care. Efficient health services are the ones that maximise
the production of benefits within the given volume of resources available.

6. Continuity
The patient has the right to get access to continuous and complete treatment. This
encompasses preventive care, treatment and follow -up care. Continuity is also ensured by
the existence and good management of medical records.

7. Safety
Preventing and minimising the risks of infection, side effects and injury is fully part of
quality of care systems.

8. Physical aspects
Physical aspects refer to the general conditions of the building, the state of the waiting room
and any other resource that could be used to affect patients’ satisfaction: comfort, cleanliness
and intimacy.

9
 The Dimensions of Quality of Care5

Dimensions Description

Effectiveness The degree to which desired results of care are achieved through
appropriate diagnosis and treatment

Efficiency The ratio of the outputs of services to the associated costs of

producing those services

Technical competence The degree to which tasks carried out by health workers and
facilities meet explanations of technical quality

Interpersonal Level of respect, responsiveness, empathy, effective listening, and

relationships communication between clinic personnel and patients

Access to service The degree to which healthcare services are unrestricted by

geographic, economic, social, organisational or linguistic barriers

Safety The level of trust, confidentiality, and privacy in the services and the
degree to which the risks of injury, infection are minimised

Continuity The degree to which consistent and constant care is provided,

including the value of visiting the same provider and continuing
treatment

Physical aspects The physical appearance of the facility and the level of cleanliness,
comfort and amenities offered

B. Perspectives on the Meaning of Quality

The dimensions of quality described in the previous chapter are very comprehensive and
encompass various aspects of health system performance. It is now important to define the
5
Santillán, D., and M. E. Figueroa. 2001. Implementing a client feedback system to improve the quality of NGO healthcare
services in Peru. Operations Research Results (2)2. Bethesda, MD: Published for the United States Agency for International
Development (USAID) by the Quality Assurance Project (QA Project).

10
concept of quality of care in a specific context. The meaning of quality varies from one
group to another: the patient, medical staff and health service managers. Let’s explore how
quality of care is perceived by each group.

The Patient
The client’s perspective is of great importance as it affects health service attendance and the
success of treatment. Indeed, satisfied clients are more likely to comply with treatment and
trust health staff.

Community members perceive quality as the capacity of health services to respond on time
to their perceived needs and be treated with respect. In other words, clients want to receive
the right treatment at the right time and to be relieved from pain and illness.

Patients often focus on the following dimensions: effectiveness, accessibility, interpersonal

relations, continuity, and physical aspects.

Medical Staff
From the medical professional’s perspective, quality of care is linked to his/her competences
to cure people with available resources and agreed clinical guidelines. Therefore, providers
tend to focus on technical competence, effectiveness, and safety as concerns the dimensions
of quality .

The Health Care Manager

The multidimensional concept of quality presented here is particularly helpful to managers
who tend to feel that access, effectiveness, technical competence, and efficiency are the most
important dimensions of quality.

C. Proven Strategies
Lessons can be learned from a certain number of studies on how to implement effective
quality improvement systems6. It is essential to note that quality improvement systems are
more effective if both demand and supply are affected by specific measures.

The first lesson is that providers and patients should communicate with each other in a way
that facilitates mutual understanding of their needs and perceptions. Patients will understand
challenges and constraints faced by health staff and providers will be more attentive to
clients’ needs and expectations.

High quality services do not only require clinical skills. They are also based on the quality of
counselling and psychological support provided by medical and non medical staff. Training
in counselling can make a significant difference in the way health staff behaves with patients.

6
Heerey M., Merritt A.P., Kols A.J., Improving the Quality of Care, Center publication No.101, 2003, Center for
communication Programs, The John Hopkins University.

11
High quality services need to be recognised as such by professionals. This means that
performance in terms of quality needs to be regularly assessed and publicised. Quality labels
or certification can also be introduced.

3. How to set up a Quality Improvement system?

Quality is a multidimensional and subjective concept. It can only be defined by people who
are concerned by health services:
• Health service managers/administrators
• Health staff
• Patients

The Vision First Programme has adopted a step by step process to define all the elements
constituting an appropriate QI system.

Step 1: Identify the key quality dimensions

The first step consists in gaining consensus on the meaning of quality of care and defining
the key priorities for the Vision First Programme in Ghana. The authors interviewed eye
care staff and patients. An exit questionnaire was tested with patients at the Sunyani Regional
Hospital (Brong Ahafo Region). Further consultations took place through the organisation
of a meeting with all key players in eye care with representatives of the community. The first
draft strategy was presented, discussed and reviewed by all members of the group.

