From quality measurement to improvement action: A stakeholder-integrated mixed-methods implementation analysis of adult outpatient care in Kenya
DOI:
https://doi.org/10.51867/ajernet.7.4.90Keywords:
Quality improvement, stakeholder participation, outpatient care, mixed methods, implementation science, KenyaAbstract
Quality measurement has limited improvement value when patient, provider and manager evidence is collected without an accountable route to action. This study examined how a Stakeholder-Integrated Quality Measurement-to-Improvement Framework (QMIF) linked role-specific outpatient quality evidence to short-cycle improvement in Kenyan Level IV facilities. A convergent mixed-methods implementation analysis was embedded in a 26-facility non-randomised, non-equivalent pretest-posttest quasi-experiment in Kisumu and Nyeri Counties (13 interventions; 13 comparisons). Baseline was collected on 10-15 April 2026, structured QMIF exposure ran from 15 April to 2 July 2026, and endline was collected on 3-5 July 2026. The longitudinal panel comprised 339 participants (260 patients, 54 providers and 25 managers) and the qualitative strand comprised 84 interviews. Theoretical interpretation was informed by Knowledge-to-Action (KTA), the Consolidated Framework for Implementation Research (CFIR) and RE-AIM. Mixed-effects ANCOVA with a facility random intercept provided baseline-adjusted inferential context for the primary perceived-quality outcome; difference-in-differences (DiD) and Hedges g were supportive. Adjusted effects favoured QMIF for patients (+21.4 percentage-of-maximum-possible [POMP] points; 95% CI 17.8-25.0), providers (+20.4; 16.3-24.6) and managers (+16.1; 11.9-20.4); all p<.001. Corresponding Hedges g values were 1.64, 1.87 and 2.13. Knowledge-attitude-practice (KAP) and reported quality-improvement (QI) action were retained as descriptive implementation indicators: intervention-arm endline KAP was 84.3%, 84.8% and 83.7% for patients, providers and managers, while QI-action POMP was 63.0%, 63.8% and 61.7%, respectively. Framework Method analysis and mixed-methods joint displays suggested a recurrent pathway of measurement, feedback, prioritisation, PDSA action and remeasurement. Sixteen of 18 stakeholder-domain combinations met the study's pragmatic criterion, while provider reliability (3.98/6) and manager appropriateness (3.96/6) remained boundary cases; medicines, diagnostics, staffing, equipment and procurement remained structural constraints. The combined evidence supports a plausible implementation pathway, but formal mediation, moderation and fidelity-outcome analyses were not performed. The study concludes that stakeholder-integrated measurement can support short-cycle outpatient QI while unresolved structural constraints require escalation; it recommends replication with stronger fidelity measurement, objective service indicators, external psychometric validation and longer follow-up.
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References
Abuosi, A. A. (2015). Patients versus healthcare providers' perceptions of quality of care: Establishing the gaps for policy action. Clinical Governance: An International Journal, 20(4), 170-182. https://doi.org/10.1108/CGIJ-03-2015-0010
Bergerum, C., Engström, A. K., Thor, J., & Wolmesjö, M. (2020). Patient involvement in quality improvement-a 'tug of war' or a dialogue in a learning process to improve healthcare? BMC Health Services Research, 20, Article 1115. https://doi.org/10.1186/s12913-020-05970-4
Bombard, Y., Baker, G. R., Orlando, E., et al. (2018). Engaging patients to improve quality of care: A systematic review. Implementation Science, 13, Article 98. https://doi.org/10.1186/s13012-018-0784-z
Cohen, P., Cohen, J., Aiken, L. S., & West, S. G. (1999). The problem of units and the circumstance for POMP. Multivariate Behavioral Research, 34(3), 315-346. https://doi.org/10.1207/S15327906MBR3403_2
Damschroder, L. J., Reardon, C. M., Opra Widerquist, M. A., & Lowery, J. (2022). The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Science, 17, Article 75. https://doi.org/10.1186/s13012-022-01245-0
Des Jarlais, D. C., Lyles, C., Crepaz, N., & TREND Group. (2004). Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: The TREND statement. American Journal of Public Health, 94(3), 361-366. https://doi.org/10.2105/AJPH.94.3.361
Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033
