improvement collaborative report november 2012 to … · 2014-04-11 · wave. this second wave...

1

IMPROVEMENT COLLABORATIVE REPORT

NOVEMBER 2012 to MAY 2013

Any questions, suggestions, clarifications, etc., may be directed at [email protected].

mailto:[email protected]

2

Table of Contents BACKGROUND .................................................................................................................................................. 3

IMPLEMENTATION ........................................................................................................................................... 3

RESULTS ............................................................................................................................................................ 3

WAVE 3 – NCHS SYSTEM .................................................................................................................................. 4

SUSTAINABILITY INITIATIVES ............................................................................................................................ 5

MATERNAL &NEWBORN HEALTH REFERRAL WORK ........................................................................................ 5

DISSEMINATION ............................................................................................................................................... 9

KEY ENABLING FACTORS .................................................................................................................................. 9

KEY CHALLENGES AND STRATEGIES TO ADDRESS THEM ................................................................................. 9

PREPARATION FOR NATIONAL SCALE-UP ...................................................................................................... 10

CONCLUSION .................................................................................................................................................. 10

APPENDICES ................................................................................................................................................... 11

Wave 1 Sustainability Results .................................................................................................................... 11

Wave 2 District-Wide Improvement Collaborative Network Results ........................................................ 12

Wave 3........................................................................................................................................................ 19

MNH Referral Work .................................................................................................................................... 20

3

BACKGROUND

In 2008 the Institute for Healthcare Improvement (IHI) and the National Catholic Health Service (NCHS)

launched Project Fives Alive!– a five-year initiative to accelerate Ghana’s efforts to achieve Millennium

Development Goal Four (MDG 4) of reducing under-5 mortality by 67% from its 1990 baseline (110-120

deaths per 1000 live births) by 2015. Supported by the Bill & Melinda Gates Foundation (BMGF) and

partnering closely with the Ghana Health Service, Project Fives Alive! (PFA) has worked closely with

communities, frontline workers, and health system leadership to improve performance of maternal and

child health programs across Ghana – first in the nation’s challenged three northern regions, and now

scaling up across the remaining seven regions of the country. This report winds up the pre-national scale-

up activities of the Project, highlights the ongoing referral project, and describes initial steps taken to roll

out the national scale-up.

IMPLEMENTATION

Between July 2008 and September 2009, PFA! worked across the continuum of care in three innovation

districts in the Northern region in the first Wave. Afterwards, key learning on high-impact interventions for

improving early antenatal care, skilled delivery, and postnatal care were documented into a sub-district

change package and scaled up across all 38 districts in the three regions of the North to mark the second

Wave. This second Wave continued until the first quarter of 2013, when planning for national scale-up

started. To learn about changes for improving safety and reliability of hospital-based care processes, a

learning collaborative network of nine NCHS hospitals was run between October 2009 and June 2011 in a

third Wave, leading to the development of a hospital change package that has since been scaled up to the

remaining 29 NCHS hospitals and 36 hospitals in Wave 2.

In August 2013, to address the role of faulty referral processes in adverse maternal and neonatal

outcomes, the project commenced innovative referral work in six districts in Ghana’s Central and Northern

regions after securing additional funding from the Bill & Melinda Gates Foundation. According to design,

four of the six districts have formed Community-Facility Collaborative learning networks to amplify the

community voice in improving health outcomes, while two maintained the more traditional Facility-only

network. Across both regions, a total of 41 QI teams have been formed consisting of 30 sub-district teams,

five hospital teams, and six district-level referral teams. The innovative phase of the referral work is

expected to run until February 2014, after which effective referral solutions will be scaled up to the rest of

the PFA! platform.

RESULTS

PFA has demonstrated a strong track record of implementing and scaling up its programming according to

design using a quality improvement (QI) approach and has shown significant impact on improving

processes of care. Across the 38 districts in the three northern regions, significant improvements have

been achieved: 10% increase in the proportion of pregnant women receiving antenatal care in the first

trimester, 20-30% increase in skilled deliveries, 40-70% increase in the proportion of neonates receiving

postnatal care on day one or two of life (highest region recording 86%), and 20-60% increase in the

proportion of neonates receiving postnatal care on day six or seven (highest region recording 57%).

4

Concerning under-5 mortality in the three regions, the Upper East region (UER) and Upper West region

(UWR) reduced institutional under-5 mortality by 33% and 39% respectively from January 2009 to March

2013. The Northern region (NR), however, has not shown significant improvement in the overall reduction

of under-5 mortality, despite recording a 34.5% reduction in the 12- to 59-month age group.

Analysis of results from the Northern region ought to take into account the contextual realities of the

region in comparison to the other two. This is important in two specific regards: health system challenges

and a possible inadequate “dose” of the QI approach. While the Upper East and Upper West regions have

doctor-to-population ratios of 1:54,234 and 1:21,472 respectively, Northern region’s ratio is 1:80,000.

Compounding this is the sheer land size of the region, forming a third of the entire country. The total

number of districts in UER and UWR (24) is less than the number in NR (26), with the total number of

hospitals in both regions (12) also being less than the total number of hospitals in NR (18). In the NR it has

taken longer to reach full scale to support all 115 QI teams (vs. UER 71 teams and UWR 72 teams); using a

phased scale-up approach, the project struggled to adequately staff the project needs for certain periods,

which further complicated scheduling conflicts and delayed project implementation. All these factors

contributed to delayed implementation of learning sessions and site visits and inadequate numbers of

fully trained change agents compared to the other regions.

The above notwithstanding, disaggregated analysis clearly shows specific areas of improvement in

Maternal and Child Health indicators in the Northern region: 5%, 20%, and 40% increases in the early

antenatal attendance, skilled delivery, and the proportion of neonates seen within the first two days of life

respectively, and 34.5% reduction in mortality in the 12- to 59-month age group. Further, the general

stagnation in neonatal mortality rates across all three regions notwithstanding, it is noted that Northern

region has the lowest neonatal mortality rate – 3.8 deaths per 1000 live births, compared to 5.4 and 3.9

for Upper West and Upper East respectively.

Regarding data quality improvement (DQI) work in the 38 Wave 2 districts, a) average timeliness of

reporting has decreased from seven to three days, b) completeness of data summary sheets has increased

from 78-80% to 95-98%, and c) data accuracy has improved from inaccurate levels at 85-150% and was

restored to 100% accuracy for selected indicators such as first trimester registration and skilled delivery.

For DQI training, UWR had four sessions and UWR had three sessions, while NR had two sessions.

WAVE 3 – NCHS SYSTEM

Between October 2009 and May 2013, the nine prototype NCHS hospitals reduced their overall under-5

mortality by 28% – a significant further improvement on the 18% mortality reduction recorded at the end

of the innovation phase in June 2011. Seven out of the nine hospitals are now showing significant

improvement. These include St. Martin de Porres Hospital, Eikwe (29% reduction); Catholic Hospital,

Battor (41% reduction); Mathias Hospital, Yeji (42% reduction); Holy Family Hospital, Berekum (43%

reduction); St. Francis Xavier Hospital, Assin Foso (50% reduction); Margret Marquart Hospital, Kpando

(54% reduction); and Our Lady Of Grace Hospital, Breman Asikuma, leading with 86% reduction in

mortality. Of the seven, Holy Family Hospital, Berekum only showed improvement after the end of the

scale-up phase. Interventions in the other two continue, as does monitoring. Between January 2010 and

May 2013, the 19 scale-up hospitals in the NCHS showed 33% reduction with seven out of the 19 now

showing significant improvement.

5

By the end of the project, PFA expects to deliver significantly lower under-5 mortality across Ghana,

through improvements in access to and delivery of care that is safe, reliable, and of the highest quality.

SUSTAINABILITY INITIATIVES

The project’s approach to sustainability has been anchored on three pillars: capacity building in QI, hard-

wiring successful changes into the health system, and development of responsive information systems.

By late 2011, when the project was on the verge of national scale-up, the first External Advisory Board

meeting advised on a year’s extension within the Northern regions in order to better integrate successful

QI practices. This sparked a year-long effort to more deliberately implement a sustainability plan

subsequently developed in active partnership with the three Regional Directors of Health Services, while

also implementing the provisions of a Memorandum of Understanding (MoU) signed between the

project and the Regional Health Directorate (RHD) with specific roles and responsibilities assigned.

By April 2013, health staff participation in Learning Sessions (LSs) for the district-wide ICN increased to

2,576 at the collaborative level (all three regions), while site visits by POs increased to 2,156 as shown in

the monthly breakdown in Figure 5. By April 2013, all the planned LSs for the hospital ICN were

successfully concluded, and a total of 572 health staff had participated in all of them across the three

regions. The regional breakdown by LS is indicated in Figure 12. Intensity of site visits from core project

staff decreased, and health staff from the health system were selected and trained as change agents to

support QI work at regional and district levels. Under this sustainability work, integration of QI into district

and hospital review meetings grew from 33% in 2010 to 93% (2012 half year) in UER, 20% to 93% in UWR,

and remained unchanged at between 10-35% in NR (Figure 20). Complete data is being collected to

complete the 2012 full year.

Regarding integration of QI support visits into District and Hospital routine monitoring, planning for such

visits increased from 20% to 69% in UER and remained unchanged at 33% in UWR and NR (Figure 21), out

of which 50%, 33%, and 75% visits were actually done in UER, UWR, and NR respectively (Figure 22).

Logistical support for conducting planned site visits improved to 69%, 33%, and 77% respectively in UER,

UWR, and NR (Figure 23). Regarding integration of QI feedback into district and hospital routine feedback

systems, the proportion of actually delivered feedback to planned feedback to managers grew from a

minimum of two out of four planned feedback systems in first quarter of 2011 to a maximum of 13 out of

17 such plans across all three regions (Figure 24). Integration of DQI updates was, however, not very

successful in the Northern and Upper West regions (median of between 10-20%), unlike the Upper East

region in which it grew from 33% in 2011 to about 87% by 2013 (Figure 25). This was because DQI in UE

was properly aligned with the activities of the data validation team at the regional health directorate and

reported quarterly, unlike UWR and NR where updates were mostly done in preparation for DQI trainings.

MATERNAL &NEWBORN HEALTH REFERRAL WORK

The following table shows key activities planned and the state of their execution from January 2012 to

April 2013.

6

Category Activities Comments

Pre-launch

Selection of innovation regions & districts Successfully completed

and on schedule

Working out detailed design of community-health

facility ICN & facility-only ICN; plus community and

stakeholder engagement on design and application

of QI with non-literate groups

Successfully detailed

design and engaged

stakeholders as planned

Literature & development of draft change package Developed a structured

draft

Launch and LS1 scheduling plus budgeting with

GHS partners

Successfully completed

and on schedule

Health records review Was done in one district

each in the NR & CR

Drafted concepts & strategies for BMGF-funded

MNH referral projects community of practice

Carried out as planned

Participation in first community of practice

meeting

Carried out as planned

Post-launch

Launch Durbars in Community-Facility ICN districts Carried out as planned

Learning Session 1 in all 6 innovation districts Carried out as planned

Activity Period 1 site visits Happened in all districts,

but with variation in the

number of visits per team

between NR & CR

Training of regional, district, & hospital information

officers in data quality improvement focusing on

MNH referral data system

First training executed as

planned

Improvement Coaches Training Carried out as planned in

the Central Region

Northern Region training

delayed

Development of an indicator dashboard for

monitoring project implementation progress,

process and outcome performance

Dashboard has been

developed and is being

used

7

Baseline data collection of the monitoring

indicators

Completed for indicators

in DHIMS; mopping up for

non-routine indicators

Learning Session 2 Complete for CR; NR

outstanding

Activity Period 2 site visits Yet to begin in both

regions

Other operational issues

Budgeting for launch Durbars and LSs Completed for all districts

Financial reporting with GHS on 1st tranche of

transfers for durbars and LS1

Completed for all districts

Other highlights include the following:

The project has designed, printed, and deployed a standard referral register in collaboration with the Ghana Health Service, with prospects for national adaptation after the innovation phase.

The project has drafted PFA! concepts and strategies to guide cross-site learning among the three MNH referral projects funded by BMGF in Ghana, Ethiopia, and Nigeria. Following this, we will participate in two referral Community of Practice meetings in May 2012 and May 2013 in Ethiopia with many useful lessons for the project.

The project has written a separate report on key learnings and insights on the referral Community of Practice.

Attached as an appendix to this report is a table showing a summary of all the changes being tested to date in the six districts to improve the referral system.

The project has outlined a set of high-level referral process indicators to track the effect of changes tested by teams to improve the key drivers of faulty referrals. It is planned that subsequent reports will share data on some of these indicators. This is still very much a work in progress.

No Data Elements Measurement Numerator Denominator Chart type

Individual and Family Barriers

1 Pregnant women with danger signs at informal care settings TBAs

Proportion of

pregnant women

with danger signs

identified by TBA

Number of

women with

pregnancy related

danger signs

identified by TBAs

Total # of women

seeking care with

TBAs P-chart

2

Neonatal /Maternal referrals

by Community-based primary

care providers(TBAs, LCs, Pc)

Proportion of

neonates /

mothers referred

by Community-

No. of neonates / mothers referred by Community-based primary care

Total # of cases seen by CBPP

Run-chart

8

based primary care

providers(TBAs,

LCs, Pc)

providers(TBAs, LCs, Pc)

3 ****1ST Trimester registrants

identified by CBV

Proportion of 1ST

Trim registrants

identified by CBV

No. of 1ST Trim registrants identified by CBV

No. of ANC

registrants

identified by CBVs P-chart

Transportation and Communication Barriers

4

Emergency obstetric

cases/neonates transferred by

CTS (community transport

solution )(bicycle, motorbike,

taxis, private cars) from

community level to health

centres

Rate of Emergency

obstetric

cases/neonates

transferred by CTS

(community

transport solution

)(bicycle,

motorbike, taxis,

private cars

No. of Emergency

obstetric

cases/neonates

transferred by CTS

(community

transport solution

)(bicycle,

motorbike, taxis,

private cars

Total No. of Emergency obstetric cases/neonates transferred by transport solution

