Quality Improvement and Clinical Governance Initiative - Piloting Quality Improvement Packages in Primary Care Centers Impact Evaluation 2014-2016 - Nigeria

Abstract
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The Nigerian Government has prioritized improving the quality of healthcare delivery throughout its care facilities. There are multiple facets to implementing successful quality improvement processes, including providing a transparent system with quantifiable outcome measures and ensuring workforce engagement for healthcare providers.

The government project team contracted a healthcare management consulting firm to provide support to 80 primary healthcare facilities in six Nigerian states to meet international healthcare standards. The IE was designed to measure the effectiveness of two different levels of consulting services on healthcare quality outcomes:

- Treatment A consisted of the "full package" of consulting services, including an initial extensive quality assessment, action plans, and continuous feedback and support.
- Treatment B was "information only". The consulting firm conducted the baseline quality assessment and provided initial feedback in the form of a report on these indicators, which was presented to center staff. Treatment B did not provide hands-on tutelage throughout the quality improvement process.

Geographic coverage
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Six Nigerian states: Anambra, Bauchi, Cross River, Ekiti, Kebbi and Niger.

Analysis unit
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- Primary Health Care Facilities
- Patients
- Primary Health Care Facility Health Workers.

Sampling procedure
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The sampling frame for this impact evaluation consists of all 80 PHCs in the 6 states that are being covered by the project.

RANDOMIZATION
Randomization of PHCs into Treatment A, Treatment B, and control followed these steps:
1. We assigned a random number to each of the 80 PHCs in our population.
2. These numbers were ranked in ascending order.
3. We ranked these numbers within each cluster (of 4 PHCs around a referral hospital).
4. The PHC with the highest random number in each was assigned to Treatment A, the second highest number was assigned to Treatment B, and the third highest number was assigned to the control group. This created groups of 20 for each treatment arm.
5. Lastly, the 20 PHCs with the fourth highest numbers were ranked again. Then, the 4 highest numbers were allocated to Treatment A, numbers 5-8 went to Treatment B, and the rest was assigned to the control group.

This resulted in the following group sizes:
- Treatment A: 24
- Treatment B: 24
- Control group: 32

Mode of data collection
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Face-to-face [f2f]

Research instrument
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As data sources, the IE will use a combination of PHC administrative data, facility level survey data, the tools developed by the healthcare consulting firm, the SDI and SURE-P surveys, as well as additional instruments to assess the quality of care.

Response rate
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Out of 80 primary healthcare facilities, the response rates for:
- round 1: 100%
- round 2: 100%
- round 3: 100%
- round 4: 100%
- round 5: 89%
- round 6: 100%
- round 7: 100%