The leadership team who drove the accreditation programme at the hospital. (From left): Elijah Ongeri, the Head of Nursing and Quality, Dr K.K Gakombe, Founder and CEO,  James Wesonga, Quality Improvement Manager and Elijah Ongeri, the head of Nursing and Quality.

The level 5[1],160-bed Metropolitan Hospital operating in Buruburu in Eastlands, Nairobi since 1994, has been making waves in terms of improved services to patients and safer care. Hospital data is showing satisfied patients with good clinical outcomes and a drop in adverse events.

The hospital entered the COHSASA programme in August 2019. In April 2022 it achieved a pre-accreditation award at Entry level. Somehow, from April to October in 2022, it switched gears and made excellent progress by addressing outstanding deficiencies in the standards to be awarded full accreditation.

Mr. James Wesonga, the Quality Improvement Manager, believes there were several reasons for the hospital’s rapid move towards full compliance with the COHSASA standards. Along with Mr. Elijah Ongeri, Metropolitan Hospital’s Head of Nursing, he led the accreditation programme from the start, working after hours to achieve the goal. “We were dedicated, and we knew how important patient safety and quality healthcare is to our hospital,” says Wesonga.

An inspiring leader in the accreditation process has been Dr. Kanyenje Gakombe, the Chief Executive Officer and Managing Director, Metropolitan Hospitals Limited. Dr, Gakombe says “The decision to sign up with COHSASA was intentional and strategic. We had done our market survey and explored all the available options and COHSASA resonated with our hospital mission. As we joined the journey it was clear how our patients and all other stakeholders  would benefit.”

But it was not easy at the beginning of the programme.

According to Ongeri, one of the difficulties of the quality journey was to convince management that it was a worthwhile to invest in the process There was already a significant delay in accreditation related to the pandemic and there was a cost to achieving the standards across the hospital.

“Management required us to present a business case and we had to show them why spending the money to meet the standards was worth it. We had to put forward a case for quality to the Board. At the start it not easy and we got quite frustrated at times. But once we could show them what we could achieve – without even a  formal quality unit requiring extra salaries – they began to see the value. We worked closely with the head of finance and in the end, the Board decided to invest fully in quality.”

Wesonga says he and Elijah would stay after their shift and work through the standards, look at policies and see what was happening on the ground and then come up with a plan.

“It was a hectic job in 2019. We had so much to do and so much training that had to be done. Fortunately, we were able to benchmark with other hospitals and we learnt a lot from them. Slowly the management began to understand just how important quality was for the safety of our patients.”

“We do not have a ‘quality unit’ in our hospital and the two of us, with Dr Gakombe leading, have driven the programme with a number of committee leaders. We motivate unit leaders and champions in all departments across the hospital to drive the quality agenda. This means that people who are familiar with how their own units and departments operate drive the standards compliance progress in those units – not an outsider who looks at quality from a generic point of view. In this way everyone in the hospital – even the casual labourers – became involved.

Says Wesonga: “We were not doing this for COHSASA – we were doing this for our patients, and we saw that the process of accreditation was very important. We changed our strategy and we benchmarked with our peers.”

It was patently clear to Wesonga and Ongeri before the COHSASA external survey in April 2022 that the hospital was nowhere near compliance with standards. They knew that they would not be accredited at that stage. When COHSASA reported back after the survey and pointed out the gaps, there were no surprises. The hospital knew about them.

“COHSASA Quality Improvement Manager, Dr Leonard Londa, told us that we would not be accredited and that the process was not ‘magic’. This was so important for us to hear,” says Ongeri.

Soon after that Wesonga and Ongeri devised a plan on how the hospital would achieve full accreditation. They set up two surveys – one an internal self-audit in July 2022 where they invited peers from another accredited facility to audit the areas that did not reach full compliance in the April survey. This was a critical move because their peers could notice shortcomings from a fresh perspective. After that was a COHSASA remote survey in September.

“Quality consciousness eliminates waste.”

This strong quality team thinks hospitals entering the COHSASA programme should be offered several remote surveys in the contracts they sign because it improved their confidence levels.

Says Ongeri: “Now, quality improvement is at the top of our senior management meeting agenda. We present quality parameters before we present anything else. Most private hospitals have money at the top of the agenda, but we have discovered that placing the requirements of a quality improvement journey first helps to prevent one from spending money in an inappropriate way or spending money you do not have. Quality consciousness eliminates waste.”

According to James Wesonga, one of the key learnings from the accreditation journey has been how many medical errors can be prevented by focusing on quality and how quality improvement has reduced the length of stay of so many of their patients.

“So many of the standards we work with are related to patient and staff safety. In the risk management service element, for example, many of the criteria are focused on critical key areas of safety like the management of medication and how to avoid errors related to high alert and look alike and sound alike medicines.

“Once you make quality your central reference, you are on a journey to prevent so many untoward things from happening to patients. We encouraged our staff to report all near misses, errors and incidents and to conduct root cause analysis.