U-chart

5

Call notification before

emergency referrals to next

level

Proportion of

emergency cases

for which a health

center/hospital

make calls to next

level prior to

referral

No. of emergency

cases for which a

health

center/hospital

make calls to next

level prior to

referral

Total No. of

emergency cases

referred to next

level

P-chart

Inadequate Clinical Skills and Management

6

Adequate referral

documentation (Adequate:

referral indication and

treatment provided)

Proportion of

referred

mothers/neonates

with adequate

referral

documentation

No. of maternal

cases/neonates

with adequate

referral

documentation

Total No. of

mothers/neonates

with referral

documentation

P-chart

7 Referral Feedback

Proportion of cases for which CHPS/HC receive feedback

No. of maternal cases/neonates cases with referral feedback

Total No. of referrals

P-chart

Governance and Accountability

8

Referral forms stock outs

Proportion of sub districts without referral forms

No. of facilities without referral forms

Total No. of facilities in the districts

P-chart

9

DISSEMINATION

The project has had phenomenal success in writing and presenting posters at various international fora,

but more limited output in peer-reviewed publications. To ameliorate this, a one-week writing retreat

was organized in April 2013 with two consultants in attendance. An additional week in dedicated time

was given to Project Officers to improve various manuscripts. Weekly calls have also been arranged for

additional technical guidance to be provided. The project currently has seven fairly advanced

manuscripts, which it plans to complete by the end of the year.

ISQua held its first regional meeting in Africa in February 2013, and the project had the opportunity to do

four oral presentations and 10 poster presentations. Three executives of ISQua also visited two project

sites. One of the project directors was also invited to take part in a debate, speaking to the effectiveness

of hospital to hospital partnerships in improving health outcomes and patient safety.

The project presented 19 posters at the 2013 International Conference in London, and the Project

Director co-facilitated a session on the “Three Delays” model. The project has submitted three speaker

proposals to teach three sessions at the next International Forum in 2014.

KEY ENABLING FACTORS

The main enabling factors are:

High level of commitment and well-engaged RHDs

High level of commitment from frontline staff and Change Agents

Peer-to-peer learning and data-driven feedback at Learning Sessions across all three regions

Strong sense of teamwork and commitment among project staff

Continuous technical guidance and support from Steering Committee/faculty members

KEY CHALLENGES AND STRATEGIES TO ADDRESS THEM

The first challenge is project-wide, while the other three are specific to the referral work.

I. Delays in funds transfer to the regions for the completion of LSs was a major challenge in the period under review. This led to the cancellation and rescheduling of some of the LSs and is partly responsible for the delayed LS4 for the districts in NR (Gushegu, Karaga, and East Gonja). Discussions have started to include Wave 2 teams in referral work that is ongoing in the region, in addition to providing some ongoing site visit support to the Northern region in particular. Additionally, the project has drawn up its programme of work until 2015 in an attempt to better align budgets to planned activities, while taking measures to ensure prompt submission of financial reports from the various regions to facilitate further transfer of funds.

II. There is substantial non-routine data for monitoring the progress of referral work, thus making baseline data collection and subsequent updates very labor intensive.

III. The request of some frontline staff and community members for motivation/refreshment after QI meetings is the practice with other projects, but contrary to PFA! practices has proved somewhat sensitive for us. Project staff have always been very careful to explain what activities can be supported by PFA! and appropriately refer such requests to health managers.

QI work began; NHIfree

for maternity &early

infant care

10

IV. Availability of Improvement Coaches for joint site visits does not always coincide with the project

officers’ plan because of other commitments of the former, leading to rescheduling and attendant delayed execution.

PREPARATION FOR NATIONAL SCALE-UP

The following activities, among others, were undertaken in the first quarter of 2013 in preparation for

national scale-up.

To prepare the seven regions for national scale-up, the project embarked on a comprehensive leadership engagement exercise comprising meetings with Regional Directors of Health services and the management of District Health Directorates and District Hospitals across all seven regions. The Monitoring & Evaluation team of the project also used data accessed from the District Health Information Management Systems 2 to rank districts and prioritize same for inclusion in the national scale-up effort. Further, a new ten-week curriculum for training of Improvement Coaches in the health system in anticipation of a leveraged approach was tested and finalized. Finally, the Project had critical technical meetings to standardize indicators internally and align same with indicators routinely collected by the Ghana Health Service (GHS) to ensure internal consistency and external validity.

