Cataracts is the leading cause of blindness worldwide; however evidence suggests that up to one in four patients in low-income countries have poor vision after cataract surgery. Obviously this is a major problem as there is little point in a patient spending scarce money and time having surgery if their outcome is likely to be poor.
Improving the quality of cataract surgery is complicated. There is no single thing that can be changed for quality to improve and every hospital has different issues. Any approach to improving quality has to take these issues into account.
The International Centre for Eye Health, part of the London School of Hygiene and Tropical Medicine, with funding from the UK Government, has assessed an approach to improving the quality of cataract surgery in Uganda using mentorship.
Mentorship has been used widely to support individual surgeons to improve their skills, so we decided to assess whether mentorship of a whole hospital could improve the quality of cataract surgery.
We selected two busy eye hospitals in Uganda and arranged for one to have a senior ophthalmologist as a mentor. We provided both hospitals with information about the quality of cataract surgery, which we collected before we started and throughout the year of the study, with regular reports on how they were doing.
We visited each hospital on three occasions to provide both hospitals with recommendations based on their performance. The mentor took part in these visits at the hospital which he was supporting.. In the first six months we asked the mentored hospital to engage with the mentor and tell him what they wanted, in the second six months the mentor was much more proactive with the hospital.
We used a set of different methods, quantitative (ie numbers) and qualitative (ie stories), to explore the impact of the mentor on the hospital.
We found that both hospitals struggled to understand their data on quality and, for a number of reasons, both initially made few changes based on our recommendations. However, in the second six months the mentored hospital made several changes to their service and awareness about the quality of cataract surgery amongst clinical staff increased considerably. In the hospital that was not mentored there were very few changes.
Examples of change in the mentored hospital included the development of a form to record information on cataract surgery and post-operative care. This resulted in an increase in the recording of refraction (testing for spectacles) after surgery from 15 per cent to 60 per cent which meant that more patients were able to see well after their surgery. The hospital also improved the way it measured and recorded visual acuity before and after surgery.
There were some consistent problems. For example; there was a view that this was ‘your’ project and that staff were involved but not responsible for the changes. There was limited understanding in both hospitals about what a high quality service should consist of (‘we did not know we were doing things wrong’) or how to change (‘we knew it wasn’t great but we did not know how to change it’).
The mentor helped the hospital with some specific actions that were widely acknowledged as practical and useful. These changes were reflected in the outcome data. For example, in the mentored hospital the percentage of surgeries with a good outcome improved from 40 per cent at baseline to 60 per cent after the input from the mentor. This was mainly due to changing the way the staff measured and recorded the vision of patients.
The study showed that mentorship has a place in improving the quality of cataract surgery in hospitals in low income countries. But, it needs to be carefully planned, with active involvement of the hospital in the planning stage. The mentor needs to provide clear, easily achievable, low-cost changes and lead hospital staff through them. This has to be part of an on-going commitment by the hospital to improve quality (ie, it cannot be a one-off or time limited exercise).
Rachel Mearkle is a public health registrar at the London School of Hygiene and Tropical Medicine.