Using health worker opinions to assess changes in structural components of quality in a Cluster Randomized Trial

Background The ‘resource readiness’ of health facilities to provide effective services is captured in the structure component of the classical Donabedian paradigm often used for assessment of the quality of care in the health sector. Periodic inventories are commonly used to confirm the presence (or absence) of equipment or drugs by physical observation or by asking those in charge to indicate whether an item is present or not. It is then assumed that this point observation is representative of the everyday status. However the availability of an item (consumables) may vary. Arguably therefore a more useful assessment for resources would be one that captures this fluctuation in time. Here we report an approach that may circumvent these difficulties. Methods We used self-administered questionnaires (SAQ) to seek health worker views of availability of key resources supporting paediatric care linked to a cluster randomized trial of a multifaceted intervention aimed at improving this care conducted in eight rural Kenyan district hospitals. Four hospitals received a full intervention and four a partial intervention. Data were collected pre-intervention and after 6 and 18 months from health workers in three clinical areas asked to score item availability using an 11-point scale. Mean scores for items common to all 3 areas and mean scores for items allocated to domains identified using exploratory factor analysis (EFA) were used to describe availability and explore changes over time. Results SAQ were collected from 1,156 health workers. EFA identified 11 item domains across the three departments. Mean availability scores for these domains were often <5/10 at baseline reflecting lack of basic resources such as oxygen, nutrition and second line drugs. An improvement in mean scores occurred in 8 out of 11 domains in both control and intervention groups. A calculation of difference in difference of means for intervention vs. control suggested an intervention effect resulting in greater changes in 5 out of 11 domains. Conclusion Using SAQ data to assess resource availability experienced by health workers provides an alternative to direct observations that provide point prevalence estimates. Further the approach was able to demonstrate poor access to resources, change over time and variability across place.

*Quinine *Septrin *Amoxil Consider out of ten most recent occasions the availability of:-*Bolus glucose -number of times drug is immediately available to treat hypoglycaemia (within 2 minutes) *FS Ringers / N/Saline -number of patients getting the fluids from ward stock / hospital pharmacy as soon as required, without delay and before paying for the fluid cannula or giving set. *Other iv fluids -number of patients getting the fluids from ward stock / hospital pharmacy as soon as required, without delay and before paying for the fluid cannula or giving set. *ORS -number of patients getting the ORS from ward stock / hospital pharmacy as soon as required on admission without delay or before paying for it. *Blood transfusion -number of children with severe anaemia getting blood direct from blood bank before finding a donor or paying a fee. *Blood transfusion -number of children with severe anaemia starting blood transfusion within 4 hours of prescription.

Nutrition and supportive care
Consider out of ten most recent occasions the:-*Ability to provide oxygen at a flow of 2l/min to each individual patient.
Consider out of ten most recent occasions the adequacy of:-*F75 / F100/Milk feeds -number of malnourished children getting correct amount feed from ward stock / nutritionists within 4 hours of admission.
*Night feeds -number of malnourished children getting 3 hourly night feeds as recommended.
*Night feeds -number of babies being ngt fed getting 3 hourly night feeds as recommended.
*Frequent solid transition feeds -number of malnourished children getting 4 or 5 meals a day during recovery phase.
*Monitoring feed intake -number of malnourished children with an accurate feed intake chart.

Cleanliness
Consider out of ten most recent occasions the availability of:-* Water from taps to wash your hands between patients * Soap / disinfectant to clean your hands between patients * Water from taps for mothers / caretakers to wash their hands after care-giving or eating * Soap / disinfectant for mothers / caretakers to wash their hands after care-giving or eating Consider out of ten most recent occasions:-* Patients bathing / washing area observed to be appropriately clean * Patients toilets observed to be appropriately clean * Ability to keep diarrhoea cases separately -not mixed with other patients * Ability to isolate highly infectious cases (measles, chickenpox etc) * Disinfectant used to clean spills of blood, stool or urine Second-line drugs Consider out of ten most recent occasions the number of patients getting the drug from ward stock / hospital pharmacy as soon as required, without delay or paying for it before it is administered :-*Coartem * Cloxacillin / Flucloxacillin * Erythromicin * Ceftriaxone / cefotaxime * Phenobarbitone Injection Maternity ward with newborn nursery(NN)

Supportive care
Consider out of ten most recent occasions the availability of:-Only one item 1 in NN had no factor loading > 0.3 for any single factor resulting in its elimination from aggregated analysis. 1 Equipment available; Consider out of ten most recent occasions the availability of:-Paediatric iv fluid drip set (with burette) when required

Hygiene and emergency care
Consider out of ten most recent occasions the availability of:-* Water from taps to wash your hands between patients * Soap / disinfectant to clean your hands between patients * Disinfectant was used to clean spills of blood, stool or urine Consider out of ten most recent occasions the number of patients getting the drug from ward stock / hospital pharmacy as soon as required , without delay or paying for it before it is administered:-

*Diazepam
Consider out of ten most recent occasions the availability of:-* Bolus glucose -number of times drug is immediately available to treat hypoglycaemia (within 2 minutes) * Ringers / N/Saline -number of patients getting the fluids from ward stock / hospital pharmacy as soon as required without delay and before paying for the fluid cannula or giving set. * ORS -number of patients getting the ORS from ward stock / hospital pharmacy as soon as required without delay and before paying it.

Drugs
Consider out of ten most recent occasions the number of patients getting the drug from ward stock / hospital pharmacy as soon as required , without delay or paying for it before it is administered:-* Coartem * Septrin *Amoxil Oxygen availability Consider out of ten most recent occasions the:-* Availability of oxygen whenever needed * Ability to provide oxygen at a flow of 2l/min to each individual patient