A qualitative study of perceived facilitators and barriers to adoption of continuous quality improvement in Western Kenya using the Consolidated Framework for Implementation Research (CFIR)

Abstract

Background: Quality health services are key to achieving Universal Health Coverage (UHC) but challenging to measure and deliver in resource-limited settings. Continuous quality improvement (QI) is an approach to health service improvement that has not yet been widely implemented in Kenya. The Academic Model Providing Access to Healthcare (AMPATH) and the Busia County Ministry of Health (MOH) piloted a QI training and mentorship program for healthcare workers (HCWs) in Bunyala Subcounty, Kenya. A 4-day training was conducted, followed by quarterly health facility mentorship visits. A qualitative process evaluation was conducted to assess perceived barriers and facilitators to forming and sustaining QI initiatives. Methods: One year after initial QI training, 11 semi-structured key-informant interviews and 5 focus groups discussions (FGDs) were conducted. 48 MOH leaders and HCWs at Bunyala health facilities were purposefully selected to participate. Interviews were transcribed, and an a priori thematic analysis was conducted using domains and constructs from the updated 2022 Consolidated Framework for Implementation Research (CFIR) with modifications recommended for low-middle income country (LMIC) settings. Results: Within the CFIR domains, constructs that emerged as key facilitators to QI implementation included: the adaptability of QI aims to facility priorities, perceived source and MOH ownership, performance measurement pressure; access to knowledge through training; tailoring strategies of mentorship through the MOH supervision, and teamwork. Key barriers were identified in Domain VI, an LMIC modification and included poor resource continuity (supply chains) and systems architecture leading to transfers of HCWs. Engagement with patients and the community emerged as a theme suggesting that QI can provide a structure for developing more patient-centered services. Conclusions: Analysis using the 2022 CFIR with modifications for the LMIC setting provided insight into the perceptions of HCWs and MOH leaders. Recommendations to facilitate continuous QI in this setting include adequate training and continued mentorship, MOH ownership, structuring QI initiatives around MOH priority indicators, and strategies to mitigate health system gaps leading to supply chain irregularities.