IMPRESS: Innovative Management PRactices to Enhance hoSpital quality and Save lives in Malawi

We will examine if improving hospital management practices leads to better health outcomes and quality of clinical care at scale in the 36 largest hospitals in Malawi, an ODA priority African country. We will study quality through the lens of newborn survival, a sensitive tracer of overall quality of care. The research focuses on quality of care and health workforce management, two priority areas for this call. Progress in maternal and neonatal mortality in Malawi has stalled despite the fact that most women now give birth in facilities. Mortality rates for small and sick neonates admitted to hospitals are extremely high. The high burden of hospital-acquired neonatal infections (HAI), with increasing anti-microbial resistance (AMR) indicates that patient safety and AMR stewardship are major quality challenges. At the clinical level, there is strong evidence from controlled studies on the effectiveness of health technologies. In practice, however, clinical care in this setting depends critically on factors at the organisational level, as exemplified by common problems such as drug stock-outs, staff absenteeism, and power outages. Recent evidence indicates that management practices – in the areas of human resource management, performance monitoring, target setting and operations – may be a driver of quality care but there are few relevant studies in low- and middle-income settings, especially ones powered for mortality outcomes. The research will build on an existing platform “Newborn Essential Solutions & Technologies” (NEST360) that provides a bundle of novel devices through government channels and collects rich patient level data on mortality and processes of care. Our multi-disciplinary team from the College of Medicine, University of Malawi and LSHTM will address the following interlinked objectives: 1. Adapt and validate measures of hospital and district management practices. Formative qualitative research and psychometric performance assessment will generate validated tools to measure management practices. 2. Examine the association between management practices and quality of clinical care. Data on management practices linked to patient level measures of clinical quality will provide observational evidence on which practices matter for quality. 3. Co-design a problem-focused hospital management intervention and scalable delivery model. Stakeholder workshops that draw in national and international expertise will result in a theory-driven intervention to enhance hospital management practices. 4. Evaluate effectiveness of hospital management intervention on neonatal mortality and secondary outcomes (including HAIs). A cluster RCT will generate evidence on the effects of enhancing hospital management practices on patient outcomes and clinical quality. 5. Assess acceptability, fidelity, and mechanisms of effect through qualitative research and estimate cost-effectiveness. A process evaluation and cost-effectiveness analysis will inform scale-up in Malawi and generalisability of the trial findings to other countries. This research will generate novel evidence on hospital management practices, with two-way skills transfer between the UK and Malawi, strengthening capacity of health systems researchers and hospital staff. Through equitable partnership with government and global policy networks, results will impact policy, to the benefit of neonates at high risk in Malawi, and beyond.