Step 2: Define quality standards

Rather than develop new standards, the authors identified existing standards mentioned in
health or eye care literature or in use in Ghana.

A standard is an expected level of quality or an acceptable performance that can be written

and documented (explicit) or agreed by all and based on the experience of professionals
(implicit).

Explicit standards can be clinical protocols, procedures or ethical rules. In the case of the
Vision First Programme and eye care in Ghana, standards have been developed by the
Ministry of Health, the World Health Organization7 and some hospitals and international
organisations. For example, WHO has developed quality standards in terms of cataract
surgery outcomes that have been tested and applied in a few hospitals in India.

7
WHO, Consultation on development of standards for characterisation of vision loss and visual functioning,
WHO/PBL/03.92, Geneva, 4-5 September 2003, WHO.

12
Implicit standards applied by eye care staff in Ghana was transformed into explicit ones in
order to ensure that all eye clinics will uniformly adopt the same standards of quality.
Harmonising QI systems in all three regions of Northern Ghana is part of the overall
strategy of the Vision First Programme. This will enable cross-comparisons between health
facilities and regions and facilitate monitoring processes.

The choice for the standards of quality was based on evidence, mainly provided by WHO,
and on experience. Standards need to be realistic and achievable. This explains why the
selection of standards can only be done by people who will apply them. Nurses and doctors
taking part in the Vision First Programme were invited to contribute to the elaboration of
the standards of quality for eye care through a wide consultation process.

Step 3: Define indicators of quality

An indicator of quality is used to measure the degree of adherence of a standard. Indicators
help the monitoring team evaluate the level of performance of health staff compared to
standards. Indicators usually are quantitative data such as ratio, proportion or number: i.e.
the proportion of patients who are satisfied.
The success of the present QI system is based on the feasibility of collecting data and
capacity of analysing it. Therefore, a selection of appropriate indicators was carried out by a
team of people who has been closely involved in the Vision First Programme
(ophthalmologists, nurses, Quality Assurance coordinators at GHS, Ghana Red Cross
coordinators, Swiss Red Cross managers). (See Appendix: The Quality Monitoring Table).

Step 4: Planning Monitoring Processes

Defining standards and indicators would be pointless if they were not regularly measured.
Monitoring processes are really part of routine work as they enable teams to learn and
progress. Monitoring will highlight which standards have not been met and help managers
make decisions for improving the system.

Monitoring pr ocesses are defined by the types of tools and techniques that will be used to
collect information and measure the indicators. A certain number of methods are popular.
The Vision First Programme has selected the following methodologies considered as the
most appropriate for the context of the project.

a. Direct observation and inspection

The evaluator observes the attitude, cleanliness and activities of the eye care team and checks
the degree of adherence to the standard.

b. Exit interviews
An interviewer meets patients when they have completed the whole process at the hospital
and asks them a series of questions. Patient’s views on the quality of the service are an

13
essential source of information8. A sample of patients will be randomly selected during a
week. A questionnaire was elaborated based on the In-patient Feedback Form designed by the
Aravind Eye Hospital in India 9. (See appendix III). Questions focus on the relationships
between medical staff and patients, counselling and information, cleanliness and waiting
time.
By assessing clients’ satisfaction, patients become the core of eye care services. They take
part in the management of eye care services and thus can influence the level of quality
offered at the health facility level. Their views will be analysed and taken into account for the
future orientations of the service.

c. Review of records
Medical records archived at the health facility level provide information about the diagnosis,
the treatment and the outcomes. In the three regions where the Vision First Programme
intervenes, information about patients’ history varies from one facility to another. Forms and
contents are not uniform. Through the quality improvement process, it is recommended to
generalise the utilisation of the Tally Sheet and the Cataract Surgery Record Form in all eye care
clinics (See appendix I and II). The Tally Sheet helps surgeons and programme managers
assess the quality and outcomes of cataract surgeries10. Forms, tables and guidelines will be
distributed to all eye care staff and explained in details during a one-day training session.

As described in the quality monitoring table, most indicators will be measured every quarter
or every semester. A wide range of people will contribute to the collection of data: surgeons
and nurses (for cataract outcomes), Ghana Red Cross volunteers (exit interviews) and Swiss
Red Cross Coordinators. Teams will be constituted in every region combining different
institutions (Ghana Health Services, Ghana Red Cross and Swiss Red Cross), skills and
background. Most teams will be composed of three members.

