Improving Quality of Healthcare in Bhutan

Added on : 28 January 2021

By: Quality of care Network Secretariat

Authors: Tashi Tenzin[1], Yoriko Nishizawa[2], Jigme Choden[3], Pema Lethro[4], Rajesh Mehta[5]


The constitution of Bhutan focuses on the quality in health care. To implement this concept, the Ministry of Health (MoH) developed a National Health Policy and established a Quality Assurance and Standardization (QAS) Division in the Ministry and in all hospitals. The QAS Division adopted Healthcare Standards for Quality Assurance (HSQA) approved by the Government and rolled out in many healthcare facilities in the country. The HSQA has 116 standards, 639 objectives and 45 Key Performance Indicators to be implemented by health facilities using SOPs and assessment tools for clinical audits.

Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB) is the only medical university in Bhutan. Its vision and mission emphasize the quality of medical education to achieve the quality of patient care. KGUMSB is currently working on curriculum integration of Quality Improvement (QI) and preparing to establish a QAS Division in the Office of the President.

Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) is one of the teaching hospitals of KGUMSB. It is a 350 bedded apex hospital in the country with ongoing expansion as a multispecialty hospital. The QAS Division in JDWNRH is currently pursuing accreditation emphasizing on quality of service.

Preparing the Educators (Faculty Members) for teaching QI

To bring sustained changes in clinical setting as a multidisciplinary team, it is important to converge the two streams of quality of care improvement viz. Quality assurance – accreditation, and continuous quality improvement.

Therefore, the University  (KGUSMB) has developed a generic Total Quality Management (TQM) training package, which combines 2-days training on National Quality Standards (BHSQA) and accreditation with 2-days training workshop on QI methodology based on the WHO Regional model of Point of Care Quality Improvement (POCQI) which was launched in 2016. The POCQI training uses a generic case study (replacing the maternal-newborn case study) to facilitate learning of nurses and doctors from all specialties. Additionally, 1 day for coaching skills will be added for the Faculty.

The plan is to conduct training of trainers (ToT) of the Faculties before mentoring QI projects by postgraduate students. The training package will be improved upon continuously based on the assessment of educational effectiveness. Due to the COVID-19 pandemic, a blended learning version for this TQM training is being developed.

 In 2020, all relevant officials including some of the faculty members in KGUMSB have been sensitized to quality improvement and well-known teaching learning programmes.  KGUMSB is currently preparing to develop first platform for like-minded people and join one of the global QI platforms. The University also improving access to quality educational materials of QI for students and the Faculty.

Way forward to inculcate QI culture:

The University plans to include education on QI across the institution including Faculty of Traditional Medicine and administrative staff. The plan is to also support intensive learning of QI by providing fellowship opportunity as an incentive to the Faculty Members who commit to become QI champions during their professional carrier and successfully inculcate QI culture in health sector in the country. The University will establish National QI web-portal as a national learning platform to connect the growing network of QI implementors and showcase the progress in QI and encourage further participation.

Quality Assurance Committee in the Office of the President, KGUMSB is coordinating these activities to ensure integration of QI across the University in the academic regulations and pre-service/undergraduate curricula.  KGUMSB has continuously worked closely with relevant national stakeholders especially the Ministry of Health in this importance of quality improvement in health services and remain guided by the international partners like WHO.


The concept of Quality Improvement (QI) was first applied in the Facility-Based Newborn care through a Nursing Training supported by WHO in 2015 and Jigme Dorji Wangchuck National Referral Hospital ((JDWNRH) initiated the first QI project on improving discharge timing in Neonatal Division in 2016.The WHO Regional model of Point of Care Quality Improvement (POCQI) launched in 2016, offers a simplified 4 steps approach to train frontline workers in continuous quality improvement. Selected master trainers comprising of specialist gynecologists and pediatricians from Bhutan were trained in a regional workshop. During this training QI projects were developed and implemented by the healthcare teams in Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) and 3 referral hospitals. Subsequently, a national Training of Trainers on POCQI was supported by WHO in collaboration with UNICEF under the leadership of RH programme in the MOH in 2017, in which healthcare teams from several hospitals and the Faculty of the University (KGUSMB) were trained. Nurses were prominently included in the POCQI trainings and subsequently engaged actively in various QI projects in many departments in JDWNRH and other hospitals. 

 Incorporating QI in the nursing education

Since the introduction of WHO POCQI model in Bhutan, the KGUMSB (the only medical university in Bhutan) has adopted this in the preservice education of nurses.

  • In 2018, POCQI was integrated in the Neonatal Critical Care Nursing Certificate Course Curriculum.
  • In 2020, the Faculty of Nursing and Public Health in the Khesar Gyalpo University of Medical Sciences has successfully completed a two day experiential training workshop on POCQI for 40 students undertaking the Bachelor of Public Health, Bachelor of Science (BSc) Nursing and Specialized nursing certificate courses (Perioperative, adult, pediatric and neonatal critical care and dialysis).
  • Following these trainings, BSc Nursing students have led multiple QI projects such as increasing skin to skin contact after caesarean section in the Department of Obstetrics/Gynecology, JDWNRH and improving Partograph compliance by nurses at Punakha Hospital.                                                                                 

Incorporating QI in Postgraduate MD/MS curriculum

Since the start of the Postgraduate residency program by KGUMSB with 5 disciplines in JDWNRH in 2014, the academic work has expanded progressively.

  • Currently 60 students are enrolled in 11 disciplines and 2 regional referral hospitals are included in the teaching hospitals along with JDWNRH.
  • All the curricula were revised as per the requirement of academic regulations of the University and the new curricula were launched during University Investiture Ceremony by His Excellency the Minister of Health in June 2018.  
  • One of the highlights of the new curriculum is the inclusion of QI and all PG students are expected to conduct 1 QI project based on standardized POCQI methodology for QI projects in their 7th semester. It carries marks for their evaluation as per the new curriculum. 


Way forward to inculcate a QI culture:

The University has plans to include education on QI across the institution including Faculty of Traditional Medicine and administrative staff. QI will also be introduced in all the private nursing colleges and institutions that are affiliated to KGUMSB.


Read more on progress in Bhutan and further countries in the WHO South East Asia Region at  Implementation experience of the WHO SEARO model of point-of-care quality improvement (POCQI)

[1] Tashi Tenzin, MD: Dean and Professor, Faculty of Postgraduate Medicine, KGUMSB

[2] Yoriko Nishizawa, MD. IBCLC: Associate Professor Faculty of Postgraduate Medicine, KGUMSB

[3] Jigme Choden JDWNRH

[4] Pema Lethro: Senior Programme Officer, Reproductive Health Program, Ministry of Health, Royal Government of Bhutan

[5] Rajesh Mehta MD: Regional Adviser WHO-SEARO New Delhi