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Practice Quality Improvement Report

Improving quality in resource poor settings: observational study from rural Rwanda

BMJ 2009; 339 doi: (Published 30 October 2009) Cite this as: BMJ 2009;339:b3488
  1. Meera Kotagal, volunteer, student12,
  2. Patrick Lee, clinical mentor, hospitalist physician, clinical instructor in medicine123,
  3. Caste Habiyakare, nurse4,
  4. Raymond Dusabe, doctor4,
  5. Philibert Kanama, nursing director4,
  6. Henry M Epino, medical director, attending physician, instructor in surgery125,
  7. Michael L Rich, director6,
  8. Paul E Farmer, co-founder, Presley professor, chief178
  1. 1Partners In Health, 888 Commonwealth Avenue, Third Floor, Boston, MA 02215, USA
  2. 2Harvard Medical School, 260 Longwood Avenue, Boston, MA 02115
  3. 3Newton-Welleseley Hospital, 2014 Washington Street, Newtown, MA 02462
  4. 4Kirehe District Hospital, Rwanda Ministry of Health/Partners In Health, Kigali, Rwanda
  5. 5Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
  6. 6Partners In Health, PO Box 3432, Kigali, Rwanda
  7. 7Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston MA 02115
  8. 8Division of Global Health Equity, Brigham and Women’s Hospital 651 Huntington Avenue 7th Floor, Boston, MA 02115
  1. Correspondence to: M Kotagal, Department of Surgery, University of Washington, Box 356410, Seattle, WA 98195, USA mkotagal{at}
  • Accepted 23 June 2009


  • Problem Hospitals in rural Africa, such as in Rwanda, often lack electricity, supplies, and staff. In our setting, basic care processes, such monitoring vital signs, giving drugs, and laboratory testing, were performed unreliably, resulting in delays in treatment owing to lack of information needed for clinical decision making.

  • Design Simple quality improvement tools, including plan-do-study-act cycles and process maps, were used to improve system level processes in a stepwise fashion; resources were augmented where necessary.

  • Setting 50 bed district hospital in rural Rwanda.

  • Measurement of improvement Three key indicators (percentage of vital signs taken by 9 am, drugs given as prescribed, and laboratory tests performed and documented) were tracked daily. Data were collected from a random sample of 25 charts from six inpatient wards.

  • Strategy for change Our intervention had two components: staff education on quality improvement and routine care processes, and stepwise implementation of system level interventions. Real time performance data were reported to staff daily, with a goal of 95% performance for each indicator within two weeks. A Rwandan quality improvement team was trained to run the hospital’s quality improvement initiatives.

  • Effects of changes Within two weeks, all indicators achieved the 95% goal. The data for the three objectives were analysed by using time series analysis. Progress was compared against time by using run chart rules for statistical significance of improvement, showing significant improvement for all indicators. Doctors and nurses subjectively reported improved patient care and higher staff morale.

  • Lessons learnt Four lessons are highlighted: making data visible and using them to inform subsequent interventions can promote change in resource poor settings; improvements can be made in advance of resource inputs, but sustained change in resource poor settings requires additional resources; local leadership is essential for success; and early successes were crucial for encouraging staff and motivating buy-in. …

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