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Compassion-based quality improvement for Cambodia’s healthcare system

In Kampot province, a joint Action Research process enabled hospital staff and management to reconnect with their cultural value of compassion for all life as basis for providing quality care to their patients. A standardised training curriculum, based on a practical toolbox, takes health worker teams on a unique self-leadership journey that increases staff motivation and improves quality of care. 

‘Health staff used to get angry with patients – now they take time to listen to them.’ Mardy Sam, Administrator of Kampot Provincial Referral Hospital, is still amazed at how quickly – and how profoundly – things have changed there.  ‘We used to feel powerless to change anything on our own: we would just wait for instructions from the hierarchy.  Previously, financial incentives or authoritarian management were used to motivate staff to perform. But since discovering holistic self-leadership, everyone is working much better.’  The videoclip shows what he means.

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The new approach Mr Sam describes and its documented effects (see below) are the result of an inspiring example of Cambodian-German cooperation which evolved as a joint journey of discovery into the linkages between health workers’ cultural and spiritual value systems and the way they approached their work. How did this come about?

Seeking authentic motivation for quality improvement in ‘core values’

In Kampot and Kep provinces, the German Federal Ministry for Economic Development and Cooperation (BMZ) supports the health system through the Social Health Protection programme implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). Dr Elias Engelking, GIZ Advisor for organisational development and quality improvement (QI), relates, ‘When I arrived in 2018, it was evident that the “carrot-and-stick” approach was not effective in motivating workers to provide quality care. In fact, focus group discussions with health staff revealed that such “extrinsic” incentives were actually having the opposite effect: paralysing individuals from taking any personal initiative to improve their working environment. We decided to conduct a series of reflection sessions in which we took a “deep dive” with participating health staff to help them discover what they actually did find motivating in their daily lives. As they gradually opened up, a consensus formed around love for their families, but extending much farther to care and respect for all life – a rediscovery of spiritual (Buddhist) roots largely obliterated under the traumatic Khmer Rouge regime. Particularly those under 40 felt that they needed to reconnect. Participants brought up long-buried memories of their grandparents telling them to respect all life, from fellow humans to ants and grasshoppers.’ 

Formulating their ‘core value’ in these deep-dive sessions was the first, liberating step for health staff, shifting responsibility for their actions back to the health workers themselves. And as this core value is presented to other health stakeholders on health centre, hospital, district or regional level, it is eagerly embraced. As Ms. Kunthy, Chief of the QI Unit of the Kampot Provincial Health Department, explains, ‘This value has touched us to our heart, it enables us to enjoy the work we are doing: Now we are working not just with our head, or our hands, but with our whole being. You need to live by your own values: Then you become a leader yourself, and others will follow you.’ According to Dr Engelking, this spiritual value aligns with GIZ’s holistic mission statement, as well as with the World Health Organization’s current exploration of the role of compassion in healthcare

Building confidence for self-leadership – one Habit at a time

What did it take to translate this newly found, or re-discovered, core value into everyday clinical practice? Dr Vuthy Huong and Ratha Nin are part of GIZ’s Cambodian team who played a key role in developing and disseminating the novel QI approach. Mr Ratha reports, ‘Our holistic approach has four elements: vision, leadership, system and processes. First, workers’ feeling of paralysis was countered by looking for the higher value that ethically orients people in their actions: the vision. Next, their self-leadership was fostered by introducing them to the frame of action developed by Stephen Covey in his ‘7 Habits of Highly Effective People’, because these principles – which were adapted to the Cambodian cultural context – enable actual action in very small steps. After training, each participant is given the Khmer translation of Covey’s book – the other day I even came across someone who hadn’t received the training reading it!’

The existing QI system was revitalised with the addition of inter-hierarchical, cross-functional ‘QI Teams’: From supervisor down to cleaner, all team members feel mutually responsible, focused on the same ideal of outstanding, compassionate service to patients and community. 

Appreciative Inquiry: Focusing on core values and a vision rather than on problems

As a user-friendly tool for planning joint processes, Appreciative Inquiry (AI), an approach developed by Cooperrider and Whitney, was introduced: Starting from their shared core value, participants are invited to Discover positive resources in their environment, Dream of how they would like their health structure to be, then Design a plan for achieving that dream, and finally Deploy the planned action. Using this participatory approach, the staff has been developing standard operating procedures (SOPs) for the hospital and repeating the cycle at monthly intervals.

‘AI makes staff feel good,’ says Dr Vuthy, ‘because the starting point is not a problem – like in tools such as SWOT – but the shared positive value and dream for how things can get better. With this training, the frontline staff can start to expect that what they want to improve will actually come about. These tools remove negatives from the working place and replace them with good positive things that make staff feel happy and want to continue.’ 

Dr Vuthy Huong of GIZ explains why the self-leadership approach proved particularly effective in the Cambodian context.

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A ground-breaking approach for capacity development

The approach is conveyed in intensive, several-day workshops, for which a comprehensive toolkit in Khmer has been developed. The training agenda propels participants from nostalgic memories of childhood to the far reaches of the galaxy, while en route running the gamut of Covey’s principles, other tools and reflections on extrinsic, intrinsic and spiritual motivation. Trainings are systematically followed by on-site coaching, to close any gaps in participants’ understanding and show how they can apply the new principles in their real-life work environment.  

