Using Data to Drive Quality Improvement in South Africa

Using Data to Drive Quality Improvement in South Africa

Duke University School of Nursing (DUSON)’s global partnerships offer students and faculty unique opportunities for scholarship, clinical experience, research, and professional growth. Over the last seven years, Associate Research Professor Susan Silva, PhD, who began her pre-retirement in February, has played a key role in a collaboration with the University of KwaZulu-Natal (KZN) School of Nursing and Public Health in Durban, South Africa, studying evidence-based care and planning quality improvement projects.


A biostatistician with methodological and secondary data analysis expertise, Silva has led multiple cohorts of students from the School’s Doctor of Nursing Practice (DNP) Program, as they developed scholarly projects based on data from the electronic data system at Grey’s Hospital in Pietermaritzburg, South Africa.  

Silva joined the initiative under the leadership of Clinical Professor Emerita Katherine Pereira, DNP ’12, MSN ’02, RN, FNP-BC, ADM-BC, FAAN, FAANP, former director of the DNP Program, to help the student cohorts with not only managing and analyzing the large volume of data available, but also with learning how to build clinical practice protocols. The goal of the DNP Program is to help the students develop their clinical scholarship, which includes understanding and promoting evidence-based practices as well as designing and implementing quality improvement initiatives in their clinical settings, Silva said. “The idea is that we are preparing our clinical nurse scholars to be leaders helping make informed decisions as to what are best healthcare practices.” Silva said. “We try to give them that skill set.” 

The province of KZN in South Africa is one of the most impoverished within the country, Silva said, and Grey’s Hospital receives most of the trauma patients from the surrounding rural communities. Most public hospitals in the area do not have an electronic health records system, but a trauma surgeon and his colleagues at Grey’s built a unique hybrid electronic health record system that captures data from patients admitted to the hospital’s general surgery and trauma services. DUSON’s collaboration included Silva taking this large relational database, which was a mixture of quantitative data and clinical notes and making it more manageable and searchable. “I was able to pull together the different fields of information that the students needed to review a case and then quantify the data needed for the planned secondary analysis.

The students then used the analysis findings to propose a nurse-led, culturally-sensitive, quality improvement project to be implemented at Grey’s Hospital by nursing students at the University of KZN.”  Silva’s work with the hospital’s data not only helped collaborators and providers learn more about the relationship between patient characteristics and outcomes at the hospital, but also provided a learning opportunity for students to experience being part of international and interprofessional team-based projects.  

Silva mentored DNP students on different secondary data analysis projects each year, then accompanied each cohort of 2 to 4 students on a three-week trip to present their findings and quality improvement project design. “Part of the process was taking the recommended quality improvement protocol and together with our partners in South Africa further adapt the project to ensure it was both acceptable and feasible in the Grey’s Hospital setting,” she said. While in South Africa, The DNP students spent days observing in the hospital, attending partnership meetings, presenting their analysis findings, meeting with nursing students to talk about quality improvement, and participating in educational workshops and seminars at the university. “We did not want the DNP students to complete their own scholarly project work in a vacuum,” Silva said, noting that cultural immersion was a critical element of the learning experience.  

Silva has led the initiative for several years, and in March of 2023, the final cohort of students presented its secondary data analysis findings and quality improvement project proposal to the program collaborators at the University of KZN and Grey’s Hospital. “The DNP-South Africa program was a very successful collaboration in terms of manuscripts, presentations, workshops and seminars that emerged,” said Silva, noting that the collaboration generated five manuscripts, three of which are published and two of which are currently under review. Under the mentorship of Silva and with support from DUSON’s Office of Global and Community Health Initiatives, a faculty member from the University of KZN with an interest in data science spent four months at DUSON as a Visiting Scholar during the Fall of 2022. 

Our partners in South Africa would like to shift the focus to a research collaborative, with an emphasis on answering research questions that can inform clinical practice changes, Silva said. Interim Vice Dean for Global and Community Health Affairs Eleanor Stevenson, PhD, RN, FAAN, professor at DUSON will lead the new chapter in research collaboration with the University of KZN. “We have been pleased with our quality improvement work in South Africa,” Silva said. “But it is time to take the collaboration in a new direction.”  

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