The Ijede General Hospital is located along the Egbin Thermal Power Station Road in Ijede Local Council Development Area (LCDA) of Lagos State. The hospital sits on land about the size of a standard football pitch and serves a population of about 40,000 Ijede citizens. A good number of patients also come from surrounding catchment areas. Some patients come from as far as communities across the Lagos Lagoon, east of the hospital.
“Our key strength in this hospital is maternal health,” says Chief Medical Director Dr Adenike Odubiyi. The hospital has been around for 36 years, and started as a primary health centre in 1983.
Deputy Medical Director Dr Olumuyiwa Balogun-Oluwa said the primary health centre attended to a little over 10 patients daily in the beginning. Over the years it was upgraded to a secondary facility. It officially became a general hospital in 2012, and now sees on average 11,000 out-patients in a month.
“In my 12 years here, we have transitioned from a health facility that referred simple blood transfusion requests to Ikorodu General Hospital to now being able to handle special cases including thyroidectomies, obstetric & gynaecological cases, performing 10 caesarean sections daily and general surgeries,” he said.
“All for one, one for all” — John C. Maxwell
The above quote holds true in the story of Ijede Hospital. “Our conference hall has a photo of all the people that led the hospital right from when it was a primary health centre. The willingness of the Medical Directors to improve on what they met on ground is one of the major factors that led to steady growth of the hospital,” Dr Balogun said.
Watching Dr Odubiyi interact with patients and staff, it is easy to notice the warm working environment. She easily exchanges pleasantries, as the patients greet her in the local Yoruba dialect commonly spoken in southwest Nigeria. This sense of ownership extends beyond the walls of the hospital. A number of critical stakeholders make the work easier for the staff by creating an enabling environment for them to thrivein.
Ijede community has been known to have occasional conflicts. The police station in the area is always willing to respond to urgent calls made by the hospital. The Egbin Thermal Power Station about 3 kilometres away adopted the hospital as a Corporate Social Responsibility (CSR) project, and provides them with electricity supply. This has been transformational to their service delivery, Dr Balogun said.
They also maintain a close working relationship with the Local Council Development Area (LCDA), and the chairman helps offset some expenses during their community outreaches. Most importantly, the community members are considered critical stakeholders, Dr Balogun explains. “We made them understand that this is their hospital and we were just brought in by the Lagos State Government (LASG) to assist in its development.” The community stakeholders now work under the Hospital Community Relations Committee (HCRC) and their contributions have been immeasurable, says Dr Balogun. He gave examples of their contribution, such as the construction of a large tent that has compartments for seven consulting rooms and a waiting area for outpatients. This has improved patient confidentiality while seeing doctors and reduced waiting times. Initially, they had only two consulting rooms which meant that it easily became crowded and patient confidentiality was not guaranteed.
Lagos State has introduced initiatives aimed at enshrining quality service delivery in public servants. Dr Balogun said the health sector focused quality improvement initiatives are helping tremendously to put square pegs in square holes and ensure that patient satisfaction is guaranteed.
The service charter initiative by the State Ministry of Health is another quality assurance effort that is helping guarantee patient-centred health institutions in the state, and the Office of Transformation, Creativity and Innovation (OTCI) is instilling a forward-thinking mindset among the staff. Ijede General Hospital also receives monitoring visits from the Health Facility Monitoring and Accreditation Agency (HEFAMAA), who monitor service delivery at the facility.
But it is one thing to have these quality improvement initiatives, it is another thing for public servants to apply them across board.Dr. Odubuyi says that for her and her team, accountability is largely about what you do when no one is watching.
The hospital has a quality improvement team that is made up of service improvement officers, conflict resolution officers, andservice angels. To gauge patient satisfaction and learn about areas of improvement, the hospital installed two transparent boxes about the height of a reading table and the shape of an offertory box. A green plastic basket is placed in the middle with balls of varying colours placed inside. Patients are encouraged to pick up the balls and drop into any of the boxes to show their satisfaction (or dissatisfaction) with services received. Boldly printed on the boxes are “satisfied” and “dissatisfied”. The role of the quality improvement team is to address any issues that patients have and to ensure the issues are resolved in a timely manner. For more serious complaints or recommendations, another box is provided, and prompt action is taken once complaints are made, says Dr. Odubiyi.
The hospital consistently comes out on top during state-led hospital assessments. As a result, staff members are often selected to mentor and lead quality improvement in other health facilities. The LASG uses various assessment criteria to rate hospitals, including governance, inventory and financial management, and patient satisfaction. Mystery clients pay impromptu visits to determine patient satisfaction. The Health Service Commission (HSC) occasionally comes to assess service delivery.
Delivering quality healthcare
The consistent effort made to improve the health of people always pays off and for Ijede General Hospital, it paid off to a large extent as it became the hospital of choice for a lot of patients. They come because they receive prompt attention and short wait times. Dr Oni Babatope, a consultant Obstetrician/Gynaecologist said the average wait time is between 10–15mins and they see a lot of patients, despite the limited availability of space at the health facility.
Ijede General Hospital has developed expertise in maternal healthcare and has plans to build a maternal care centre outside the hospital. Even though some women still give birth at home, with the help of Traditional Birth Attendants (TBAs), facility delivery is high and maternal mortality quite low. Dr Balogun said they achieved this by organising quarterly community outreaches and working with community stakeholders to encourage facility deliveries for women. They also worked with Traditional Birth Attendants (TBAs), training them about best practices, identifying the danger signs of pregnancy, understanding their limitations and when to refer to the hospital. They also provide them with a maternity helpline to call when they have a woman in need of care. This way, the hospital can send an ambulance to pick up the pregnant woman.
In the air-conditioned maternity ward, two new mothers, Mrs Rashidat and Mrs Olufemi expressed their excitement for their safe deliveries. Mrs Rashidat, who had given birth the previous day, said she decided to come because she heard about their effectiveness. She said she is glad about the decision because she could have lost her baby due to complications, but for the expertise of the Ijede General Hospital team. She said her husband was so excited and wanted to personally thank the CMD. “I am calling all my friends that are pregnant to come here now and this is definitely where I will come for my next delivery,” she said. Hospital records show they had 89 deliveries in June 2019 and by mid-July, had already performed 39 caesarean sections.
Like every other hospital, Ijede General Hospital has similar challenges around human resources, but they have learned to use what they have to deliver the best possible care to their patients. Another challenge, also not unique to Ijede, is the inability of some patients to pay for services.
Dr Balogun said this is sometimes addressed by giving waivers to patients, creating a structured payment plan for clients who cannot afford it, and even relying on the philanthropic individuals who come to offset the bills of poor patients. They also encourage the HCRC members to let their communities understand that when they don’t pay for services, they hurt the next person coming to access care. He hopes the Lagos State Health Insurance Scheme will help improve this because it focuses more on communities than the National Health Insurance Scheme (NHIS).
There are institutions working hard both nationally and internationally to ensure patients receive quality care such as the International Society for Quality in Health Care (ISQua), Society for Quality Healthcare in Nigeria (SQHN) and PharmAccess Foundation, which is implementing the quality improvement methodology known as SafeCare. Ijede General Hospital underwent a SafeCare quality assessment in 2017 and is participating in the 18-month quality improvement program. SafeCare was also adopted by the Lagos State Ministry of Health in 2016. But before we look nationally or even internationally, let’s begin locally. Health care providers at every level should be more intentional about providing quality patient-centred care. If they don’t, they might have to contend with the Patient Bill of Rights as patients are becoming more aware of their rights, and consequences for breaching those rights.
Leadership does matter
The story of Ijede General Hospital goes against the standard narrative about government-run health facilities in Nigeria. A critical component that has underpinned the hospital’s consistent performance, especially in offering quality care is the leadership of the facility. Dr. Odubiyi has demonstrated that quality care is possible, it requires working closely with every stakeholder in the supply chain of care to patients. From the maintenance staff in the facility to the nurses and doctors. This has helped embed a culture of quality healthcare throughout the facility. Staff members have opportunities for continuous professional developmentand are encouraged to have a growth mindset that has given them the impetus to further hone their skills.
Despite the space constraints the facility faces and infrastructure challenges (the access road to the hospital is in a state of severe disrepair), the active stakeholder engagement the hospital CMD and management staff have done has enabled the positive working relationship that has developed with the local community. They have been able to build a culture of trust and have identified channels of communication to engage with the community i.e through community events, outreach activity or door-to-door health promotion campaigns.
In the recently concluded 5th edition of the annual Future of Health Conference, which focused on improving health outcomes through quality healthcare, Nigeria Health Watch Curator, Dr. Ike Anya, said, “Quality healthcare is not something you get in a fancy hospital expensive hospital. It’s simply about giving care the way we ourselves will like to receive it”. Even something as simple as ensuring that patients don’t spend more time than they are supposed to amounts to quality care and Ijede General Hospital has shown in several ways how this can be achieved.