CONCLUSION

The next Collaborative Report, scheduled for the last quarter of 2013, will focus on the ongoing national scale-up effort, plans by the project to tackle stagnating neonatal mortality, and the MNH referral work.

11

APPENDICES

Wave 1 Sustainability Results

Figure 1:Wave 1 Improvement Collaborative Network – Early Registration of ANC, 4th ANC Visit &Skilled Delivery Coverage: Jan.’08 to March’13

37.0%

0%

10%

20%

30%

40%

50%

60%

Ja

n-0

8M

ar-

08

May-0

8Ju

l-08

Sep

-08

No

v-0

8Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

WAVE 1 COLLABORATIVE - EARLY REGISTRATION OF ANC

Aim: ≥80% OF ANC REGISTRANTS IN 1ST TRIMESTER

Subgroup Center

UCL LCL

0.5

0

0.2

0.4

0.6

0.8

1

1.2

Ja

n-0

8M

ar-

08

May-0

8Ju

l-08

Sep

-08

No

v-0

8Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2

Aim: ≥0.9 ANC REGISTRANTS ATTENDING ANC CLINICS FOR 4TH TIME BEFORE DELIVERY

PER EXPECTED PREGNANCY

Subgroup Center

UCL LCL

58.6%

80.5%88.8%

0%

20%

40%

60%

80%

100%

Ja

n-0

8M

ar-

08

May-0

8Ju

l-08

Sep

-08

No

v-0

8Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

WAVE 1 COLLABORATIVE - SKILLED DELIVERY COVERAGE

AIM: ≥75% OF DELIVERIES CONDUCTED BY SKILLED PERSONNEL

Subgroup Center

UCL LCL

Figure 2: Wave 1 Improvement Collaborative Network –Stillbirth Rate, Neonatal Death, Jan’08 to March’13

16.7

0

10

20

30

40

50

Ja

n-0

8M

ar-

08

May-0

8Ju

l-08

Sep

-08

No

v-0

8Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

Wave 1 Collaborative - Stillbirth RateAim: <10 stillbirths per 1000 skilled deliveries

Subgroup CenterUCL LCL

4.8

UCL

LCL0

2

4

6

8

10

12

14

16

Ja

n-0

8M

ar-

08

May-0

8Ju

l-08

Sep

-08

No

v-0

8Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

Wave 1 Overall Collaborative - Neonatal DeathsAim: <2 facility-based neonatal deaths per 1000

deliveries

Subgroup Center

UCL LCL

12

Wave 2 District-Wide Improvement Collaborative Network Results

Figure 3: Scale-up from Wave 1 to Wave 2 Collaborative, Jul’08 to April’13

0

50

100

150

200

250

300

Jul'0

8

Sep

t'0

8

No

v'0

8

Jan

'09

Mar

'09

May

'09

Jul'0

9

Sep

t'0

9

No

v'0

9

Jan

'10

Mar

'10

May

'10

Jul'1

0

Sep

t'1

0

No

v'1

0

Jan

'11

Mar

'11

May

'11

Jul'1

1

Sep

t'1

1

No

v'1

1

Jan

'12

Mar

'12

May

'12

Jul'1

2

Sep

t'1

2

No

v'1

2

Jan

'13

Mar

'13

Wave 1 Wave 1+2

Nu

mb

er

Progress in Scale-up from Wave 1 to Wave 2

# of sub-district QI teams# of hospital QI teams# of districtsWave 2 sub-district QI team aimWave 2 hospital QI team aimWave 2 district aim# of QI teams

Figure 5:Site Visit Frequency in Waves 1 & 2, July’08 to April’13

0

20

40

60

80

100

120

140

160

Mar

-…M

ay…

Jul-

10

Sep

-…N

ov-

…Ja

n-1

1M

ar-…

May

…Ju

l-1

1Se

p-…

No

v-…

Jan

-12

Mar

-…M

ay…

Jul-

12

Sep

-…N

ov-

…Ja

n-1

3M

ar-…

Frequency of Site Visits to Support QI teams in Waves 1 & 2 Collaboratives (as of March, 2013

No

. of

Site

Vis

its

Figure 4:Wave 2 Collaborative – LS Participants by Region, Sept’09 to April’13

0

50

100

150

200

250

300

350

UE UW NR

L1 L2 L3 L4

No

. of

Par

tici

pan

ts

13

Institutional stillbirth rates remain above 10 per 1000 skilled deliveries across the three regions. The UER is at a

rate of 20 per 1000 skilled deliveries, compared with a regional target of 10 per 1000 skilled deliveries (Figures

8)

Figure 7: Wave 2 Improvement Collaborative Network – Skilled Deliveries as Percentage of Total Deliveries, Jan’09 to April’13

