Request for expression of interest on analysis of quality and outcome indicators for regional and district hospitals in Lesotho

Introduction

The Ministry of Health of Lesotho with the support of the World Bank funded
Nutrition and Health Systems Strengthening Project (P170278) seeks to hire a
consultancy team to conduct a study of Lesotho’s regional and district
hospitals. The goal of this study is to (i) conduct a baseline analysis of 17
hospitals for the NHSSP against which future progress can be assessed, and (ii)
provide analysis to compare hospital performance against the performance of the
Queen ‘Mamohato Memorial Hospital (QMMH) in Lesotho.

Lesotho has 17 district/regional hospitals in the public and church-owned
sector: two regional and 15 district hospitals. The 2017 Public Expenditure
Review (PER) identified very low bed occupancy rates in hospitals in 2015. This
points to idle capacity in hospitals or problems in access to care. By contrast,
the bed occupancy rate at the QMMH has been consistently higher than 70%.

An analysis of the QMMH quality and outcome indicators is currently being
conducted by Boston University. This study compares 2018 data with the prior
endline (2012) and baseline (2009) indicators to provide decision-makers with
information to manage and improve the performance of QMMH as a public-private
partnership.

With the support of the previous World Bank health project, public and
church-owned health facilities have received substantial training in quality maternal
and childcare in the past years. Hospitals now regularly prepare quality
improvement plans (QIP) and conduct morbidity and mortality audits to learn
from past experience. The health project also financed a performance-based
payment (PBF) to eligible hospitals, which contributed to improved quality
scoring.

Objective of Study

The objective of this
hospital study is to:

• measure and evaluate the
  performance of government and church-owned district and regional hospitals in
  2018, using both quantitative data and qualitative information;
• compare results for the
  hospital study with the ongoing QMMH study and the end line survey (2018)
  conducted for the QMMH; and
• interpret findings from the
  analysis to provide explanations for variations across hospitals and the QMMH,
  with reference to performance, challenges and other factors.
• based on the findings,
  propose actionable recommendations for hospital management and policymakers.

Approach and Methods

The analysis will include
quantitative and qualitative data collection and analysis. To allow comparison
between public and church-owned hospitals and QMMH, the same data collection
tool will be used as for the QMMH study. The study
includes the following data collection activities:

Collecting quantitative and descriptive data for
indicators (Objectives 1 and 2) includes four methods for data
collection.

• First, extract and analyze existing hospital
  administrative data from the admissions, discharges, and transfers (ADT) and
  patient utilization information systems, as well as data collected in
  monitoring reports of hospitals (by government and donors). Assess the validity
  and reliability of these existing data collection systems.
• Second, conduct a medical records review to determine
  neonatal survival by birthweight and maternal deaths. Identify quality of care
  issues affecting outcomes.
• Third, conduct direct observation to obtain data on
  patient flow, triage, and emergency supplies.
• Fourth, identify and assess at least five quality of
  care indicators across hospitals.  

The list below shows indicators organized by data
collection method. The indicators will be reviewed with key stakeholders prior
to finalization. Data will be collected on the three most recent years. It will
be used in the analyses for all four objectives.

1. Review of existing reports and calculation of indicators from routine hospital data:

• Population and demographic characteristics in
  catchment area
• Number of beds by ward
• Number of staff by ward
• Number of inpatient admissions by ward
• Number of readmissions by ward
• Number of inpatient days by ward
• Average length of stay by ward
• Hospital occupancy rate by ward
• Ambulatory visits
• Prevention of mother-to-child transmission (compliance
  with standards)
• Newborn care (compliance with standards)
• Availability and completeness of medical records (compliance
  with standards) by ward
• Rapid treatment of hip fractures (compliance with
  standards)
• Availability of thrombolytics
• Patient satisfaction (based on findings of hospital
  surveys)
• Number of deaths by ward
• Number of deaths due to pneumonia in children
• Number of caesarean sections
• Number of stillbirths
• Number and types of referrals to QMMH, other hospitals
  (specify) and to health centres
• Surgical waiting time

2. Medical Record Review:

• Neonatal birth weight and survival
• Morbidity and mortality audit reports

3. Direct observation on infection control, medical equipment and patient flow:

• Infection control (compliance with standards on
  availability of soap and water in hand-washing stations)
• Availability of emergency equipment and supplies
• Well-functioning emergency triage system
• Patient flow and average length of outpatient visits
  (waits and delays, etcetera)

4. Qualitative interviews with key informants (objective 3 and 4):

The consultants will conduct approximately 20-30 key
informant interviews with hospital managers, staff, and Ministry of Health
authorities. The purpose of the interviews is to gather general perceptions on
current performance and to explore factors affecting performance, quality of
care, challenges, effects of the QMMH on public hospitals, and lessons learned.

Data Analysis

• Once quantitative data are collected, the consultants
  will conduct an analysis comparing the results of the quantitative data for
  public hospitals with the results of the QMMH ongoing and endline surveys.
  Variations in outcomes will be explained.
• Indicators shall be grouped by category, including
  indicators of medical equipment, service access and capacity, utilization,
  quality of care, patient satisfaction, and outcomes. Analysis will be conducted
  in Excel and statistical software to show cross-tabulations and trend analysis
  where possible.
• The consultants will replicate tables and organization
  of data from the QMMH endline study, in order to facilitate comparison.
• Qualitative data shall be analyzed thematically using
  NVivo software.

Presentation and Reporting

The data from this study shall be submitted to the
World Bank and Medical Officer of Health (MOH) in the form of a written report
and a PowerPoint presentation. A presentation of the study findings shall be
made to the MOH and the World Bank to accompany finalization of the report.

Workplan

1. Finalize
design (2 weeks: Lesotho)

• The same protocol and tools
  will be used that have been developed by BU and approved by the WBG and the
  Ministry of Health for the QMMH study.
• Refine data collection plan with input from World
  Bank, MOH and hospitals
• Initial meetings and visit to hospitals, review of
  records
• finalize inception report and commence data collection

2. Data
collection and analysis (7 weeks: Lesotho)

• Quantitative data collection and key informant
  interviews
• Data cleaning and analysis
• Preliminary draft indicator tables with summary bullet
  points
• Data will be provided to World Bank and the MOH

3. Analysis and
report writing (6 weeks)

• Write draft report
• Give oral presentation of
  results in Lesotho to hospitals and the MOH
• Revise draft report based on
  feedback from the World Bank and the MOH
• Discuss results with QMMH
  and public- and church-owned hospitals.

Deliverables

The consultancy team
will provide the following set of deliverables: