Discussion
The lack of local and central registration systems makes it broadly difficult to track and evaluate the progress and development of QI work across the Gaza Strip. However, up until 2015, no evidence is available of any systematic QI work undertaken by medical students or healthcare practitioners in Gaza Hospitals.
The implementation of measures endorsing audit activities by local medical schools, MoH and PMC led to a growing awareness of the concepts of QI work and harnessed the cooperation between healthcare professionals and medical students to conduct clinical audits. This was reflected by a steady increase in the number of audits undertaken in local healthcare practice. An increasing number of abstract submissions to the international Lancet Palestinian Health Alliance (LPHA) annual conference was also observed between 2015 to 2018 with some positive impact reports 16 17.
Crucially, the cycle has to be completed in order to assess the impact of the original audit. In this study, the cycle was found completed in only one fifth of all projects (20.9%). This number is low but, nonetheless, similar to those reported in other studies9 10 1819 20. Although such studies were undertaken in the context of a well-developed and supported audit programmes unlike that of this study, efforts should still be made towards achieving higher completion rates in our local practice and elsewhere.
Although the observed spike in audit numbers is encouraging, the impact of audit activities in Gaza is still lagging behind with only seven studies (11.3%) reporting subsequent improvements in practice. In general, audits with local staff involvement and senior leadership proved to be most effective in initiating and leading improvements7 8 9. The provision of feedback to the local staff through presentation of results at internal meetings has also been shown to be effective12. Other measures such as the availability of dedicated support teams or the provision of protected time for QI work5 21 2223 24 are often difficult to implement in the case of low-income countries 2526. Therefore, it is imperative to focus on factors that can potentially be supported in such settings in order to produce QI work with the highest possible impact 2726.