72.2%

82.9% 87.1%

92.1%

50%

60%

70%

80%

90%

100%

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% OF TOTAL DELIVERIES THAT ARE ATTENDED BY SKILLED HEALTH

PERSONNEL IN UE REGION

Subgroup Center

UCL LCL

54.2%

63.6%72.0%

84.4%

30%

40%

50%

60%

70%

80%

90%

100%

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13


PERSONNEL IN UW REGION


38.2%

56.7%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13


PERSONNEL IN NORTHERN REGION WAVE 2A


Figure 8: Wave 2 Improvement Collaborative Network – Facility-Based Stillbirth Rate, Jan’09 to April’13

18.6

0

5

10

15

20

25

30

35

40

45

50

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF STILLBIRTHS PER 1000 SKILLED DELIVERIES IN UE REGION

Subgroup Center

UCL LCL

27.6

21.5

0

5

10

15

20

25

30

35

40

45

50

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF STILLBIRTHS PER 1000 SKILLED DELIVERIES IN UW REGION

Subgroup Center

UCL LCL

24.2

19.2

0

5

10

15

20

25

30

35

40

45

50

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF STILLBIRTHS PER 1000 SKILLED DELIVERIES IN NORTHERN

REGION WAVE 2A

Subgroup Center

UCL LCL

Figure 6:Wave 2 Improvement Collaborative Network – ANC registration in first trimester, Jan’09 to April’13

34.9%

45.5%

10%

20%

30%

40%

50%

60%

70%

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% OF ANC REGISTRANTS IN 1ST TRIMESTER AT REGISTRATION IN UER

Subgroup Center

UCL LCL

42.6%

52.1%

10%

20%

30%

40%

50%

60%

70%

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% OF ANC REGISTRANTS IN 1ST TRIMESTER AT REGISTRATION IN UW

REGION


28.0%33.9%

10%

20%

30%

40%

50%

60%

70%

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% OF ANC REGISTRANTS IN 1ST TRIMESTER AT REGISTRATION IN

NORTHERN REGION WAVE 2A

Subgroup Center

UCL LCL

14

Wave 2 Hospitals Improvement Collaborative Network

As noted earlier, the LS2 for hospitals in the NR was completed in this period and increased the number of

health staff participating in LS2 of the hospital ICN to 212 with the regional breakdown indicated in figure 12.

The low participation in LS1 from the UWR is because the participant’s evaluation form, which is the main

source of this data, was not filled by majority of the participants.

Figure 11: Wave 2 Improvement Collaborative Network – Facility-Based Neonatal Mortality Rate, Jan’09 toApril’13

3.9

0

2

4

6

8

10

12

14

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF INSTITUTIONAL NEONATAL MORTALITY IN UE REGION


5.4

0

2

4

6

8

10

12

14

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF INSTITUTIONAL NEONATAL MORTALITY IN UW REGION

Subgroup Center

UCL LCL

1.7

0

2

4

6

8

10

12

14

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF INSTITUTIONAL NEONATAL MORTALITY IN NORTHERN REGION

WAVE 2A

Subgroup Center

UCL LCL

Figure 9: Wave 2 Improvement Collaborative Network – Early Postnatal Care for Neonates, Jan’08 to April’13

21.6%

85.5%

0%

20%

40%

60%

80%

100%

Ja

n'0

8M

ar'08

May'0

8Ju

l'08

Sep

t'08

No

v'0

8Ja

n'0

9M

ar'09

May'0

9Ju

l'09

Sep

t'09

No

v'0

9Ja

n'1

0M

ar'10

May'1

0Ju

l'10

Sep

t'10

No

v'1

0Ja

n'1

1M

ar'11

May'1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% of Neonates who Received PNC on Day 1 or 2: UER

Subgroup Center

UCL LCL

8.2%

81.0%

0%

20%

40%

60%

80%

100%

Ja

n'0

8M

ar'08

May'0

8Ju

l'08

Sep

t'08

No

v'0

8Ja

n'0

9M

ar'09

May'0

9Ju

l'09

Sep

t'09

No

v'0

9Ja

n'1

0M

ar'10

May'1

0Ju

l'10

Sep

t'10

No

v'1

0Ja

n'1

1M

ar'11

May'1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% of Neonates who Received PNC on Day 1 or 2: UWR


2.1%

27.0%

57.1%

43.6%

0%

20%

40%

60%

80%

100%

Ja

n'0

8M

ar'08

May'0

8Ju

l'08

Sep

t'08

No

v'0

8Ja

n'0

9M

ar'09

May'0

9Ju

l'09

Sep

t'09

No

v'0

9Ja

n'1

0M

ar'10

May'1

0Ju

l'10

Sep

t'10

No

v'1

0Ja

n'1

1M

ar'11

May'1

1Ju

l'11

Sep

t'11

No

v'1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% of Neonates who Received PNC on Day 1 or 2: NR


