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Case Study: Integration of 5S and Continuous Quality Improvement Approaches to Improve Maternal, Newborn and Child Health (MNCH) Services at Entebbe General Hospital

At Entebbe General Hospital (GH) in Central Uganda, integration of 5S (Set, Sort, Shine, Standardize and Sustain) and Continuous Quality Improvement (CQI) approaches into the healthcare service delivery system registered remarkable improvements in provision of services to HIV-infected mothers and their babies. Following implementation of various changes using these two methods and subsequent improvement in performance, the hospital was informally ranked as a “Gold Star” healthcare facility by a site visit team representing the Uganda Ministry of Health (MOH), United States President’s Emergency Plan for AIDS Relief (PEPFAR), Centers for Disease Control (CDC) and United States Agency for International Development (USAID), in November 2013.

Snapshot: Entebbe General Hospital MNCH Services

In 2011, the hospital received over 150 daily antenatal attendances with an observed HIV prevalence rate of 9%.  Like other public healthcare facilities, Entebbe GH faced human resource constraints and system challenges to effectively deliver quality HIV services in MNCH unit.  There were several challenges, including frequent loss of client files, duplicated files for a single client, poorly updated client registers, and long client waiting time in the MNCH department. Performance data showed that the rate initiation of HIV-positive pregnant women on anti-retroviral therapy (ART) remained low at 39.8% (of the number identified as HIV positive in MNCH) by December 2011.

Hospital leaders and staff acknowledged the need to address these issues and hospital adopted the Ministry’s recommended 5S concept to improve the work environment and, ultimately, the quality of patient care.


The hospital administrative team selected Sister Roselyn Mutonyi, who, as a Nurse In-charge, had successfully implemented 5S activities in the hospital Casualty Department to head the MNCH unit and introduce and implement 5S activities in the unit. Implementation of 5S activities created a foundation for subsequent introduction of CQI methods within the MNCH unit in 2012. The USAID/SUSTAIN team introduced and demonstrated to the Entebbe team how to integrate both the CQI approaches into existing 5S interventions and systems to further improve the quality of services provided, including client outcomes. Through training, regular mentorship and coaching, Entebbe team were empowered to implement the following interventions:

  • Working with nursing students and volunteers, staff sorted all client files, discarding unwanted/duplicate files as the first steps of 5S—set and sort. The sorting process enabled tracking of patients on treatment. In addition, staff realized that because client files were not regularly updated, mothers who would miss their scheduled appointments could not be traced. Now, client cards and files are updated on the same day the client visits the hospital. ART and EID registers are also updated daily to improve tracking of clients. Through a problem analysis exercise, staff determined that the location of the Early Infant Diagnosis (EID) room, placed very visibly at the MNCH department’s entrance, hindered mothers from accessing EID services due to stigma. Therefore, a more private room was selected and allocated to EID services. Through task rationalization, EID staff were allocated different sections of the EID form to complete, which eased the workload per staff.
  • A duty roster was introduced; this reduced work monotony and improved skills as staff rotated among the different sections.  
  • Internal performance review meetings and spot checks are conducted by the nurse in-charge on a regular basis.


Through integration of 5S and CQI approaches, the percentage of pregnant women on ART increased from below 40% in 2011 to 86.5% (of those identified at HIV infected in MNCH units) by December 2013. HIV prevalence among infants born to HIV infected women reduced from 10.8% to 2.6% by December 2013.

Consequently, patient waiting time reduced by half— the last clients are attended to by 12:00pm of each working day, whereas before the integration of CQI and 5S, clients were often still in the waiting queue  up to 6:00pm.

Graph showimg Entebbe's performance after implementation of QI projects

Lessons Learned

  • Participation and support from hospital leadership makes integrated implementation of 5S and CQI approaches easier and builds a firm foundation for sustaining these practices/methods. This often requires upfront engagement and frequent dialogue with leaders to detail the importance of improvement initiatives, discuss the role they, as leaders, play and demonstrate how their engagement benefits the service beneficiaries, contributing to improved overall performance.
  • 5S sets a foundation for implementing CQI interventions. The initial work done through 5S to improve the working environment frees staff to focus more on patient care and to identify issues for further improvement. When 5S and CQI activities are integrated, teams are able to quickly achieve Total Quality management.

Entebbe GH was supported by the USAID Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project between June 2010 and December 2013.


Written by; Julian Natukunda, Communications Specialist,  Dr. Cordelia Katureebe, Senior PMTCT/PEAD Technical Advisor (USAID/SUSTAIN project) with contributions from Dr. Maureen Kwikiriza, Programme Officer-PMTCT at USAID/SUSTAIN and Jessica Ziegler, Knowledge Management Specialist at URC