Improving antenatal care follow-up documentation through Electronic health Recordings towards enhancing maternal mortality in a primary healthcare Centre

Acknowledgment

Table of contents

Contents

Executive Summary. 5

1.0 Introduction. 7

1.2. Literature review.. 8

1.2.1. The significance of antenatal care. 9

1.2.2. The role of health information systems in enhancing positive health outcomes during antenatal care  11

1.2.3. The challenges associated with paper-based routine health information systems and the need to transit fully to electronic documentation. 12

1.2.4. Challenges in Family Health Care provider (FHC) adoption of e-documentation during antenatal care  13

1.2.5. The importance of antenatal care follow-up documentation through electronic health recordings to improve maternal mortality. 13

1.2.6. Justification for choosing PORT HARCOURT, RIVERS STATE, Nigeria. 14

1.3 The aim and objective of this business proposal 16

1.3.1 The Aim.. 16

1.3.2 The objectives. 16

  1. Project plan. 16

3.1. SWOT.. 17

3.1.1 Table 1. 17

3.1.2. Strengths. 19

3.1.3. Weaknesses. 21

3.1.4. Opportunity. 22

3.1.5 Threats. 23

3.2 PEST Analysis. 24

3.2.1 Political 24

3.2.2. Economic. 25

3.2.3. Social 25

3.2.4 Technology. 25

3.2.5 PEST Tool 26

3.3. Stakeholder Assessment. 26

3.4 Conceptual Framework. 27

Figure 1: The International Association of the Public Participation (IAP2) model for stakeholder engagement 29

Stakeholder Mapping grid. 29

Adapted from International Association of Public Participants and the BSR Stakeholder Mapping. 32

3.5 The Milestone of Implementation. 32

Figure 2: The Plan-Do-Study-Act Cycle. 33

3.6. The Plan-Do-Study-Act Cycle. 33

3.6. 1 Plan Strategy. 33

3.6.2 Developing Test Strategy. 34

3.6.3 Monitor strategy. 34

3.6.4 Reassessing and responding. 35

  1. Financial cost. 35

4.1 Commentary and Justification. 37

4.2 Ethical consideration. 37

  1. Evaluation Plan. 38
  2. Mainstreaming the project. 39

Project sustenance. 39

Recommendation. 39

  1. Reflection. 40

Figure 3: Discroll’s What Model 41

What?. 41

So what?. 41

Now What?. 41

References. 42

Executive Summary

Traditionally, health care providers were reliant on paper documentation throughout a patient’s treatment plan. So many challenges accompany such an approach entailing inconsistent recording of patient information, missing files, and misplaced patient notes. Such gaps contributed to poor patient care outcomes because physicians would find it difficult to link a patient’s history to the current diagnosis and treatment plan.  With growing technological advancements, E-documentation has increasingly replaced paper-based documentation. However, this is not ruled out possible flaws with e-documentation; instead, it situates it as a better option that addresses a vast array of challenges with the traditional approach. Without adequate information on the vulnerable populations, particularly in developing nations, mortality rates from preventable complications become a familiar occurrence. This is true for pregnant mothers seeking antenatal care in Port Harcourt, Nigeria.  To this end, the business proposal focuses on improving electronic health recording to enhance access to optimal antenatal care at Port Harcourt, Nigeria.

Glossary of terms

WB= World Bank

WHO= World Health Organization

USAID= United States Agency of International Development

FHC= Family Health Care

TCC= Digital Targeted Client Communication

CASP= Critical Appraisal Skills Program

MMR=Maternal Mortality Rates

MDG=Millennium development goals

IT= Information Technology

EHR=Electronic Health Recording

1.0 Introduction

1.2. Literature review

The business proposal employs a desk-based systematized review of academic literature as a research method. As for this business proposal, the researcher will use evidence-based reviews through qualitative and quantitative studies, gaining insights on the contribution of other authors on the topic area. The systematic review allows the researcher to employ precise methods to gather and assess other research results, leading to robust and reliable assimilation of evidence, which invariably leads to a reliable conclusion. According to Siddaway et al. (2019), the process of systematic research entails a comprehensive search to locate all relevant published and unpublished work on a topic; systematic integration of search results, providing grounds to critique the extent, nature, and quality of evidence concerning the research question. The author synthesizes studies, drawing broad theoretical conclusions concerning the implication of the existing literature while at the same time linking theory to evidence and vice versa. The research in this business proposal will plan, conduct, organize and present a systematic review of qualitative (meta-synthesis, narrative review) and quantitative (meta-analysis) information. The systematic review seeks to answer the research questions:

  1. What is the significance of antenatal care?
  2. What is the impact of electronic antenatal care documentation on mortality rates compared to paper-based records?
  3. What are the challenges associated with the adoption of electronic documentation in health care settings?
  4. What is the impact of introducing electronic systems in addressing gaps and complexities of antenatal care documentation in existing paper documentation practices, mainly in the follow-up, towards reducing maternal mortality?

The literature review focuses on practices in Nigeria, Africa, and elsewhere across the globe, providing the author with a vast array of comparative literature towards identifying points of convergence and deviations. Such a trajectory will help the author to make an informed conclusion and recommendations on the topic area. The research goes through Locate, the school’s digital college library, to access a vast array of the systematized literature searches relevant to the topic of interest. Using the EBSCO host database will be instrumental in the search because it contains diverse user-friendly literature with inbuilt search functions, eliminating duplicates. The author will use the Boolean operator as the core search function, with the first essential search being: be “maternal mortality” AND “antenatal care” OR “prenatal care,” AND “Health documentation” OR recording.” A different search will highlight critical words such as “electronic medical recording” OR “Handheld” AND “Africa” OR “Nigeria” due to the geographic location of the proposed organization. Databases like CINAHL, which shows literature from thousands of health and worldwide biomedical journals, AMED, MEDLINE, PUBMED, AJOL, SCIENCE DIRECT, APA PsycINFO will be navigated and a hand search through GOOGLE SCHOLAR showing databases like African journals, BMJ journal, and Science Direct. The author will restrict the search to the last 10years, which would be insightful towards understanding the use of paper documentation and complexities surrounding the inception of electronic antenatal care follow-up documentation. The researcher will use the truncation technique to broaden the search results.

