Development and testing of the IMPRESS hospital management survey (IHMS) to measure hospital management practices in a low-income country setting

Strong hospital management has long been recognised by policymakers and the public as important for hospital performance, yet it has received limited empirical research attention. This paper aims to describe the rigorous development and performance testing of a tool to measure hospital management practices in Malawian hospitals. Using a systematic process informed by a scoping review of existing tools, government policies and guidelines, qualitative interviews with hospital managers, a team workshop, and pilot testing, we developed a tool to assess 28 management practices across five domains: clinical care delivery in the neonatal unit, human resource management, target setting and monitoring, financial management, and leadership and governance. The tool was implemented by trained data collectors in 36 Malawian hospitals between April and May 2022, with five managers interviewed per hospital (n = 180). Guided by psychometric techniques and supplemented by qualitative feedback from 36 hospital dissemination meetings, we evaluated the tool’s acceptability, reliability and validity, and compare the primary measure of management with two alternative scoring methods. Our findings are threefold: first, the tool was feasible to implement and acceptable to the interviewees. Second, it demonstrated strong psychometric performance: factor analysis showed that one principal component loaded positively on all the management practices, thus the tool measures a single latent factor of hospital management. Results from item analysis indicate that the tool detected variation between the hospitals for each management practice and none of the management practices are redundant, with low inter-item correlation. Finally, the primary management measure was highly correlated with alternative scoring methods. To our knowledge, this is the first study to describe the systematic development and rigorous validation of a tool that quantitatively measures management practices in a low-resource, hospital setting. We discuss methodological insights and suggest adaptations for implementing the tool in other low-income settings. This paper contributes to the limited evidence base on the development and performance testing of tools for quantitatively measuring management practices in the healthcare sector.