Developing a conceptual and practical framework for outcomes measurement to support a quality improvement project in Rwanda: an observational study

Abstract Background A landmark study in 2009 demonstrated that a WHO surgical safety checklist decreased mortality and complications in surgical patients. Attempts to replicate this in the developing world have been mixed. We piloted the implementation of a surgical safety checklist with outcomes measurement in one district hospital in Rwanda, with the goal of creating a scalable model to use in all public hospitals in the country. Methods We sought to develop a conceptual and practical framework for ongoing outcomes measurement that can be applied to quality improvement projects in resource-poor settings. We accomplished this through interviews with global checklist implementation teams and Rwandan hospital staff, as well as observation. Findings We developed the following framework with specific examples from our experience. (1) Define the elements of data collection and who will perform each. In particular, the data audit function must be carefully outlined. (2) Understand the potential motivators for each participant in data collection and align incentives; these may be financial or non-financial. (3) Choose a data collection training method including initiation, maintenance, and troubleshooting. (4) Select a database software considering the following: availability of consistent or intermittent internet access, user interface complexity, flexibility of software for Mac and PC operating systems, need for mobile access, initial and ongoing costs, and technical support. Based on these criteria, we chose to pilot a new offline version of REDCap, which may have important implications for global health projects in settings without consistent internet access. (5) Be flexible. The framework provides a best first guess at the methods that will work for high-quality data collection, but a willingness to change course is critical. Interpretation Monitoring outcomes in quality improvement projects in resource-poor settings is difficult, but a framework makes it possible to effectively plan, initiate, and sustain data collection. Funding Lifebox Foundation, London, UK.