The author will achieve citation tracking through peer-reviewed articles and journals from referenced materials, broadening the literature search for a robust and authentic data gathering for the systematized literature review.

The use of critical appraisal tools like CASP and JBI would help the researcher establish rigor of the systematic review, demonstrating the relevance of the selected literature to the business proposal.

Exclusion criteria would be papers not written in the English language, Non-full-text papers, Papers published before 2011, Ethically flawed papers as measured by appropriate CASP/analysis tools. The inclusion criteria will factor in research that is relevant to the topic area, a study published after 2011, Grey literature (which includes documents, reports, working papers), English written full-text papers, Quantitative and qualitative data. Data analysis will be done using the narrative method for literature evaluation, gaining more insight into the structure of the qualitative and quantitative studies. Tools like READER will further triage the literature review search and PICO to minimize errors within my search terms with a reflective journal utilized to reduce bias and enhance the rigor of the processes through metanalysis. Tracking the search history depicting the flow of information through the phases involved in the review will be done through the preferred reporting items for systematic reviews and meta-analyses criteria (PRISMA). A PRISMA tool is attached as a word document to this paper.

 1.2.1. The significance of antenatal care

The rate of pregnancy-related preventable morbidity and mortality remains persistently high. In his research, Abebe et al. (2019) argue that almost 99% of maternal deaths happen in developing nations. According to WHO (2016) report, there has been substantial progress in minimizing such rates; however, countries across the globe need to consolidate and increase such advances by expanding their agendas beyond survival and maximizing their populations’ health and potential. The WHO wants a world where all pregnant women access quality care. Within the axis of reproductive health care, antenatal care offers a platform for crucial health care functions, entailing but not limited to health promotion, screening, diagnostic care, and disease prevention.

Consequently, research establishes that antenatal care can save a life (Mbuagbaw et al., 2014). With antenatal care, nurses secure the opportunity to communicate and support pregnant women, their families, and communities (Asim et al., 2017). The process of achieving such an end requires proper documentation, enhancing the provider’s ability to address psychological, biomedical, socio-cultural, and behavioral issues (Patel et al., 2016). During antenatal care, the support and communication functions are instrumental in saving lives while simultaneously improving lives, health care utilization, and quality of care.

A baby’s growth and development in the womb are highly dependent on the health of future generations. Therefore, good antenatal care is crucial for individuals and future generations (Barker et al., 2013), as the mother’s health is also a factor of good antenatal care. However, de Graaf et al. (2013) posits that significant disparities exist in antenatal care across countries, cities, and population groups’ health challenges, including fetal restrictions, prematurity, and asphyxia. Access to antenatal care from early pregnancy helps prevent these anticipated occurrences, boosting the provider’s ability to respond. Furthermore, access to antenatal care also allows nurses and other care providers to intervene and react to some changeable lifestyle risks such as alcohol consumption, smoking, drug abuse, malnutrition, inadequate folic acid intake, and occupational exposures (Woldeyohannes & Modiba, 2020). Optimal antenatal care requires health care professionals to have a greater awareness of pregnant women’s personal and community life, such as domestic violence and social life deprivation. Provision of services must be multi-professional to facilitate a multifaceted approach to care that covers medical and social issues (Beeckman et al., 2012). Antenatal care offers pregnant women the opportunity to acquire knowledge concerning pregnancy and the health considerations they should embark on during this period because substandard antenatal care directly links to adverse maternal outcomes (Salman Hassan & A. Omer, 2020). With antenatal care, women have access to advise, nutrition education, reassurance, danger signs of pregnancy, and detection of issues that expose women to high risks (Mohammed & Isa, 2020). That is why there is a critical need for robust patient data, held through efficient e-documentation, to allow for a nearly flawless, data-based follow-up, which enables health care providers to produce positive health outcomes for pregnant mothers.

 

 

1.2.2. The role of health information systems in enhancing positive health outcomes during antenatal care

The health information system, first of all, deals with collecting data from the health sector and other health-related sectors. Using robust health information systems is key to enhancing patient health outcomes (Davidson et al., 2019). However, the prevalence of substantial gaps in the reliability, timelessness, and efficiency of data collection, analysis, and use in different nations, hampers informed decision-making processes across health systems (Lindberg et al., 2019). At times, inefficient and uncoordinated data processing and management characterize the health systems (Lopetegui et al., 2013). Such a scenario exposes health care providers to the challenge of repeatedly collecting, compiling, and reporting redundant health data. This shortens their time on one-to-one direct patient care, resulting in a neglected patient and an overworked staff. The implementation of health information technologies can significantly impact care practitioners’ workflow and clinical work processes. Existing literature, particularly from developed nations, indicates that timely access to relevant health information is because of the use of electronic health information systems (Lindberg et al., 2019). Consequently, there is limited evidence on the impact of electronic health information systems on workflow or efficiency in developing nations; therefore, providers in developing countries can benefit from enhanced efficiency of health information management (Lindberg et al., 2019). Hence, it remains critical to examine and understand the challenges that providers working in settings with fewer electronic health systems face, as health care documentation is an indicator of the quality of antenatal care delivery. Nurses and the administrative staff responsible should complete such documentation at the highest standards, ensuring the efficiency and reliability of the health care services. The policies and actions targeting quality documentation must focus on improving administrative and nursing competencies, knowledge, practice in the nursing process while at the same time promoting a conducive work environment and nursing workload (Lindberg et al., 2019). This is instrumental because it reduces nurses’ workload, facilitating efficiency and reducing the possibility of stress among staff, especially the nursing fraternity.

1.2.3. The challenges associated with paper-based routine health information systems and the need to transit fully to electronic documentation

Paper-based health information systems pose a cascade of challenges to health organizations. There is frequent repetitive data entry in facilities utilizing paper-based information systems, making maternal and child health providers spend more time maintaining multiple files and client registers (Joukes et al., 2019). Such challenges prompt the need for the implementation of electronic registries, which allows providers to enter client-level data at the point of care while providing a platform for supporting diverse digital health interventions that take shape through documented clinical information, encompassing but not limited to, automated public health report and guideline-based clinical decision support (Hawley et al., 2014). Paper-based records are labor-intensive, and given that effective care is a factor of adequate information, full utilization of e-documentation in the family healthcare center (FHC) enhances legibility and accessibility (Nguyen, Bellucci, & Nguyen, 2014. The health profession advocates transforming data into information and knowledge towards improving health communication, justifying the development of e-health information systems.