Step 5: Compile and Analyze the Data

Information must be analyzed. Data need to be presented in a convenient format that will
help project managers make decisions for the future11. Information can be displayed with
graphs, figures and charts. Chronological and geographical comparisons can be made to
identify strengths and weaknesses in each situation.

The following table (Quality Monitoring Table) presents the standards of quality, indicators
and monitoring tools that have been selected by the Vision First Programme through a
multiple step consultation.

8
Cox I., The Patient’s View: How can we improve patient care?, Community Eye Health, 2002, Vol.15 No.41.
9 Muralikrishnan R., Sivakumar A.K., Patients’ Perspective: An Important Factor in Assessing Patient
Satisfaction, Community Eye Health, 2002, Vol.15 No.41
10
Limburg H., Monitoring Cataract Surgical Outcomes: Methods and Tools, Community Eye Health Journal,
2002, 15 (44): 51-53.
11 Rubin H.R., Pronovost P., Diette G.B., From a process of care to a measure: the development and testing of

a quality indicator, International Journal for Quality of Health Care, 2001, 13(6): 489-496.

14
 The Quality Monitoring Table
Dimension Site Staff involved Indicator Standard Monitoring Frequency Monitoring
tool team
Technical Regional Ophthalmologists Cataract - The posterior capsule Tally sheet carried out for GHS
Competence hospitals, outcome rupture rate is less than 10%. system; every patient and Surgical team:
District - The vitreous loss rate is less analysed every doctors and
and
hospitals than 10%. quarter nurses
effectiveness - The presenting Visual
Acuity at discharge is more + external annual + external
than 6/60 in more than 90% evaluation evaluator every
of cases year
-100% surgeries with IOL
- A cataract record form for
every patient
Regional Equipment Equipment - Minimum list required for Checklist for Every 6 months GHS
hospitals, manager and available and each theatre regional hospital; SRC
District ONs maintained - 100% surgical tools are Checklist for
hospitals (type and maintained for each surgery District hospital;
quantity) observation
access to Regional Health service - Patient - 80% of patients are satisfied Questionnaire; Every quarter GHS
services hospitals, managers; satisfaction - less than 4 hours for the observation SRC and GRCS
District ophthalmologists; rate whole process (screening,
hospitals ophthalmic - Drop out consultation, pharmacist)
nurses; rate - Patient drop out rate less
optometrist than 20%
interpersonal Regional Ophthalmologists Patient - 80% of patients are satisfied Questionnaire GHS
relations hospitals, and Ophthalmic satisfaction with doctors, optometrists’ GRCS and SRC
District nurses; rate and nurses’ attitude
hospitals optometrist - 80% of patients were
informed about their
condition
efficiency Regional Ophthalmologists Number of 500-700 surgeries per year statistics Every semester GHS
hospitals, surgeries per per doctor (depending on the Doctor and SRC
District day per region)
hospitals doctor

15
 Dimension Site Staff involved Indicator Standard Monitoring Frequency Monitoring
tool team

Continuity Regional Ophthalmologists Number of - 90% of cataract patients Medical records Ongoing and GHS
hospitals, and Ophthalmic patients referred by volunteers for analysed every ONs, GRCS and
District nurses; GRCS coming back surgery are visited by quarter SRC
hospitals volunteers for follow-up volunteers
- 70% of referred patients go
back to hospital for follow-
up
Safety Regional Ophthalmic adherence to - Proper use of new gloves observation Every quarter in GHS
hospitals, Nurses asepsis for every new patient regional and Doctor and SRC
District - Autoclaving of surgical district hospitals
hospitals instruments after every
surgery
Physical Regional Hospital Cleanliness Comfortable and very clean Checklist; Every quarter GHS
Aspects hospitals, administrator and and comfort Observation SRC
District Ophthalmic
hospitals nurses

16
4. The Monitoring Process
Let’s describe dimension per dimension which tools need to be developed to ensure
appropriate and valid data collection.

Technical competence and effectiveness

Cataract surgery outcomes will be self-assessed by surgical teams (surgeons and nurses) and
externally evaluated once a year. All eye care teams will adopt the new Patient Record Form
and the Tally Sheet. Guidelines and forms will be available at all levels and the regional
ophthalmologists will train all people involved in reporting. The same standard forms will be
used in every facility.
Cataract outcomes will be assessed for every surgery undertaken in the three regions at all
levels; regional hospitals, the districts hospitals or eye camps. Data will be analysed every
quarter by the monitoring team.

Another indicator for measuring effectiveness is the availability of equipment. The Swiss Red
Cross and the ophthalmologists will agree on a standard list of equipment that is required in
district hospitals and regional hospitals. These lists will ensure that the standard equipment is
available at all levels to enhance quality of care.
.

