Using data for more responsive programme improvement

September 28, 2016

Copyright The Water Institute at UNC 2016

Overview

• Introductions

• World Vision and UNC Partnership

• Overview of Continuous Quality Improvement (CQI)

• WaSH CQI experience in W. Africa

• Ghana and Niger teams present CQI Experiences

• CQI in W. Africa: Results

• CQI in Health Care Facilities

• Next steps for CQI for WV

World Vision – UNC Partnership

The Water Institute at UNC

Introductions: Advisory and Management Team

Pete Kolsky

M&E AdvisorRohit Ramaswamy

CQI AdvisorKaida Liang

Project Manager

Jamie Bartram

Water Institute Director

The Water Institute at UNC

Introductions: MEL Research Team (Selected Members)

Dr. Mike Fisher

Postdoctoral Researcher

Emily Madsen

Field Researcher

Allison Fechter

Research Associate

Ryan Cronk

Research

Assistant

The Water Institute at UNC

• Develop solutions to improve WaSH for all.

• Conduct work that is relevant and practical by linking advanced methods with policy and practice.

• The MEL Focus Area uses high-quality monitoring and analysis methods to measure and improve WaSH programs.

• Annual Water & Health Conference at UNC!

Overview of CQI

What is CQI?

CQI is a systematic way of using data to solve complex problems without intuitive solutions

Problem

Complex?NoYes

CQI Fix it

A formal approach to the analysis of performance and systematic efforts to improve it

Institute for Healthcare Improvement

What is CQI?

• Get a good understanding of the system

• Understand where it is failing - Identify what is wrong

• Understand the root causes for failure

• Generate and test solutions

• Implement and monitor

What is CQI?

What is WaSH CQI?

Data

WaSH CQI Process

15.0%9.4%

23.6%

52.0%

0%

10%

20%

30%

40%

50%

60%

Conformity Low Intermediate High

Pro

po

rtio

n o

f H

ou

seh

old

s

Microbial Risk

Safety of Water Consumed in Households: Northern Ghana

• Some complex problems in WaSH

Sustaining water source functionality

Reducing the proportion of dry wells drilled

Improving water quality

WaSH CQI: Define the Problem

• Create CQI Team

• Kickoff Meeting

• Identify Priorities

• Create Charter

• Data Collection Plan

• Communication Plan

WaSH CQI: Define the Problem

Plan Improvement Project

• 4 districts in N Region

• 230 Communities

• 926 water sources

• 527 households

• Water quality testing

• Data on source and household characteristics

WaSH CQI: Measure

Collect Data

Ghana CQI ExperienceMr. Godfrey Bongomin (GI-WASH Program Manager)

Zakariah Seidu (CQI Coordinator)

Achievements

• Form CQI team and develop initial project charter (2014)

• Assess water and sanitation situation in 230 communities in 4 districts in Northern Ghana

• Analyze data and develop improvement package

– Refresher training and tools for WSMTs

– Safe storage containers for households

• Deliver improvement package to 50% of communities in all 4 districts (selected at random)

• Follow-up monitoring to assess impact

• Deliver remaining tools to intervention communities

Challenges

• Delay in procurement of tools

• Logistical difficulties implementing solutions in over 100 intervention communities

– Distance, weather, road conditions

• High turnover of CQI team members in Northern Ghana (change in PM, CQI project coordinator, many CQI team members, GIS officer, etc.)

Lessons Learned

• WSMT Performance and Borehole Functionality Some WSMT’s have added members after receiving the

WSMT training

Many communities conducted borehole maintenance without external help

Some communities have started revenue mobilization

• Many HHs using Safe Water Storage Containers for primary drinking water More children than adults drink water from SWSCs

Some broken containers observed, most knocked down accidently by a person or an animal

Some HHs still serve drinking water from unsafe containers to children below age 5

Continuous Quality Improvement (CQI) implementation

Niger experience

By Hamissou Maliki NIWASH Assistant Manager

Achievements

• Producing CQI Action Plan

– Problem statement, charter, data collection plan, etc.