E-documentation enhances health care providers’ ability to improve patient safety, access to health care information, optimal use of resources, and improving communication with patients and colleagues (Secginli, Erdogan, & Monsen, 2014). The electronic documentation process enhances data quality by incorporating content, documentation process, and structure. The aspect of content guarantees completeness and accuracy of the data that reflect the actual reality (Wang et al., 2013). The documentation process ensures the entirety of a patient’s data and the regularity of the patient’s records (SH et al., 2016). The structure aspect entails the physical presentation, which captures the completeness and legibility of a patient’s information. Research recommends the implementation of EHRs towards improving documentation instead of paper-based records because the latter allows for greater accuracy and enhances interdisciplinary collaboration among health care providers (Collins et al., 2013). Although electronic documentation has its challenges, it provides a better platform to strengthen health care, filling many gaps from paper-based records.

 1.2.4. Challenges in Family Health Care provider (FHC) adoption of e-documentation during antenatal care

Most developing nations are resource-constrained, impacting the level of IT implementation. For instance, similar to hospitals in rural settings, Family Healthcare Centers face limited finances, inadequate IT infrastructure, trained staff, and increased workload due to understaffing, which inadvertently influence providers’ attitudes and adoption levels. Mensah et al.’s (2015) study in two developing nations, Ghana and Tanzania, reveals that upgrading from manual paper entry to electronic systems enhances efficiency in care systems during antenatal care.

However, the negative attitude among providers who believe that introducing new technologies may lengthen the amount of time they require to carry out routine activities hinders the adoption rate. This challenge requires adequate training to raise awareness among health care providers. A mandatory data entry requirement may help the health care leaders ensure health care providers adhere to all set procedures ensuring standard decision making that is responsive to individual patient needs (Chukwu, 2017). Identifying challenges facing poor electronic documentation is critical in understanding the factors that may hinder the implementation process.

 

1.2.5. The importance of antenatal care follow-up documentation through electronic health recordings to improve maternal mortality

With developing nations showing low effective antenatal care, the need for innovative approaches during follow-up remains critical. Creative, high-quality interventions are essential towards achieving Universal Health Coverage in maternal and child health care and reaching Sustainable Development Goals. The use of digital health systems boosts a nation’s ability to improve health care systems (Venkateswaran et al., 2018). For example, Antenatal E-registries help providers systematically collect and manage data, an entry point for preventive, curative, and promotive health services (Rurangirwa et al., 2018). Against this backdrop, and as of 2015, a report by different organizations, which include: The World Bank (WB), WHO, and USAID, highlighted strategies for enhancing data collection, analysis, access, and use. The report indicates that the lack of adequate, timely, and accurate maternal and child health data limits a nation’s ability to measure progress in reducing maternal and child deaths (Myhre et al., 2016). Efficient systems containing patient-level data and mobile technologies are gaining popularity across the globe, providing opportunities to support, involve and influence the behavior of providers and patients.

With optimal documentation, health care providers can assess and adjust their performances, providing grounds for the quality of the care they deliver. For instance, Digital Targeted Client Communication (TCC) employs data, entailing demographic characteristics and health status, creating communications responsive to patient needs, mainly when good-quality individual-level information is available. Health care providers utilize Short Message Service (SMS) as a medium to deliver TCC interventions (Bogale et al., 2020). Customizing the message to suit the health needs of individual patients requires robust and up-to-date documentation, an end that is only possible with electronic documentation (Swift, 2018). An electronically stored data can help tailor appointment reminders either singly or coupled with generic health promotion messages that positively impact people’s knowledge, attitudes, and health literacy, improving health behavior and consumption of health care services (Mørkrid et al., 2021). Therefore, digital innovations add value to investments in e-registries. Also, the use of customized checklists of care and decision support driven by the point of is data entry into e-Registry for maternal and child health can enhance health care providers’ compliance with established best-practice clinical and public health guidelines (Venkateswaran et al., 2018). The use of checklists and clinical decision support for providers are tools that boost health care delivery, allowing for the standardization of decisions across the continuum of health care.

With interactive checklists on electronic platforms, providers have access to decision and guideline support that takes shape through structured data entry. Compared to static indexes, interactive lists are advantageous in providing customized case-based management suggestions. Therefore, with an online data entry, providers have access to a centralized electronic registry, which supports the delivery of quality care and patient-centered continuity across the health system. According to Myhre et al. (2016), e-Registries for maternal and child programs offer a unique opportunity due to their ability to support clinical and public health decision-making, enhance health care coverage, and improve health outcomes by availing individual data along the continuum of care. With adequate data, providers can pinpoint where, when, and why pregnant women encounter health problems.

 

1.2.6. Justification for choosing PORT HARCOURT, RIVERS STATE, Nigeria

Maternal deaths are a global health problem. According to WHO, about 830 women die daily from preventable causes linked to pregnancy and childbirth. Such trend corresponds to similar statistics of 2015, which indicates that an estimated 303,000 maternal deaths occurred globally, with low to middle-income countries accounting for 99% (Oyeneyin et al., 2019). Of these numbers, 99% of the cases occur in developing nations (Olonade et al., 2019), with Nigeria owning 14%. As a social indicator, maternal and infant mortality rates measure a country’s development; and the issue is of great concern in the Nigerian context. Similar to the UN Millennium Development Goals (MDGs) of 2015, the Sustainable Development Goals (SDGs)had 17 targets, reducing global maternal mortality to less than 70 deaths per 100 000 live births by 2030 being a priority. Also, Shoo et al. (2017) illustrate how the “aim of the Millennium Development Goal 5 (MDG5) was to reduce the MMR by 75 percent between 1990 and 2015, of which only 43.9 percent has been realized”.  Despite the efforts to reduce mortality rates through improving the health of pregnant and maternal mothers and child death by 2030, global commitments are yet to realize substantial gains (Tok et al., 2017). This is because the death of women due to pregnancy-related complications has been on the rise in most sub-Saharan African countries (Gonzalez & Ren, 2017). Statistics indicate that Nigerian women are 500 times more likely to die in childbirth than their counterparts in developed nations (Okonofua et al., 2019). Also, Nigeria ranks second behind India in the global maternal incident rate and the worst in the continent. Nigeria’s maternal mortality stands at 545 per 100,000 births (Olanrewaju et al., 2020). Such high prevalence rates in maternal mortality in Nigeria are worrying, prompting the need to identify strategies that can reverse the trend.