Access to services
Access to services can be perceived in different ways. The programme has decided to focus
on a limited number of priority issues:
• Satisfaction of patients regarding waiting time and price: This information will be
extracted for questions 3 and 5 of the exit questionnaire.
• Waiting time: the evaluator will observe the total amount of time patients spend at
the clinics to complete the whole process. This will be carried out every quarter for
10 patients randomly selected in every clinic.
• The patient drop out rate is the rate at which patients do not come back for follow -
up after an initial visit, or do not respond for surgery after they have been asked to
come for surgery. This will be checked through medical records.

Interpersonal relations
Interpersonal relations will be assessed through exit interviews and the analysis of answers to
questions 1 and 2 of the exit questionnaire. Ghana Red Cross volunteers will administer the
questionnaires every quarter. Twenty patients will be interviewed in each eye care facility by
means of structured questionnaire.

Efficiency
The team came out with the number of 500-700 surgeries that should be performed every
year by each ophthalmologist. This figure has been evaluated by taking into account the

17
current existence of facilities, equipment and consumables. Statistics will be used to check
the total number of surgeries performed in each region.

Continuity
Follow up visits of patients performed by Ghana Red Cross volunteers will be assessed on
an ongoing basis and analysed every quarter. Follow-up visit forms available at the regional
coordination of the Ghana Red Cross will be checked and analysed.

Safety
Safety measures can be assessed in various ways. The team selected two indicators that can
easily be measured. Every quarter, the monitoring team will spend half a day with the
surgical team and observe if standards of quality are met.

Physical Aspects
Two criteria will be used for the Vision First Programme: cleanliness and comfort. These
concepts are obviously very subjective. This is the reason why the working group decided to
explain what they meant.

These two criteria will be specifically applied to two places: The waiting room and the
consultation room.

Very comfortable Comfortable Not comfortable

Comfort - padded chairs - Benches - No bench
- Information - Well ventilated - Not well
available (TV, - No direct sunlight ventilated
leaflet, newspapers) - Clean toilets - Exposed to
- Well ventilated sunlight
- Drinking water - No clean toilet
- No direct sunlight
- Clean toilets

Very clean Clean Not clean

Cleanliness - No dust on - No litter - litter
furniture - dust
- No litter

Comfort and cleanliness of waiting rooms and consultation rooms will be checked every
quarter by the monitoring team. This will take place in every regional and district hospital.

18
5. Implementing Change
The Vision First Programme has introduced in March 2005 a performance-based
management that encourages eye care staff to introduce changes based on evidence and
lessons learned. The Quality Improvement system is at the core of the strategy. Monitoring
processes will allow staff and eye care service managers to get access to data, analyse
information and make informed decisions. The stake is to turn public health information
into management information for eye care services12.

The Quality Improvement system facilitates the use of scientific data and valid information
for decisions. Communication between managers and eye care staff is essential to ensure the
implementation and acceptance of change. For training purposes, a power point presentation
has been made available to eye care managers 13. Innovations will be accepted if staff
recognises a need for change and builds new measures. Sense of ownership has been
identified as a key factor to attenuating resistance to change14.

Improving quality of eye care in Ghana is a new initiative that requires the existence of a
support and incentive system.

Support teams are constituted in each of the three regions. The regional QI team is
composed of:
• The Ophthalmologist
• The Quality Assurance Coordinator that has already been identified by GHS
• The Swiss or Ghana Red Cross Representative

The role of the three regional QI teams shall be:

1. Monitoring quality and conduct support supervision
2. Organising regional Training Programmes on quality
3. Developing and review ing Quality Standard reflecting Regional Priorities
4. Disseminating policies, guidelines and QI learning materials
5. Co-ordinating, guiding and coaching District eye units in QI
6. Promoting best practice

The regional QI team will provide support to the District Action Team. At the district level,
the team is limited to:
• Ophthalmic Nurse
• Head of District Hospital

The district action team will:

1. See daily Quality Assurance issues

12
Rubin H., Pronovost P., Diette G.B., the advantages and disadvantages of process-based measures of health
care quality, International Journal for Quality in Health Care, 2001, 13(6): 469-474.
13
Blanchet K., Quality Improvement in Eye Care, Power Point presentation, Swiss Red Cross, Switzerland.
14 Scott T., Mannion R., Davies H.T.O., Marshall M.N., Implementing culture change in health care: theory and

practice, International Journal for Quality in Health Care, 2003, 15(2): 111-118.