The GIZ team developed a hospital handbook in Khmer – and a colourful, larger-than-life poster presenting Covey’s Habits, that integrates the AI cycle plus additional QI tools used by the Ministry of Health, prominently displayed in each hospital unit, durably reminds staff of their ideal and the small steps they can take to attain it.

Extending the novel QI approach

The self-leadership initiative was soon attracting attention. Dr Tann Chheng, Deputy Head of Kampot’s Provincial Health Department, recalls, ‘With the holistic approach, I discovered a new way to solve problems. I saw with many people, when they got the training, that it changed their mindset to optimistic, from passive to active and proactive.  We worked with GIZ in extending the training to all public health facilities in Kampot and Kep provinces: a total of 6 hospitals and 71 health centres – 10 workshops for 180 participants over two years. The poster is hanging on all the walls, and it reminds staff to think. When we supervise the health facilities, we reinforce the practice of holistic self-leadership.’

Ms Kunthy adds, ‘The training has changed their mindset and created an inner drive, to no longer just wait for outside support. They do research to try to improve their environment. One health centre contacted their commune council and persuaded them to help construct a small building for post-maternal care that everyone can use.’

On social media, the initiative takes off like wildfire

When the COVID pandemic forced the project team to conduct its self-leadership trainings online, they turned the crisis into an opportunity: Participants were asked to produce short videos about the self-leadership principles, what they mean in their lives and for their work. This initiative took off like wildfire. Dozens of short videos were produced including attractive inserts of daily life in Kampot province, presenting an almost cathartic outpouring of positive sentiments. One young woman refers to her baby and the happy future she dreams of for him and all humanity, a nurse describes how he treated an elderly woman patient ‘as if she were my mom’, another man pledges to be kind to his patients as he is to his wife. These videos are posted on a Facebook page entitled ‘We act for our community well-being’, which has over 700 followers. Certain posts have up to 30,000 views, totalling to date over one million altogether. The audience includes both health personnel, for whom the videos model examples of integrity and compassionate care, and the general public, who are reassured that they will be well-treated in the public health facilities (which in Cambodia are all too often a last recourse). The videos are a simple, low-resource tool, multiplying the impact of the self-leadership training, and spreading the concepts outside the two provinces, including to development partners and higher levels of government.

Solid evidence of effectiveness

The changes both in staff attitude and in quality of care have been researched and measured. People’s sense of how much they – or external forces – control their lives is known as their ‘psychological locus of control’. Staff’s initial sense of powerlessness corresponded to an external locus of control, and their new-found proactivity reflects an internal locus of control. This change in attitude was confirmed by testing 164 participants before and after a five-day workshop on holistic self-leadership, applying the Nowicki-Strickland Locus of Control questionnaire, which attributes a maximum of 25 points to a strong external psychological locus of control, while a score of 0 points would correspond to a strong internal locus of control. As the graph shows, participants’ scores on the post-test were strikingly lower than on the pre-test, indicating their significantly strengthened internal psychological locus of control – i.e. confidence in their own ability to have an impact. 

A consequence of staff’s new proactivity, the changed approach has resulted in dramatically improved quality of care indicators. In Cambodia, routine monitoring of all health facilities is carried out nationwide with the standardised H-EQIP Quality Enhancement Measurement Tool. In Kampot and Kep provinces, the changes on the ground have been as remarkable as those in the attitude of health workers: From the baseline in early 2018, when hospitals’ quality was assessed on average at barely 50%, and health centres at 32%, both now have quality scores of over 80%.

H-EQIP quality improvement

Compassionate care has become a new corporate identity

The core value of compassionate care has become the new identity of the public health services in Kampot and Kep provinces. This is not just visible in the logo, T-shirts and the poster, it has become an integral part of the lived culture of the organisation. The self-leadership principles are regularly referred to in daily activities of the health staff.

A turning point was the organisation in 2020 of a multi-stakeholder Training of Trainers workshop including the Provincial Health Department and the Operational Health District teams. Going a step further, the provincial government itself has requested the training be extended beyond the health sector to its own administration as well as to the commune level. 

Reflecting on the past three and a half years, Dr Engelking states, ‘This has been an insightful journey, understanding the importance of health workers’ self-esteem and their connectedness to a deeper purpose. Digging down to their cultural roots, people can change the organisational culture. Hospital management has moved away from a culture of blame towards an appreciation of patients and of frontline staff.’

Moving towards nationwide dissemination of holistic self-leadership in healthcare

The quality improvement approach with participatory development of the SOPs has laid the foundation as the central knowledge management instrument for health facility accreditation, as well as for the standardisation of continued medical education for all five professional councils – two other quality improvement initiatives being supported by GIZ in Cambodia.

The holistic self-leadership approach is to be implemented by the other GIZ provincial team in Kampong Thom province in 2021. With the support of other development partners, the approach is being integrated into Cambodia’s overarching health sector programme H-EQIP, to enable more holistic leadership concepts to fulfil the vision of GIZ and of the Ministry of Health. Now based in GIZ’s Decentralisation programme, Dr Engelking is supporting the nationwide dissemination of the holistic self-leadership approach. 

Dr Mary White-Kaba, July 2021

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