Following the above disturbing statistics, government and other stakeholders should come together to address the causative factors. Given the vast benefits that accompany electronic documentation in healthcare, this business proposal, therefore, aims to improve its use in primary healthcare centers. The author engages project management provisions to shape the business proposal, presenting a precise formula of bringing relevant stakeholders together, soliciting adequate resources that can help reduce the prevalence of pregnant women’s mortality rates.

Antenatal care is a vital element of maternal health that determines pregnancy outcomes. For example, all stages of pregnancy require optimal planning and attention to avoid pregnancy complications during and after birth. Such an end is not achievable unless health providers have access to comprehensive patient data, which allows them to connect all the dots. The business proposal to fully utilize e-documentation promotes maternal health, thus, reducing maternal mortality. Over 70% of Maternal deaths in Nigeria are a factor of pregnancy difficulties associated with hemorrhage, infection, hypertensive behavior, and obstructed labor (Muftau Adesina & Adegboye, 2020). Such difficulties are preventable with access to adequate patient data.

Concisely, the literature review reveals increasing mortality rates among pregnant mothers in developing nations. Nigeria presents many such statistics, prompting the need to introduce approaches that can reverse the trend. The electronic documentation process, which is part of the e-health plans, plays a crucial role in helping providers connect dots during antenatal care visitations, enhancing their decision-making process (Wills et al., 2012). Underutilization of antennal care harbors adverse effects on the mother and the child, and the lack of adequate documentation is needed (Mekonnen, 2021). The introduction of the electronic documentation process sidesteps the challenges that accompany the use of handheld records, enhancing health care providers’ ability to develop individual patient responsive treatment plans while at the same time facilitating interprofessional collaboration, which is critical for optimal antenatal care. Stakeholder collaboration in Nigeria to enable e-documentation would help reverse the current mortality death rates in pregnant women.

1.3 The aim and objective of this business proposal

1.3.1 The Aim

To improve antenatal care follow-up documentation through Electronic health Recordings towards enhancing maternal mortality in a primary healthcare Centre in Port Harcourt, Nigeria.

1.3.2 The objectives

  1. I) to employ project management tools to articulate stakeholder management and resource utilization towards ensuring a 99% utilization of electronic health recordings during antenatal care follow-up in Port Harcourt, Nigeria, by the end of the year 2022.

II). To enhance awareness on the importance of electronic documentation in antennal care among diverse stakeholders, soliciting their support to facilitate successful project implementation that will enhance Family health care nurses’ buy-in towards reducing antenatal mortality by 60% in Port Harcourt, Nigeria.

3. Project plan

Evidence-based antenatal care enhances health care facilities’ capacity to reduce adverse health outcomes during pregnancy. Optimal utilization of electronic health recordings enhances e-documentation, allowing nurses to comprehensively capture patient information from screening to diagnosis, allowing them to arrest potentially preventable complications (Doubova et al., 2014).  Despite electronic health recording infrastructure in Port Harcourt, Nigeria health care facilities, Family health care practitioners underutilize it. Often, they use monthly record sheets and ad hoc electronic systems, which segments a patient’s information, making it a challenge to identify emerging antennal care complications while at the same time limiting collaboration between different health care practitioners. System interruptions and flaws in ERP design are technical barriers that hinder quick navigation from one application to another, demotivating the family health care nurses from registering all the information (Adler-Milstein et al., 2020). The system cannot lock or warn against implausible data. Such limitation informs this business proposal, arguing that improving Electronic Health Systems in the target region would sidestep such challenges, ensuring nurses capture all the information about patients seeking antenatal care services (Cline, 2020). The business proposal suggests that full utilization of e-documentation will facilitate information exchange between family health care practitioners, patients, and other health care specialists.

The author utilizes SWOT and PEST tools to understand the strengths, weaknesses, opportunities, and threats that the e-documentation faces while at the same time analyzing the political, Economic, Social, Technological, Legal, and environmental aspects that may influence its implementation.

3.1. SWOT

3.1.1 Table 1

Strengths

·         Ease of access to patient data enhancing sharing among health care providers

·         Accurately stored data reduces the possibility of medical errors.

·         The system reduces duplicate testing during screening, diagnosis, and treatment, achieving integrity.

·         The use of electronic health systems allows the exchange of information, access to accurate records of services FHC nurses offer, practitioner participation in medical care, and the ability of the e-system to analyze and interpret data provides a platform of training for physicians and other health care providers and access to different systems.

Weaknesses

·         Inadequate training and education on health practitioners

·         Insufficient staff numbers may counteract the gains from an effective e-documentation system

·         The old erroneous or missing data may affect the effectiveness of the EHR system

Opportunity

·         With training, staffing working at Port Harcourt facilities will develop a culture of e-recording.

·          As the nation’s GDP grows, the government may offer a progressive budget towards supporting technological changes.

·         Stakeholder buy-in to expand the program

Threat

·         A knowledge gap may arise if new staff members join a health facility at Port Harcourt and fail to undergo the necessary training.

·         Misuse of patient data may expose the health facilities to legal battles.

·         Possible resistance from Family Health Practitioner who are used to traditional documentation

3.1.2. Strengths

The implementation of e-documentation has several strengths. Firstly, the project acknowledges that medical errors can occur due to missing data. Therefore, improving e-documentation offers the Family Health Care nurses access to accurate data, enabling them to connect the dots are make informed decisions (Wu et al., 2019). Donna (2015) supports this position by arguing that e-documentation offers information in formats that are impossible with paper charts. For instance, she posits that care providers can now view and print graphs concerning a patient’s weight, blood pressure, and cholesterol levels. With comprehensive data, the FHC nurses have a rigorous view of patient health, allowing them to offer practical, targeted care that can also help lower office visits (Weberg & Davidson, 2019; Garies et al., 2021). Such an aspect is significant for a patient seeking antenatal care across Port Harcourt, Nigeria, due to the region’s remoteness. Also, comprehensive health records through e-documentation allow for a reliable health system that takes care of preventable ailments, reducing mortality rates among pregnant mothers while enhancing positive patient outcomes and patient satisfaction.