19
 2. Implement Quality Assurance Policies
3. Establish client complaints and counselling desk
4. Facilitate monitoring exercises
5. Analyse monitoring data

Second, quality is promoted through the implementation of a financial incentive scheme15.

Team-based financial incentives have been introduced to encourage better performance in
eye care. Quality Improvement is one of the major indicators of performance in the Vision
First Programme. Eye care staff will receive financial bonuses in function of their
performance in terms of quality.

15
Blanchet K., Hagan M., Osei-Bonsu P., Addae-Kyereme S., The right incentive for the right performance in eye care,
2005, Vision First Programme, Ghana Health Service, The Swiss Red Cross, Ghana.

20
Appendix I

CATARACT SURGERY OUTCOME TALLY SHEET16

Hospital: Period:
Personal & Surgery Discharge > 4 weeks post-op
Serial Patient Surgeon IOL Surgical Good Borderline Poor Cause of poor No of Good Borderli Poor Cause o f poor outcome (<6/60)
number Number Y/N Compl 6/6- 6/24-6/60 <6/60 outcome (<6/60) wks 6/6- ne <6/60
or 6/18 post- 6/18 6/24-
Patient op 6/60
name
Selection Surgery Spec's Selection Surgery Spec's Sequelae

N=total Y C G P D1 D2 D3 G1 P1 F1 F2 F3 F4

Excluded: age < 20, trauma, combined procedures

Abbreviations:
Surgery: Selection: Spec's: Sequelae:
CR Capsule Rupture CO Corneal Opacity Tick if VA improves to 6/60 or better UV Uveitis
VL Vitreous Loss OI Old Iritis with pinhole or spectacles RD Retinal Detachment
BL Bleeding( > 1/3 hyphaema) RD Retinal Disease CME Cystoid Macular Edema
CE Corneal Edema GL Glaucoma PCO Posterior Capsule Opacification
OT Others (specify) OT Others (specify) OT Others (specify)

16
WHO, Developing an action plan to prevent blindness at national, provincial and district levels, World Health Organisation, International Agency for Prevention of Blindness,
2004.

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 Appendix II17

17
WHO, Developing an action plan to prevent blindness at national, provincial and district levels, World Health
Organisation, International Agency for Prevention of Blindness, 2004.

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Appendix III 18

Exit Questionnaire
Quality of Eye Care

Hello, My name is…… I am working for ………as a. ........ We are currently doing a survey on eye care
services. Would you accept to answer a few questions? It should not take more than a few minutes. The
questionnaire is anonymous.
Thank you very much.

Circle the number you feel to be appropriate. If you would like to add any comments or make suggestions,
please use the box at the end.
Excellent = 1; Good = 2; Average = 3; Poor = 4; don’t know = 5
1. Your opinion about doctor(s) and medical care: 1 2 3 4 5
Doctors’ Attitude and Behaviour Smiling face / polite / friendly 1 2 3 4 5
The doctor listened to my problems 1 2 3 4 5
Explanation about my health and treatment 1 2 3 4 5
2. Your opinion about nurses/optometrists and nursing care: 1 2 3 4 5
Smiling face / polite / friendly 1 2 3 4 5
Promptness in meeting your needs 1 2 3 4 5
Explanation about treatment & progress 1 2 3 4 5
Provision of psychological support and counselling 1 2 3 4 5
(in wards) Enquiries about food/night rest/discomfort/etc. 1 2 3 4 5
Provision of advice and health education 1 2 3 4 5
3. How would you rate the charges and costs of services at the eye clinic? 1 2 3 4 5
Low/Reasonable/High/Unaffordable /Don’t know
1 /2 /3 /4 /5
4. How do you rate the general cleanliness of the eye clinic? 1 2 3 4 5
5. How would you rate the general facilities in the clinic (space, furniture, etc.)? 1 2 3 4 5
6. Did you experience long waiting times? 1 2 3 4 5
Not at all/Reasonable/Long/Very long/No opinion
1 /2 /3 /4 /5
7. Would you recommend this eye clinic to friends and relatives? 1 2 3 4 5
Strongly/As a second choice/Hesitantly/Will Not/Don’t Know
1 /2 /3 /4 /5
8. Overall, how would you rate the services offered at the eye clinic? 1 2 3 4 5
Please add any further comments or suggestions you would like to make.

THANK YOU FOR YOUR VALUABLE FEEDBACK!

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Aravind Eye Hospitals, Management Principles and Practices for high quality and large volume, sustainable cataract surgery
programmes, 2001.

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