Endalamaw, A., Khatri, R. B., Mengistu, T. S., Erku, D., Wolka, E., Zewdie, A., & Assefa, Y. (2024). A scoping review of continuous quality improvement in healthcare system: Conceptualization, models and tools, barriers and facilitators, and impact. BMC Health Services Research, 24, Article 487. https://doi.org/10.1186/s12913-024-10828-0
Fetters, M. D., Curry, L. A., & Creswell, J. W. (2013). Achieving integration in mixed methods designs-principles and practices. Health Services Research, 48(6 Pt 2), 2134-2156. https://doi.org/10.1111/1475-6773.12117
Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the Framework Method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology, 13, Article 117. https://doi.org/10.1186/1471-2288-13-117
Glasgow, R. E., Harden, S. M., Gaglio, B., et al. (2019). RE-AIM planning and evaluation framework: Adapting to new science and practice with a 20-year review. Frontiers in Public Health, 7, Article 64. https://doi.org/10.3389/fpubh.2019.00064
Graham, I. D., Logan, J., Harrison, M. B., et al. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 26(1), 13-24. https://doi.org/10.1002/chp.47
Hedges, L. V., Tipton, E., Zejnullahi, R., & Diaz, K. G. (2023). Effect sizes in ANCOVA and difference-in-differences designs. British Journal of Mathematical and Statistical Psychology, 76(2), 259-282. https://doi.org/10.1111/bmsp.12296
Karume, A. K., Nyongesa, K., Okutoyi, L., & Kinuthia, J. (2025). Patient's expectations and perceptions on quality of care: An evaluation using SERVQUAL gap in Kenya. PLOS ONE, 20(3), Article e0315910. https://doi.org/10.1371/journal.pone.0315910
Kruk, M. E., Gage, A. D., Arsenault, C., et al. (2018). High-quality health systems in the Sustainable Development Goals era: Time for a revolution. The Lancet Global Health, 6(11), e1196-e1252. https://doi.org/10.1016/S2214-109X(18)30386-3
Leyrat, C., Morgan, K. E., Leurent, B., & Kahan, B. C. (2018). Cluster randomized trials with a small number of clusters: Which analyses should be used? International Journal of Epidemiology, 47(1), 321-331. https://doi.org/10.1093/ije/dyx169
Marx, M., Nitschke, C., Nafula, M., Nangami, M., Brodowski, M., Marx, I., Prytherch, H., Kandie, C., Omogi, I., Paul-Fariborz, F., & Szecsenyi, J. (2018). If you can't measure it-you can't change it: A longitudinal study on improving quality of care in hospitals and health centers in rural Kenya. BMC Health Services Research, 18, Article 246. https://doi.org/10.1186/s12913-018-3052-7
Ministry of Health, Kenya. (2020). Quality of care certification manual for the Kenyan health sector. Government of Kenya. https://medbox.org/document/quality-of-care-certification-manual-for-the-kenyan-health-sector
Ministry of Health, Kenya. (2024). 2024 Kenya health facility assessment: Quality of care and human resources for health report. Government of Kenya. https://www.afro.who.int/countries/kenya/publication/024-kenya-health-facility-assessment-quality-care-and-human-resources-health-report
Mohamoud, G., & Mash, R. (2022). The quality of primary care performance in private sector facilities in Nairobi, Kenya: A cross-sectional descriptive survey. BMC Primary Care, 23, Article 120. https://doi.org/10.1186/s12875-022-01700-3
Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411
Okeny, P. K., Pittalis, C., Brugha, R., & Gajewski, J. (2026). Patient-centred care measurement in sub-Saharan Africa: A scoping review of the evidence (1990-2024). International Health, 18(4), 570-590. https://doi.org/10.1093/inthealth/ihaf139
Okibo, S. S., & Wagude, J. (2026). Influence of management commitment to occupational safety and health-OSH on service delivery in level 4 public hospitals in Kisii County, Kenya. African Journal of Empirical Research, 7(2), 287-299. https://doi.org/10.51867/ajernet.7.2.27
Owuor, V. A., Gachanja, P. M., & Nzau, M. (2026). Enhancing health security system preparedness: The impact of operational practices on medical supply chain resilience in Kenya. African Journal of Empirical Research, 7(3), 661-672. https://doi.org/10.51867/ajernet.7.3.55
Skivington, K., Matthews, L., Simpson, S. A., Craig, P., Baird, J., Blazeby, J. M., et al. (2021). A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. BMJ, 374, Article n2061. https://doi.org/10.1136/bmj.n2061
Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862
World Health Organization. (2025, May 19). Quality health services. https://www.who.int/news-room/fact-sheets/detail/quality-health-services
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