The business proposal posits that electronic documentation enhances collaboration across the health care fraternity. With such a platform, the practitioners can utilize the available information to connect and brainstorm solutions to pregnant mothers presenting with health complaints (White & Danis, 2018). The robust data enables the nurses to trace the origin of a particular complication, arresting the situation before it exacerbates a worse scenario that may culminate into maternal death (Tietze & McBride, 2018; Garies et al., 2021). The presence of electronic data cultivates a culture of connectedness in the interdisciplinary teams through standardization of referral procedures and communication while at the same time promoting underutilized services to foster flourishing and sustainable collaboration (Hong et al., 2015). Such practice within the antenatal care in the Port Harcourt area provides room for improved health care, reducing maternal deaths.

The business proposal provisions to implement e-documentation improvements acknowledges that the traditional manual documentation is prone to duplication of effort. Adequate documentation is a component of nursing practice, allowing for accurate communication of nursing actions and patient outcomes.  In their research comparing paper-based and e-documentation, Akhu-Zaheya (2018) reveals that both approaches harbor drawbacks concerning process, structure, and content.  For example, the lack of data consistency makes it a challenge for the health practitioners to trace the results of the previous testing, forcing them to repeat a process. The duplication of testing during screening, diagnosis, and treatment takes away the health care provider’s time, limiting the number of patients they can see in a day. This may lengthen the time for accessing care, discouraging some of the patients from coming back. With antenatal care playing a critical role in pregnant mothers’ health and their child, skipping antenatal clinics compromises such provisions (Meehan, 2020). However, Witkowski et al. (2021) note a substantial improvement in documentation with EMR implementation while highlighting the need for hospital administrators to improve identifiable gaps consistently. Improving e-documentation at the Port Harcourt will sidestep the identified challenges, reducing mortality rates among the target population.

3.1.3. Weaknesses

Improving e-documentation cannot succeed without a positive attitude, optimal knowledge, and skills of the Family Health care nurses.  According to The Royal College of Nursing (2014) report, only two-thirds of nurses have received training on information technology. Such statistics indicate a nursing skill and knowledge gap that may negatively impact their attitude on using electronic health systems. The lack of training and education for FHC nurses at Port Harcourt limits their ability to leverage improvements in e-document to advance antenatal care, adversely affecting the implementation of the business proposal provisions.

Nurse shortages are commonplace across the globe. The Port Harcourt area faces a similar predicament (Okoroafor et al., 2019). Nursing shortages may impact the implementation process of the e-documentation project, limiting the number of patients they can attend to in a day. This compromises the gains from the improved e-document because the long queues expose the nurses to workload stress, adversely affecting patient outcomes (Yahya Muabbar & Zayyan Alsharqi, 2020). Haddad et al. (2020) argue that nurse shortage contributes to higher medical errors, mortality, and morbidity. Therefore, unless staffing ratios improve, the e-documentation proposed improvements may not fully realize the anticipated gains.

The improvement in e-documentation cannot be effective without a rigorous exercise that corrects past and current health care data gaps. Ajobo et al. (2020) argue that Nigerian health records quality is characterized by incomplete data, untimely data submission, and inconsistencies in data reporting.  According to Charalambous & Goldberg. (2016), complete, accurate, and relevant nursing documentation forms the basis for multidisciplinary collaboration. Jones & Johnstone (2018) support such an analogy by arguing that gaps in client care continuity expose them to the risk of preventable adverse events. The two authors recommend that new methodologies be found to streamline existing documentation to ensure records are complete, timely, and person-centered. The business proposal lacks modalities of providing any missing data in the past patient visits is updated. Such a gap will have a spiral impact on the delivery of antenatal care for repeat patients.

3.1.4. opportunity

The emphasis on creating awareness to improve e-documentation will create a culture that persistently spreads across health facilities in the region. West (2013) supports this position by arguing that reinforcing a culture of high-quality care in medical services underpins the need to understand the core elements that each level of a health care system must nurture. Following such a narrative, the business proposal anticipates that the facility health care system at all levels at Port Harcourt can leverage this opportunity to reinforce the gains both in the short term and long term. The health care facility leadership should take the proposed improvements to the next level by avoiding treating the opportunity as a one-off event.

According to the National Health Act, the Nigerian government provides for a Basic Health Care Provision Fund. The government appropriates this funding through the Federal Government Annual Grant. It caps it at not less than one percent of its Consolidated Revenue Fund or in combination with third-party funding sources (Enabulele & Enabulele, 2016). This is an opportunity the business proposal can tap in the future, allowing policymakers in the region to leverage future growth in national GDP to advocate and solicit funds that support continuous system improvements. According to Walsh University (2018), health care is ever-evolving, challenging health care practitioners to consistently learn how to use emerging technologies and integrate such into their practice. The business proposal situates itself within such an argument by acknowledging the dynamism that accompanies any technological interventions. By tapping on available funding opportunities, the health care players at Port Harcourt can assess and progressively improve the existing technical platform, ultimately fulfilling antenatal patients’ needs and expectations.

The program can tap on stakeholder buy-in in the future to expand the e-documentation. Hospital leadership at the Port Harcourt region can invite relevant stakeholders and bring them on board towards making the program better in the future. According to (Wolf & Toebes, 2016) the international human rights allows states to freely choose any mix of private and public collaboration in the health sector. Given that non-state actors harbor a tentative and progressive obligation in the health sectors, the business proposal anticipates tapping their input. They will include nongovernmental organizations working in the health sector, private entities interested in corporate social responsibility in the health settings, and international bodies such as the World Health Organization, World Bank, and the European Union to advance its objectives.

3.1.5 Threats

Hospital staff are principal stakeholders who drive the provisions of this business proposal home. According to Malhi (2013), successful entities sustain a culture that creates a work environment that supports long-lasting quality improvement (Smakic, 2012). Despite the proposal advocating for rigorous training to enhance the current staff awareness on the importance of e-documentation and equip them with pre-requisite skills to improve their capacity to interact with the system, incoming staff members after the project implementation may not receive similar training, compromising the projects ability to achieve its objectives in the long run fully. Therefore, staff transfers and intakes may segment the process, watering down the already made gains on improved e-documentation.

