Wait For It

Your clinic is filling up with women who look increasingly frustrated as wait times inch up. Mobile phones trill and children fuss. You hear murmurs that the clinic down the road – run by a popular quack, or untrained medical provider – is treating patients more quickly despite a continually heavy client load that rivals your own. Do you:

a) Rush patients through with little counseling or attention to their concerns. You need to make sure you can pay your bills this month and there’s no way you’re turning people away.
b) Assume re-using needles once won’t do much harm. Your sharps bin is full and there is no time to empty.
c) Kick out everyone who looks healthy enough, then lock the door and post a sign that reads ‘at capacity – come back tomorrow’.
d) Implement your quality assurance scheme to manage client expectations, people flow and technical standards.

If you are not standing in the aforementioned busy clinic, answer #d seems like the obvious answer. Of course, it’s the only answer, but the choices reflect the dangerous uncertainty providers navigate in the absence of a quality assurance plan.

Nabeel Akram has implemented quality standards in clinics in countries including Bangladesh, Pakistan and the Philippines. Now at Jhpiego, Akram shared tips for franchise managers who perceive difficult tradeoffs.

1. Turn wait time into counseling time
Clients don’t like to wait for care. Reduce the time patients need to spend with providers by shifting the job of counseling patients to lower cadres of workers. Jhpiego’s counselors and nurses talk to patients in the waiting room about family planning methods and cervical cancer prevention. Counselors pass out educational pamphlets, show videos and address many patient concerns. Patients often feel calmer and more informed when they see the doctor.

2. Speed up registration with electronic patient records Using record-keeping software can significantly decrease waiting time since patient records are easier to pull up and complete, and are of higher quality. Before implementing the Community Health Information Tracking System (CHITS), an eHealth system used widely in the Philippines, health workers sifted through a roomful of Manila envelopes to search out patient records. If they couldn’t be located, patients had to pay a fee to create a new record. Today, patients’ records are pulled up electronically in seconds – this includes lab requests, results and reports (daily service reports, census for number of vaccinations, supplies, etc.), which can be generated automatically.

Another add-on that can boost quality and efficiency is electronic prescriptions. In a submission to CHMI’s Reported Results program, an e-prescription service in Indonesia said that “the eHealth system has significantly shown its effectiveness in reducing paper usage, retrieving registered patients’ data and generating reports quickly.” The system also made providers more careful in selecting drugs during the prescribing process because they would be informed of medication errors.

3. Set and post expectations in a clear, public place
Akram suggests that franchise managers post checklists in prominent places so patients know what to expect from providers. Supervisors can set standards by breaking down clinical guidelines into step-by-step processes – or adapt those already created, like this PSP-One guide for midwives. According to UCSF’s social franchising compendium, 90% post checklists. They can display these steps in job aids – guiding health workers on the steps required to sterilize sharps, for example. Supervisors can use job aids to assess providers’ performance.

4. Build in time for training
For Key Social Marketing – a USAID-funded project implemented in Pakistan with Jhpiego, Constella Futures and five local training organizations – Akram and his team provided franchisees with 7-day trainings on contraception, information on performance standards that could improve service quality in franchises and technical support visits. While seven days is a long time to be away, this training really boosted the quality of care delivered at these franchises. Providers trained in Standards-Based Management demonstrated significantly improved clinical performance, although many still gave poor quality counseling on less popular methods like IUCDs. Learn about best practices in training here.

5. Motivate staff to manage high client loads
Akram stresses the importance of keeping teams incentivized to perform well, particularly in busy workplaces. Step-by-step job aids help supervisors assess who has been performing well. Many programs reward good performance with bonuses or other financial incentives. Non-financial incentives like public recognition at small gatherings, including district or provincial-level health authorities, are valuable for staff motivation as well. Provider coaching and mentoring on how to manage client loads can serve as lessons learned for newer staff members. Check out tips on how to get providers to do their best.

Nabeel Akram is the quality assurance advisor for the USAID-funded project to Strengthen Health Outcomes through the Private Sector (SHOPS).

This post is part of a series on social franchises for health leading up to the First Global Conference on Social Franchising (taking place Nov. 9-11 in Kenya). Find this post, and others in the series, here.