Quality improvement in reproductive, maternal, newborn and child health
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Transcript of Quality improvement in reproductive, maternal, newborn and child health
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Quality Improvement
RHMNCH
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USAID Applying Science to Strengthen and Improve Systems
Outline
a) ASSIST evolutionb) Approaches, and experiences of QI in
MNCHc) Select results in process improvementsd) Next steps
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USAID Applying Science to Strengthen and Improve Systems
The history of the USAID ASSIST Project
16 countries 19 countries 26 countries 38 countries 26 countries
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Global mechanism: 26 countries (14 in Africa)
Technical leadership and assistance in health quality improvement
Mandate up to September, 2017
Managed by URC & nine other partners
In Kenya, working with National, County governments and other USG funded projects
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USAID Applying Science to Strengthen and Improve Systems
Kenya: What are we trying to accomplish?
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Activity – Support national systems and select county governments in application of QI approaches in:
Scale
1. Country Ownership and Institutionalization of QI at the national level: Support operationalization of a national QI policy in select counties
National & 4 counties
2. HIV Care and Treatment/Nutrition: 6 counties59 sites
3. MNCH/RH: 5 counties46 sites
4. Malaria: 3 counties25 sites
5. OVC and Child Protection (national level and counties)
National and 8 counties
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2. Approaches and experience
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USAID Applying Science to Strengthen and Improve Systems
Sustainable Response
Objective 4 of the National MNH Implementation Plan, 2016
QI embedded in county health strategic plans
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USAID Applying Science to Strengthen and Improve Systems
Focus on Improvement science and not improvement jargon
Walshe K. Pseudoinnovation: the development and spread of healthcare quality improvement methodologies. Int J Qual Health Care 2009; 21:153-9.
Implementation scienceDelivery scienceExecution scienceQuality improvementQuality management Continuous quality improvementPerformance improvement+ many more
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USAID Applying Science to Strengthen and Improve Systems
Emphasize on the science of delivery, not discovery
“We need to give equal attention to the science of delivery. In medicine, we have an abundance interventions that can save lives, but what is the point of having so much if they are not reaching the people who need them?”
- Dr Jim Yom Kim, World Back President
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USAID Applying Science to Strengthen and Improve Systems
Contextualize: What do we use in Kenya?
Focus on the concepts not models!
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USAID Applying Science to Strengthen and Improve Systems11
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USAID Applying Science to Strengthen and Improve Systems
Use of conceptual frameworks to define QI Approaches
The Model for Improvement
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USAID Applying Science to Strengthen and Improve Systems13
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USAID Applying Science to Strengthen and Improve Systems
Model for improvement - Simplified
1414 Adapted from: T. Nolan et. al. The Quality Improvement GuideAdapted from: Massoud et al. A Modern Paradigm for Improving Healthcare Quality
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USAID Applying Science to Strengthen and Improve Systems
Model for improvement - Simplified
1515 Adapted from: T. Nolan et. al. The Quality Improvement GuideAdapted from: Massoud et al. A Modern Paradigm for Improving Healthcare Quality
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USAID Applying Science to Strengthen and Improve Systems
Use of simple Problem Identification Tools
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USAID Applying Science to Strengthen and Improve Systems
Focus a lot more on the means, not ends
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QI Focus
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USAID Applying Science to Strengthen and Improve Systems
Universal principles and frameworks
Fundamental Concept of Improvement: “Every system is perfectly designed to achieve exactly
the results it achieves”
Principles of Improvement:– Understanding work in terms of processes and
systems– Developing solutions by teams of health care
providers and patients– Focusing on patient needs– Testing and measuring effects of changes– Shared learning
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USAID Applying Science to Strengthen and Improve Systems
Collaborative improvement
QI team
site
Site-level summaryQI team
LearningSession
representative
Site-level testing of changes and analysis of results
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QI team
site
QI team
site
QI team
site
QI team
site
QI team
siteQI team
site
QI team
site
Collaborative-level sharing and synthesis of best practices
QI team
site
QI team
site
Multiple sites simultaneously testing
changes, common indicators, peer
learning about how to improve that area of
care
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3. What are we seeing?