Electronic health recording systems are subject to data breaches, either internally or externally. Seh (2020) argues that between 2005 to 2019, 249.09 million individuals were affected by health care data breaches.  The report cites that unauthorized access leads to sensitive health care information exposure, resulting in loss, theft, or disclosure. Therefore, unethical practices or technical breaches may expose the organization to legal tussle (Floridi, 2019). Therefore, training users on this topic while providing clear guidelines and standards that guide nurse interactions with patient data would be critical to overcome the threat.

Possible resistance from health staff members may cause implementation delays. According to Mares (2018), implementation of change in health care elicits objections on health staff. The health personnel who believe in the old system feel insecure with the new processes. This requires utilizing project management tools to ensure a successful change process, ensuring that the improvement process does not exceed the set deadlines.

3.2 PEST Analysis

3.2.1 Political

The country’s constitution provides for three tiers of government, entailing the federal, semi-autonomous and local government areas. Each of these political units exercises autonomy in resource allocation and utilization. Different states run a ministry of health, and each local government area has a health department. The National Health Policy and the National Health Bill stipulate the responsibilities and roles of each level (WHO, 2017). For example, the local government areas are responsible for funding primary health care (PHC) facilities, the core entry points for health care services. However, the system faces segmentation because of the existence of parastatals and single-disease vertical programs. The federal government offers specialized services at tertiary hospitals. The federal government provides overall stewardship and leadership for health provisions at the tertiary healthcare centers through the Federal Ministry of Health. Also, other state agencies such as the National Primary Health Care Development Agency, the civil service commission, the state hospitals management boards, local government service Commission, to name a few, jointly manage the PHC services (WHO, 2017). According to Stange (2009), health care fragmentation that underlies the ongoing care crisis compromises the implementation of new programs. As a point of concern, the health care system is characterized by vertical and horizontal fragmentation, including the management of PHC facilities, staff funds, and other resources, which would negatively affect the implementation process.

3.2.2. Economic

The economic situation of a nation affects the implementation of health programs. According to Frakt (2018), a link exists between long-run improvements in health and economic growth through enhancing public health infrastructure, better nutrition, and effective medical technology.  With a contracting Gross domestic product (GDP) amidst the backdrop of income inequality of 43.7, Nigeria ranks among the poorest nations in the world. The majority of the population (approximately 70%) lives below the US $ 1 per day (WHO, 2017). The poor economic conditions will negatively affect the improvement of e-documentation in antenatal care at Port Harcourt, Nigeria.

3.2.3. Social

A significant difference exists in the number of women who seek antenatal care between rural and urban dwellers. In Nigeria the ratio is 75% vs 38%, respectively (Fagbamigbe & Idemudia, 2015). Port Harcourt, Nigeria, is the fifth-largest city in Nigeria (Bodo, 2019); hence, the business proposal anticipates the high utilization of improved e-documentation in antenatal care.

3.2.4 Technology

E-documentation is not a new phenomenon in Port Harcourt, Nigeria. The business proposal anticipates tapping on the existing infrastructure to enhance utilization among health care users. The project manager will work with the current health Officer’s Registration Board of Nigeria to implement the improvement program. However, aspects such as power supply, inadequate ICT equipment, and inadequate computer skills among the medical staff may hinder optimal implementation.

3.2.5 PEST Tool

Political The vertical and horizontal healthcare segmentation increases the stakeholder interests that the business proposal must fulfill, comprising the implementation process
Economic The poor economic conditions limit resource availability, prompting the need to engage non-public stakeholders for resource support
Social Port Harcourt is an urbanized region, the uptake of antenatal care remains high, providing conducive grounds for the business proposal to realize set objectives
Technological The existing infrastructure will support the implementation process.

3.3. Stakeholder Assessment

The stakeholder assessment is a critical phase in the implementation process of a project. It helps identify the potential recipients of information, informing the plan for disseminating the data. Akwanalo (2019) supports this analogy by arguing that early stakeholder identification and engagement eases the explanation of project objectives, builds consensus, and shapes the implementation process. Through stakeholder assessment, the author of the business proposal will generate information, which will be insightful for subsequent process analyses, informing the development of an action plan to enhance support for a reform process. Also, the analyses serve as a participatory and consensus-building process. With the stakeholder assessment, the business proposal will gain grounds for developing an action plan, ultimately identifying concrete actions and behind-the-scenes activities that the steering committee will implement to enhance stakeholder support (Franklin, 2020). The results of the stakeholder assessment will help situate open discussions with diverse stakeholders towards consensus-building (Franklin, 2020). This would allow stakeholders to position themselves within the big picture, encouraging discussion towards addressing opposition concerns (Schemeer, 2021). Through stakeholder analysis, the business proposal will build a consensus among all stakeholders regarding the purpose of the target users and the anticipated results.

3.4 Conceptual Framework

The business proposal employs the IAP2 framework. This model helps clarify the roles of different stakeholders in the planning and decision-making while noting their influence over the implementation process. As of this tool, five levels of stakeholder engagement ranging from inform, consult, involve, collaborate, and empower come in handy to guide the process. Different levels articulate the engagement goal while promising each stakeholder from the vantage point of the business proposal. The informed level of the engagement allows the author of this business proposal to offer the stakeholders honest, balanced, and objective information, giving them a greater understanding of the importance of e-documentation in antenatal care (Akwanalo et al., 2019). This level informs the business proposal success due to adequately informed stakeholders reaching their conclusions as to the appropriateness of the proposal and the adequacy of the solutions presented beforehand by the project team. The consult level allows for stakeholder feedback on the decision and alternatives. The project team will listen and acknowledge the stakeholder concerns and aspirations; ultimately, incorporate stakeholder feedback into the planned improvements.  The project team will directly engage with the stakeholders to ensure their concerns and aspirations are consistently addressed at the involved level. The collaboration level allows the project team to partner and share diverse aspects of the project with the stakeholders. The stakeholders at this level can participate in the decision-making process while developing alternatives where appropriate (Akwanalo et al., 2019). The empower level situates the final decision at the stakeholder’s hands by articulating varying degrees of engagement ranging from low to high.