• Hiring and training enumerators

• Ethical approval for surveys

– National and local

• Logistics and organization

• Data collection and quality control

– Group supervisor, regular meetings and feedback

Lessons Learned

• Competency building for WaSH staff (M&E and technical skills)– Ensure data quality

– Identify areas of concern

– Additional training as needed

• Regular meetings of CQI team

– Share challenges

– Identify practical solutions

• Full time enumerators

– Quality and continuity of data collection

• Language barriers

• Rainy season delayed data collection

Way Forward

• Complete data collection

• Analyze the data• Identify solutions• Implement

solutions • Standardize

solutions

Ghana CQI Experience: Continued

Factors affecting water quality:

• Source Type

• Safe storage

• Latrine

• Soap present

• Proper handwashing

WaSH CQI: Analyze, Identify

Household Water Quality

Source Type

Safe Storage

Soap PresentHandwashing

Latrine Present

Safe storage containers distributed

• Tap and lid to prevent contamination

• Problems identified:– Users removed lid to dip with

cups

– Containers knocked over by children, goats

– Containers locked inside to prevent breakage- not used

WaSH CQI: Implement Solutions, V 1.0

WaSH CQI: Implement Solutions, V 3.0

Container Improvements:

– Small opening prevents dipping

– Can still pour from head or shoulder

– Metal stand more stable

V 1.0 V 3.0Water in Container 79% 89%Signs of recent use 77% 89%Container cracked or broken 21% 5%Water safely extracted 89% 95%

• Improved W. Quality

• Still room for improvement

WaSH CQI: Implement Solutions, V 3.0

WaSH CQI: Sustain and Scale

• V 4.0?

• Adapting to local context

• Using data to improve Implementation

– When you hear “Everyone knows we just need to do X”

– Don’t forget to ask “Is it goat-proof?”

Continuous Quality Improvement in Health Care Settings

• 21 beds

• Up to 50 babies at once

• Bed sharing occurred on 86% of days

• Hand hygiene training; Visual reminders posted

• Weekly reinforcement during staff meetings

• Additional hand towels supplied to NICU

67%53%

74%

89%92% 89%98%

88%

0%

20%

40%

60%

80%

100%

120%

TotalObservations

DiaperChange

Feeding Examination

% A

dh

ere

nce

NICU Activities

PRE %Adh

POST %Adh

Handwashing increased from 67% to 92%

NICU hand hygiene: Ridge hospital Ghana

•Dedicated maternity theater

•“Banding” for high- priority cases

•Training medical officers to perform surgery

• Improved monitoring of post-surgery recovery

• High wait times for surgery

• No differentiation between high and low priority cases

• Limited availability of staff surgeons

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101520253035

10

12

0

23

0

34

0

45

0

56

0

67

0

78

0

89

0

10

00

11

10

12

20

13

30

14

40

Fre

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Post Surgery Recovery Times in Minutes

BEFORE Post Surgery Recovery

Time

0

10

20

30

40

10

14

0

27

0

40

0

53

0

66

0

79

0

92

0

10

50

11

80

13

10

14

40

Fre

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cy

Post Surgery Recovery Times in Minutes

AFTER Post Surgery Recovery

Times

Surgery Wait Times: Ridge hospital Ghana

•Hand Hygiene interventions in maternity ward

•Weekly scrubbing of maternity wards

•Antibiotic eye ointment given to new mothers

•Reliable ward rounds, on-call medical officer

• High rates of maternal infections after childbirth

• Frequent eye infections in newborns

• High rate of breastfeeding complications

Improving Neonatal Outcomes: Ruiru Sub-county hospital Kenya

17%24%

49%

33%

0%

12% 15%

0%0%

10%

20%

30%

40%

50%

60%

NewbornInfections

(Except eyes)

Newborn EyeInfections

MaternalInfection

BreastfeedingComplications

Neonatal and Maternal Complications

PRE POST

Next Steps for World Vision CQI

• CQI projects launched in Ghana, Niger, Mali

• CQI to expand to one new region by 2017

• Additional new regions planned

• Hub and spoke model

Regional Training

Hub

UNC WIFacilitator

Role

Spoke Country

Spoke Country

Spoke Country

Online training

Resources

Questions