Quality improvement in emergency units in low resource settings: A qualitative assessment for understanding challenges and delivering solutions

ObjectiveTo meet the World Health Organization (WHO) requirement of strengthening integrated Emergency, Critical and Operative (ECO) care, it is necessary to develop ECO-related guidance and tools for Quality Improvement (QI) in Emergency Units (EUs). This study aimed to identify the barriers and facilitators for QI in EUs in Low- or Middle-Income- countries (LMICs) and explore potential measures for assessing quality of care, to inform guidance and tool development across all quality domains. MethodsWe conducted in-depth interviews (IDIs) with 11 specialist emergency physicians from LMICs and organized a workshop with global technical experts in emergency care. Transcribed interviews were thematically analysed, integrating WHO quality domains and the WHO Health Systems Framework. The workshop included presentations, discussions, and interactive ranking exercises to evaluate QI measurement methods and identify priority WHO quality domains. Related outcomes were synthesized to generate insights for the development of QI guidance and tools. FindingsQI efforts in LMICs primarily focused on effectiveness, timeliness, safety, and occasionally patient centeredness. Key barriers to QI specific to LMIC EUs included high patient turnover, a lack of skilled staff, limited funds and resources, and prioritizing patient care quantity over quality. Facilitators included the availability of QI guidance, training, initiating small-scale projects, enhancing documentation and communication, and supportive hospital management. Safety and effectiveness were considered the most feasible QI domains for improvement, though all were recognized as important. Inconsistencies in how participants defined the domains highlighted the need to develop clear guidance on definitions, and importance of all domains and measures appropriate to each. ConclusionsEmergency unit is a unique environment handling time-critical health conditions and therefore requires the development of specific tools and guidance for delivery of QI. Addressing barriers and leveraging facilitators identified in this study can inform the development of effective QI strategies for LMIC EUs.