Figure 1: The International Association of the Public Participation (IAP2) model for stakeholder engagement

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7250005/#:~:text=Stakeholder%20engagement

 

Stakeholder Mapping grid

Name of the stakeholder Contact person Level of influence Type of Influence Priority of engagement Role and kind of engagement
The Federal Ministry of Health Health Minister of permanent Secretary High ·         Guides the implementation process

·         Issues policy guidelines to cultivate correspondence with National Health Act stipulations

Important (Inform, collaborate, consult) ·         Steering the implementation process

·         Feedback loop

·         Continuous engagement

Federal Ministry of

Finance

Finance minister/ permanent secretary High ·         Guides the Financial outlay and determines the allocation procedures Important (Inform, collaborate) Through the Federal Ministry of Health, Nigeria
LGA

health departments

Chairman High ·         Policy direction support

·         Budgetary support

Important (Inform, collaborate Through the Federal Ministry of Health, Nigeria
Primary Health Care Board Executive director High ·         Budgetary support

·         Policy influence

·         Adoption of the implementation process

Important (Inform, involve, and collaborate Continuous engagement
Local Government Service Commission Chief Executive Officer High ·         Budget support

·         Policy influence

Important (Inform, collaborate Through the Federal Ministry of Health, Nigeria
nongovernmental

organizations

Program Director High ·         Resource influence Important (Inform, collaborate, involve Continuous engagement
Health Record Officers Registration Board of Nigeria Registrar health Records High ·         Dissemination

·         Promote the improvement plan

Important (Inform, collaborate, involve) Offer support through the implementation process while ensuring all training needs are met.
Professional Bodies The Chairman of Board Moderate ·         Dissemination

·         Implementation process influence

High (inform, involve, consult ·         Early engagement

·         Promotion through online communities and society conferences

Adapted from International Association of Public Participants and the BSR Stakeholder Mapping.

3.5 The Milestone of Implementation

Quality improvement in health care is core to safe, timely, effective, efficient, cost-effective, and equitable care delivery. Reed & Card (2016) support using the Plan, Do, Study, Act (PDSA) cycle as a quality improvement tool that helps situate change while translating ideas and intentions into action. The project team will employ the PSDA cycle, which offers a systematic series of steps to gain meaningful learning and knowledge for persistent process improvement. As of this model, interdependent and interacting elements characterize micro-systems and systems; hence, any changes in the system produce a significant impact on the entire system. In the context of this business proposal, the author utilizes the PDSA approach to learn whether the intervention works in health care facilities in Port Harcourt, Nigeria, making necessary adjustments to enhance the chances of delivering and sustaining e-documentation improvement in antenatal care. Consequently, using a work breakdown structure (WBS) will be instrumental in breaking the tasks, deliverables, and activities relevant to the business proposal into manageable portions (Van Aartsengel & Kurtoglu, 2013). The WBS will allow the project team to understand the requirements they must undertake to get desired results

Figure 2: The Plan-Do-Study-Act Cycle

Source:  https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html

 

3.6. The Plan-Do-Study-Act Cycle

3.6. 1 Plan Strategy

This phase will entail the creation of a conducive environment that sets the foundation, helping the project team elicit the support of all staff members working in the antenatal care unit. The project team will train the health care workers, highlighting the importance of e-documentation in enhancing antenatal care. The team will mobilize the Family health care nurses working within the Port Harcourt region while creating an environment for peer-to-peer communication, helping them understand why the change is critical. In this stage, open communication will be vital to ensure the project team addresses emerging concerns.

The project team will highlight the missing links in the current e-documentation while noting possible points of improvement. The project team will engage the family healthcare providers to solicit their buy-in at every point of progress. This approach restricts resistance from the target audience, ensuring they are up to speed with the set goals.

3.6.2 Developing Test Strategy

The project team will engage the Family health care nurses to discuss the key aspects that will benchmark effective e-documentation. The improved system will utilize different components that ward the users of incomplete records. For instance, the system must capture any existing pregnancy complications, pre-existing conditions that worsen during the pregnancy, and the impact of unhealthy lifestyles. According to WHO (2021), quality health care depends on pregnant women’s support services during the antenatal period. This phase of the milestone implementation recognizes the contribution of the efficiency of antenatal care, positioning itself to implement changes that support the course.

The project team will also conduct small tests of change to demonstrate to the end user’s applicability of the improved system. The project team will expose the Family health care nurses to practical cases involving visiting patients in antenatal care who will receive services under the improved e-documentation system.

Once the project team steers the pilot testing, it will disseminate the changes across the board. They will encourage open communication to ensure the end-users communicate any barriers they are experiencing, creating grounds to address each challenge.

3.6.3 Monitor strategy

The project team will reinforce the improvements by constantly working with Family health care teams while helping them navigate challenges. This will be critical in ensuring the end-users identify with the improved system. The project team will also monitor progress against criteria, noting any points of deviation and correcting them.

3.6.4 Reassessing and responding

The project team will use the data derived from the previous phase to identify what worked against failures. This will help the team identify reasons for failures, serving as learning points towards improving the exercise in future projects while leveraging the positives to boost the success of similar projects. The team will then spread the successful innovations to all health facilities and invite all stakeholders to witness the exercise.

4. Financial cost

The project requires a robust budget to support the improvement process. The project manager acknowledges the federal government’s financial constraints; hence, it will make concerted efforts to work within a budget. According to Gyan & Ampomah (2016), budget overrides are a possible cause of delay in the project, leading to conflicts with stakeholders.  Therefore, this approach will be critical to avoid potential stakeholder conflict.

Item Cost (NGN/Annually) Justification
Project team coordinator (Glassdoor, 2021) 2400 The project coordinator will be responsible for ensuring the project activities adhere to the scope and schedule
Training of staff 1,000 Staff will require adequate training to identify with the process
Software improvements (EZDI, 2021) 7,500 The funds will cater for the identified improvement points
Financial advisor (Glassdoor, 2021) 2,200 The individual will guide the projects financial requirements ensuring adherence to set budget
Grants manager (My salary scale, 2021) 1,500 The grants manager will help in writing grant proposals to acquire funds from stakeholders to support the project
Leads software engineer 2,300 The lead software engineer will collaborate with the lead procurement engineer to ensure all software requirements and standards are met.
Leads Procurement Personnel 1,500 The lead procurement personnel will guide the acquisition of a software improvement company.
Total 18,400  

4.1 Commentary and Justification

Pregnant mothers require adequate support to reach antenatal care services for positive health outcomes. With optimal access to antenatal care, expectant mothers can manage complications linked to the pregnancy, pre-existing conditions that worsen during pregnancy, and the impact of poor lifestyles. Improvements in e-documentation help healthcare nurses access critical information necessary to connect dots concerning a patient’s health, detecting any emerging maternal complications (Burch & Sguassero, 2020). Other benefits include facilitating interventions to improve health outcomes and offering grounds to make pregnancy and life a positive life experience while affording those who provide or receive care to learn.

