TABLE 2.

Summary of Key Factors That Facilitated Change in Quality of Care

Participatory ethos and involvement of hospital managers and district health personnel	A participatory approach motivated and enabled staff to implement WHO guidelines, build training teams for rollout, establish standards, and set expectations for improved quality of care.
Data gathering for action and advocacy	Reporting of CFRs at ward and national levels aided monitoring of progress and problem solving. Operational research led to advocacy for guideline adoption and wider actions.
Building of local capacity for sustainability	Collaborations helped build specialist teams to improve staff competencies. Capacity building took many years due to lack of skilled and experienced trainers. eLearning offered an opportunity to build local capacity quickly.
Induction of incoming doctors and nurses	In-service training of new staff and those on rotation was essential to deal with inadequacies in pre-service medical and nurse training.
Triage and emergency care	Triage and timely treatment reduced early deaths. Emergency care was adjusted to allow for the physiological/metabolic changes that exist in SAM.
Supervision, leadership, teamwork, and post-training support	Supportive supervision on the ward, post-training mentoring of staff, good leadership, and teamwork built confidence, raised morale and job satisfaction, and helped sustain improved quality of care.
Keeping it short and simple	Identifying memorable key messages aided guideline adherence. Wall charts served as reminders, and job aids reduced errors.
Political commitment and administrative policies for sustainability	Implementing and sustaining WHO guidelines at scale required ministerial support, regulatory and administrative policies, strategic planning at provincial and district levels, and budgetary provision.
Partnerships	Partnerships and collaborations aided credibility, operational research, capacity building, and technical and financial support. Short term financial support hindered sustainability.

Abbreviations: CFR, case fatality rate; SAM, severe acute malnutrition; WHO, World Health Organization.