“ When we checked the trends of adverse events and near misses, there was a steady decline of incidents in the hospital thanks to the accreditation journey. We have learnt a lot as a hospital and as a team,” he said.

With artful insight Ongeri says that for him the actual process of the quality improvement journey was possibly more important than the accreditation. “The most important thing about the process is planning. If one does not plan, one will fail. One needs to internalise all the documents and tools the accreditation programme provides and then break them down to actionable items. Then you plan and that plan has to trickle down to the lowest cadre of staff. Staff need to know, with a clear instruction, how to engage with the process.

“I think the most important aspect is how the accreditation process affected patient outcomes. For example, the average length of stay for the past three years has dropped. We have started a new programme to follow up on patients at home. Each patient gets a follow-up call once they are home to find out how they are. They are asked specific questions about pain management, medication and follow-up.

“That’s the importance of the accreditation programme. It changes how you think and how you plan. It has completely changed how we think about our patients and about our processes. We found that when you start with quality, everything else falls in place. It changes how you look at construction because everything we have constructed after COHSASA follows quality standards,” says Wesonga.

When you start with quality, everything else falls in place.”

“For example, it was very difficult to accredit some units that were built before we entered this programme, but a theatre built recently and after we entered the COHSASA programme meant that there were a lot of considerations about patient flow. It changed health management teams and how much money has been allocated to items that improve staff and patient safety. We have reduced staff incidences and needlestick injuries substantially. It looks like magic but when you look back at programmes you put in place required by the standards, you start seeing the consequences of careful planning. Root cause analysis has meant that we prevent adverse events recurring,” Wesonga said.

“We trained staff to capture quality indicator data accurately and, as a result, we have accurate statistics about what is going on in our hospital and we can act on that information.”

Ongeri believes that teamwork began to emerge as a very positive feature in the hospital. “Not only does the COHSASA process require formal teamwork, but it allows leaders to emerge. The success of each committee depended on the leadership qualities of the person who held that committee together. Every person in the hospital belonged to a specific team – either a fire response team or a resuscitation team – in addition to their daily routine. This arrangement completely changed our resuscitation figures.

“Previously resuscitation was not well coordinated. When the alarm sounded for resuscitation, only those willing to respond would do so. With the introduction of the QI process, we had to train people on resuscitation, and they were given duties according to a roster. Thus, they knew that if cardio-pulmonary resuscitation was required and they were on call, they had to respond.

Wesonga and Ongeri have worked closely with the Customer Relations Manager who gets feedback from patients about the hospital. There has been an increase in the number of patients who report that access to the hospital is better and that cleanliness of the hospital has improved. They report that patient care has improved: things are different and healthcare workers treat their patients with respect.

The numbers of patients or their relatives demanding to speak to management (usually because something is wrong) has dropped substantially.

“The first thing patients say when they come here is, ‘Wow! Things have changed!’” says Ongeri.

He recalls that last year, after a meeting with Judy Njino,  the UN Global Compact Executive Director for Kenya, when they met her at the main door she said, “Wow! This is happening in Eastlands!”

“You know we are in that part of the city – Eastlands – where people don’t expect great things and when great things happen, it gets the attention of everyone,” says Ongeri.

The UN Global Compact was so excited about what she saw at Metropolitan Hospital that she mentioned it on LinkedIn, and she also requested  they write a paper about the innovations and improvements. This is due for publication in Poland soon.

Another positive outcome resulting from the QI journey has been significantly improved surgical outcomes. If a hospital is known to have high surgical site infections, surgeons are less likely to use the hospital. Metropolitan is gaining a reputation for having good surgical outcomes and the number of surgeons and physicians seeking to become consultants at the hospital has tripled.

“We are gaining a reputation for having the correct theatre equipment, the correct processes and our outcomes are good. Thus, we are attracting more patients and that affects our top line in a very positive manner,” says Ongeri.

He recalls an example of how quality teams  affected good outcomes. “During surgery, a patient flatlined and the surgical team was overwhelmed. The resuscitation team responded quickly, and everyone knew what to do and the patient’s life was saved. That might not have happened before we began the COHSASA process.

“Measuring data, something we learnt during the QI programme, had a direct effect on how we treated our COVID-19 patients. We used the data to analyse why one particular doctor was achieving higher survival rates and found that a particular approach – using steroids earlier – had better outcomes.  The Ministry of Health and other stakeholders  noted our results via our daily bulletin. We trained hospitals beyond our border in this method, and I think we had an impact,” said Ongeri.

Wesonga agrees with this assessment and says that meeting standards in service elements such as risk assessment and infection control assisted the hospital in managing COVID-19 patients.

“We had no cross-infections from patients to our doctors or nurses. We ensured that the PPE equipment – masks and goggles – and clothing that our staff used underwent quality testing.

“This is what quality improvement does. It makes you think in a whole new way,” said James Wesonga.

[1] Hospitals classified under Level 5 in the Kenyan health system include county referral hospitals and large private / mission (faith-based) hospitals.