Figure 10: Wave 2 Improvement Collaborative Network – Neonates who Received Second Postnatal Care within First Week of Life, Jan’08 to April’13

47.4%

62.9%

0%

20%

40%

60%

80%

100%

Ja

n'0

8M

ar'08

May'0

8Ju

l'08

Sep

t'08

No

v'0

8Ja

n'0

9M

ar'09

May'0

9Ju

l'09

Sep

t'09

No

v'0

9Ja

n'1

0M

ar'10

May'1

0Ju

l'10

Sep

t'10

No

v'1

0Ja

n'1

1M

ar'11

May'1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% of PNC Registrants who Received Follow-up Care on Day 6 or 7: UER

Subgroup Center

UCL LCL

30.2%

54.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Ja

n'0

8M

ar'08

May'0

8Ju

l'08

Sep

t'08

No

v'0

8Ja

n'0

9M

ar'09

May'0

9Ju

l'09

Sep

t'09

No

v'0

9Ja

n'1

0M

ar'10

May'1

0Ju

l'10

Sep

t'10

No

v'1

0Ja

n'1

1M

ar'11

May'1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% of PNC Registrants who Received Follow-up Care on Day 6 or 7: UWR


18.6%

37.6%

22.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Ja

n'0

8M

ar'08

May'0

8Ju

l'08

Sep

t'08

No

v'0

8Ja

n'0

9M

ar'09

May'0

9Ju

l'09

Sep

t'09

No

v'0

9Ja

n'1

0M

ar'10

May'1

0Ju

l'10

Sep

t'10

No

v'1

0Ja

n'1

1M

ar'11

May'1

1Ju

l'11

Sep

t'11

No

v'1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

% of PNC Registrants who Received Follow-up Care on Day 6 or 7: NR

Subgroup Center

UCL LCL

15

Wave 2 Hospitals Improvement Collaborative Network

Figure 13: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Deaths among Children 0-11 Months Old: Jan’09 to April’13

39.2

26.6

0

20

40

60

80

100

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF INSTITUTIONAL DEATHS AMONG 0-11 MONTH OLD INFANTS PER 1000

ADMISSIONS, UE REGION

Subgroup Center

UCL LCL

25.1

13.4

0

20

40

60

80

100

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF INSTITUTIONAL DEATHS AMONG 0-11 MONTHS OLD INFANTS PER 1000

ADMISSIONS, UW REGION


38.5

0

20

40

60

80

100

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF INSTITUTIONAL DEATHS AMONG 0-1 1 MONTHS OLD INFANTS PER 1000

ADMISSIONS, NORTHERN REGION


Figure 12:Wave 2 Hospitals ICN – LS Participants by Region

0

20

40

60

80

100

120

140

UE UW NR

L1 L2 L3

Figure 14: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Deaths among Children 12-59 Months Old: Jan’09 to April’13

15.5

9.3

0

10

20

30

40

50

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13

RATE OF INSTITUTIONAL DEATHS AMONG 12-59 MONTHS OLD CHILDREN PER 1000

ADMISSIONS, UE REGION

Subgroup Center

UCL LCL

14.6

8.5

0

10

20

30

40

50

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13


ADMISSIONS, UW REGION

Subgroup Center

UCL LCL

20.3

0

10

20

30

40

50

Ja

n-0

9M

ar-

09

May-0

9Ju

l-09

Sep

-09

No

v-0

9Ja

n-1

0M

ar-

10

May-1

0Ju

l-10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11

May-1

1Ju

l-11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12

May-1

2Ju

l-12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13


ADMISSIONS, NORTHERN REGION

Subgroup Center

UCL LCL

16

Figure 15: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Deaths among Children Under 5 Years Old: Jan’09 to April’13

Figure 16: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Malaria Case Fatality Among Under 5s, Jan’09 to April’13

Figure 20: Sustainability of Wave 2: Integration of QI into District and Hospital review meetings

17

Figure 21: Sustainability of Wave 2: Integration of QI support visits into District and Hospital routine monitoring