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USAID Applying Science to Strengthen and Improve Systems
Area of focus Process indicators
Essential ante-natal care - Screening for anaemia, BP, syphilis and HIV at 1st visit
Maternal care - Monitoring of labour using partograph- Appropriate use of oxytocic- Response to emergency care : Decision to Incision
New born care - Administration of Vit K at birth- Helping babies breath, resuscitation at birth- Cord care with chlorhexidine 4%- Monitoring new born sepsis
Child care - Processes of care at paediatric wards
Family Planning - PPFP - FP at six weeks post-natal visit
Client centred care - Respectful maternity care (exploring the metrics)
Outcomes - Direct obstetric case fatalities- Peri-natal mortality
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USAID Applying Science to Strengthen and Improve Systems
Key MNCH/FP Accomplishments
• Inclusion of QI process indicators in biannual national assessment of facilities’ readiness to provide essential obstetric and new born care
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USAID Applying Science to Strengthen and Improve Systems
Key accomplishments
QI structures at counties
Coordination through county led technical working groups
Focus on measuring processes of care
Sustained high performance on monitoring of women during child birth in 39 facilities in five counties
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USAID Applying Science to Strengthen and Improve Systems
MNCH results
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J-15 F-15 M-15 A-15 M-15 J-15 J-15 A-15 S-15 O-15 N-15 D-15 J-16 F-16 M-16 A-16 M-160.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Proportion of women giving birth in the health facility with a complete partograph in 40 facilities in Kenya (USAID ASSIST), January, 2015 –
May, 2016
J-15 F-15 M-15 A-15 M-15 J-15 J-15 A-15 S-15 O-15 N-15 D-15 J-16 F-16 M-16 A-16 M-160
5001000 No. of women in labour at facility (sampled files)
Accomplishments and notes:a) This is now a standard government indicator for
monitoring intra-partum careb) Level of monitoring not up to 100% due to other system
attributes e.g. staffingc) Facilities to focus on other PDSAs, while this is to be
monitored at less frequency
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USAID Applying Science to Strengthen and Improve Systems25
J-15 F-15 M-15 A-15 M-15 J-15 J-15 A-15 S-15 O-15 N-15 D-15 J-16 F-16 M-16 A-16 M-160%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage of deliveries at the health facility for which oxy-tocin was delivered within 1 minute of delivery in 40 facilities
in Kenya (USAID ASSIST), January, 2015 – May, 2016
Notes:Now a critical indicator of review during routine supervision. This replaces an earlier measure that focused on availability of the oxytocic suppliesProvision of heat stable oxytocic drug is part of the essential drug supplies at the counties. Missing of the drug is notifiable to the hospital director or des-ignate senior technical officer
0500
10001500
Number of deliveries at the health facility (sampled files)
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USAID Applying Science to Strengthen and Improve Systems26
Wk1 April Wk2 April Wk3 April Wk 4 April Wk1 May Wk 2 May Wk3 May Wk4 May Wk1 June0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
Percentage of patients receiving appropriate FP services at six weeks post-natal clinic at two sites in Kakamega County, Kenya
Wk1 April Wk2 April Wk3 April Wk 4 April Wk1 May Wk 2 May Wk3 May Wk4 May Wk1 June0
100200300 Denominator: Number of clients at the six weeks post-natal clinic at two sites,
Kakamega County 2016
Activity started in April to improve FP uptake at six weeks post natal clinic. Quality gaps identified include;a) Priority given on child immunization than FPb) ‘Integration’ not evident in service delivery, service
provided on client request c) No individualized counselling because of lack of
privacy with separate triage for mother and baby Changes being tested include:a) Review of client flow to reduce
waiting time especially triage at child immunization clinic
b) The weekly tracking introduced at two facilities to inform package of spread to other facilities
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USAID Applying Science to Strengthen and Improve Systems
Wk1
-Sep
t
Wk3
-Sep
t
Wk1
-Oct
Wk3
-Oct
Wk 1
-Nov
Wk3
-Nov
Wk1
-Jan
Wk3
-Jan
Wk5
-Jan
Wk2
-Feb
Wk4
-Feb
Wk2
-Marc
h
Wk4
-Marc
h
Wk1
-Apr
Wk3
-Apr
Wk1
-May
Wk3
-May
Wk1
-June
Wk3
-June
0%
5%
10%
15%
20%
25% Median 15%: Pre-in-tervention Phase
Median: Intervention Phase 1
Median 2%: Interven-tion Phase 2
Percentage of neonates with neonatal sepsis at Isiolo County Hospital, Sep 2015 - June, 2016
020406080
45406455675660534956484133394651485142465452414046
614049
65556269634542515550
Denominator: Number of live births at Isiolo County Referral Hospital
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USAID Applying Science to Strengthen and Improve Systems
What happened?
Sept 2015: Meeting with Hospital management, concerns over high neonatal infections
Oct 2015: Root cause analysis done, problems identified as poor infection control practices, lack of knowledge by the support staff on critical IPC requirements at the unit
Changesa) Orientation on IPC protocols for new born unitb) Patient education on handling of new bornc) Avail cleaning agents for each woman post delivery d) Isolation room established for the very sick babies
NB: Weekly tracking until improvement is significant
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USAID Applying Science to Strengthen and Improve Systems
C/S: Decision to Incision – Kitui
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0102030405060708090
100
Axis Title
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USAID Applying Science to Strengthen and Improve Systems
Lesson from RRIs – HTC at MCH
Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-140
102030405060708090
100
Axis Title
Per
cent
age
PITC should be embed-ded as part of routine service delivery, not as a special activity or else, health workers will be waiting for this ‘special event’ which does not demonstrate improve-ments in the processes of care. By this evidence, there is even a drop in PITC to below pre-RRI period.
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Next Steps
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USAID Applying Science to Strengthen and Improve Systems
Scale or spread – Use of QI champions and Learning Session
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USAID Applying Science to Strengthen and Improve Systems
Lessons during implementation
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Avoid: Doing what you’ve done before: “Let’s have a training”
Low-impact changes: “Let’s put up a poster”; “Let’s have an education session”; “Let’s send out reminders”
Technical slow-downs: “We will build a computer program to do this…”
Provide next steps, not routine work plans that have no follow through mechanism
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USAID Applying Science to Strengthen and Improve Systems
Invest in Coaching in Quality Improvement
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USAID Applying Science to Strengthen and Improve Systems
In QI
“Don’t Eat the whole Elephant”
Introduce one concept at a time
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USAID Applying Science to Strengthen and Improve Systems
Sharing through Learning Sessions
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USAID Applying Science to Strengthen and Improve Systems
Asses teams maturity – Kitui (Jan, 2016)
NO. FACILITY MATURITY INDEX1. KDH 2.02. MWINGI DH 3.03. MUTOMO MISSION 3.54. IKUTHA HC 2.55. MUTITU SDH 3.06. IKANGA SDH 1.57. TSEIKURU HOSPITAL 1.58. MUTHALE MISSION 1.59. KAUWI SDH 1.010. YATTA SDH 3.011. KYUSO SDH 3.012. MIGWANI SDH 2.537
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USAID Applying Science to Strengthen and Improve Systems
Thank You
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