Improved e-documentation offers an evidence-based approach to individualized care. Adequate documentation allows nurses to differentiate between high and low-risk pregnant women, enabling them to identify and institute early interventions that are specific and objective. This avoids antenatal services not supported by evidence, such as routine third-trimester ultrasound examination of the fetus, routine electronic fetal monitoring, or home uterine activity monitoring. Therefore, improving e-documentation will help nurses establish the extent of monitoring and services and save resources that health care facilities would otherwise have used to offer non-evidence-based services (Burch & Sguassero, 2020).  The cost savings can be transferred to other needy cases such as pregnant women with proven complications, major health-related risk factors, and medical conditions, allowing the health care facility to offer affordable quality care.

4.2 Ethical consideration

e-documentation benefits maternal and child health because it enhances quality interventions.  However, offering intensive antenatal care to low-risk pregnant women would be unethical because it leads to the waste of scarce resources that would have otherwise been useful elsewhere.

According to the above analysis, improvements in e-documentation are necessary at the health care facility in Port Harcourt, Nigeria. The facility’s financial status is not adequate, and the funds provided by the government are not enough to cover the implementation of this proposal. Healthcare is financed through tax revenue, donor funding, health insurance, and out-of-pocket payments in the Nigerian context. Notably, the nation’s health expenditure is relatively low compared to other African countries (Eboh et al., 2016). Therefore, the business proposal will not rely on the existing structures to fund the improvement portfolio; instead, it will solicit grants from external stakeholders such as the WHO, WB, and the private sector to realize financial obligations.

 

  1. Evaluation Plan

The project will evaluate the project against the set objectives. According to Hosp (2017), an evaluation plan allows the project team to monitor and assess the project’s success and effectiveness. The project will utilize a formative evaluation plan to evaluate continuing activities, cover phases from development to implementation, and allow the lead personnel from different departments to review the process.

To employ project management tools to articulate stakeholder management and resource utilization towards ensuring a 99% utilization of electronic health recordings during antenatal care follow-up in Port Harcourt, Nigeria, by the end of 2022.  The project will utilize questionnaires to solicit stakeholder feedback, which will be critical in understanding their satisfaction with the project’s progress.

II). To enhance awareness on the importance of electronic documentation in antennal care among diverse stakeholders, soliciting their support to facilitate successful project implementation that will enhance Family health care nurses’ buy-in towards reducing antenatal mortality by 60% in Port Harcourt, Nigeria. The project manager will use a questionnaire to solicit feedback from Family health care nurses, which will help assess their satisfaction levels with the process.

  1. Mainstreaming the project

The project management will benchmark the project progress while noting points of deviation and making the necessary adjustment. For example, if the project team identifies discontent among stakeholders, it will have to revisit the issue and see the root cause of the conflicts. This approach will be necessary because the project is highly dependent on stakeholder support. The strategy corresponds with Wang and Wu’s (2020) assertions that effective conflict management ensures the project team identifies with their causes and impacts and employ principles and models for a resolution to guarantee project success. Effective conflict resolution ensures the project sticks to set deadlines, scope, and budget.

Project sustenance

Erratic power supplies characterize Nigeria’s grid. Therefore, the project team must provide power backups in the facility to ensure continuity in case of blackout (Agbeboaye et al., 2019.  The use of solar panels will offer an environmentally friendly power supply to sidestep this challenge.

Recommendation

The literature review reveals antenatal care as a must-have for all pregnant mothers towards reducing mortality rates among this vulnerable care. Achieving this end requires concerted efforts towards enhancing documentation, ensuring the Family health care nurses tap on the benefits of accessing efficient and quality information. Such settings will allow the practitioners at Port Harcourt, Nigeria, to collaborate towards achieving positive health outcomes.

The PEST analysis reveals that the political, Economic, Social, and Technological aspects are unfavorable for the business proposal implementation. Therefore, the project implementation team will require a robust resource mobilization to fund and shape the identified gaps, ensuring a smooth implementation process.

The SWOT analysis reveals that the business proposal stands a higher chance of success. This is because the identified strengths and opportunities produce grounds for implementing the proposed e-documentation improvements while sidestepping the challenges arising from identified weaknesses and threats. Therefore, the project is a viable one.

  1. Reflection

The reflective exercise will take shape through Discroll’s What Model (1970). The “what,” “So what,” and “Now what” characterize the model, allowing the author to make an all-rounded reflection.

Figure 3: Discroll’s What Model

Source: Models of reflection – Reflective Practice Toolkit – LibGuides at University of Cambridge Subject Libraries

What?

I must acknowledge my struggles with the MSC Global Healthcare Management business proposal. Despite my efforts, I realized that I was always falling behind schedule. My attempt to produce a perfect document that contributed to positive health outcomes among the target population must have contributed to the poor time management.

So what?

After realizing I was falling short of my supervisors’ expectations, I decided to structure my dissertation in different sections outlined in the guideline. My approach corresponds with Naoum’s (2019) assertions that an optimally structured approach to dissertation writing offers students a platform to produce critical work within a deadline. This allowed me to articulate my findings while incorporating project management tools to realize the set proposal objectives. It was only at this point when I made substantive progress.

Now What?

With my experience, I can now use the insights gained from this exercise to articulate patient needs through research and project management tools. With patients in developing countries struggling with access to care, I decided to focus on the impact of improving e-documentation in antenatal care in Port Harcourt, Nigeria. According to Lund et al. (2021), the systematic and transparent use of prior research informs new studies towards answering authors questions in an efficient, valid, and accessible manner (Lund et al., 2021).  I will utilize the knowledge to advance similar projects in the future, advancing the nursing profession’s requirements for producing positive health outcomes among all patients.

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