20

69

0

20

40

60

80

100

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Planned site visits UER

% Planned Median

33

0

20

40

60

80

100

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Planned site visits UWR

% Planned Median

33

0

20

40

60

80

100

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Planned site visit NR

% Planned Median


69

0

20

40

60

80

100

Jan

-11

Mar

-11

May

-11

Jul-

11

Sep

-11

No

v-11

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-12

Jan

-13

Mar

-13

Logistical support UER

% support based on plan visit Median

35

0

20

40

60

80

100

Jan

-11

Mar

-11

May

-11

Jul-

11

Sep

-11

No

v-11

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-12

Jan

-13

Logistical support UWR

% support based on plan visit Median

77

0

20

40

60

80

100

Jan

-11

Mar

-11

May

-11

Jul-

11

Sep

-11

No

v-11

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-12

Jan

-13

Mar

-13

Logistical support NR

% support based on plan visit


50

0

20

40

60

80

100

Jan

-11

Mar

-11

May

-11

Jul-

11

Sep

-11

No

v-11

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-12

Jan

-13

Actual site Visit UER

% Actuals Median

33

0

20

40

60

80

100

Jan

-11

Mar

-11

May

-11

Jul-

11

Sep

-11

No

v-11

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-12

Jan

-13

Actual site Visit UWR

% Actuals Median

75

0

20

40

60

80

100

Jan

-11

Mar

-11

May

-11

Jul-

11

Sep

-11

No

v-11

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-12

Jan

-13

Actual site Visit NR

% Actuals Median

18

Figure 25: Sustainability of Wave 2: Integration of DQI updates into District and Hospital routine work

0

20

40

60

80

100

% DQI Updates (Completeness & Timeliness) UER

% DQI updates

0

20

40

60

80

100

Jan

-11

Mar

-11

May

-11

Jul-

11

Sep

-11

No

v-11

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-12

% DQI Updates (Completeness & Timeliness) UWR

% DQI updates

0

20

40

60

80

100

Jan

'11

Mar

'11

May

'11

Jul'1

1

Sep

'11

No

v'11

Jan

'12

Mar

'12

May

'12

Jul'1

2

Sep

'12

No

v'12

% DQI Updates (Completeness & Timeliness) NR

% DQI updates

Figure 24: Sustainability of Wave 2: Integration of QI Feedback into District and Hospital routine feedback mechanisms

0

2

4

6

8

10

12

14

16

Q1(2011)

Q2(2011)

Q3(2011)

Q4(2011)

Q1(2012)

Q2(2012)

Q3(2012)

Q4(2012)

Q1(2013)

Quaterly feedback to Med. Dir./DDHS/DHMT UER

Planned Quaterly feedback to Med. Dir./DDHS/DHMT

Actual Quaterly feedback to Med. Dir./DDHS/DHMT

0

5

10

15

20

Q1(2011)

Q2(2011)

Q3(2011)

Q4(2011)

Q1(2012)

Q2(2012)

Q3(2012)

Q4(2012)

Q1(2013)

Quaterly feedback to Med. Dir./DDHS/DHMT UWR


Actual Quaterly feedback to Med. Dir./DDHS/DHMT

0

5

10

15

20

Q1(2011)

Q2(2011)

Q3(2011)

Q4(2011)

Q1(2012)

Q2(2012)

Q3(2012)

Q4(2012)

Quaterly feedback to Med. Dir./DDHS/DHMT


Actual Feedback to Med. Dir./DDHS/DHMT

Figure 26: Sustainability of Wave 2: Integration of QI feedback into District routine feedback mechanisms

0

5

10

15

20

Q1(2011)

Q2(2011)

Q3(2011)

Q4(2011)

Q1(2012)

Q2(2012)

Q3(2012)

Q4(2012)

Quaterly feedback to Subdistricts/Hos. Units UER

Planned Quaterly feedback to Subdistricts / Hos. Units

Actual Quaterly feedback to Subdistricts / Hos. Units

0

5

10

15

20

Q1(2011)

Q2(2011)

Q3(2011)

Q4(2011)

Q1(2012)

Q2(2012)

Q3(2012)

Q4(2012)

Q1(2013)

Quaterly feedback to Subdistricts/Hos. Units UWR


Actual Quaterly feedback to Subdistricts / Hos. Units

0

5

10

15

20

Q1(2011)

Q2(2011)

Q3(2011)

Q4(2011)

Q1(2012)

Q2(2012)

Q3(2012)

Q4(2012)

Quaterly feedback to Subdistricts/Hos.Units NR


Actual Feedback to Subdistricts / Hos. Units

19

Wave 3

0

5

10

15

20

25

30

Jan

-08

Ap

r-08

Jul-

08

Oct-

08

Jan

-09

Ap

r-09

Jul-

09

Oct-

09

Jan

-10

Ap

r-10

Jul-

10

Oct-

10

Jan

-11

Ap

r-11

Jul-

11

Oct-

11

Jan

-12

Ap

r-12

Jul-

12

Oct-

12

Jan

-13

Ap

r-13

Jul-

13

Oct-

13

Wave 3 Innovation Hospitals Showing Under 5 Deaths per 1000 Admissions (Jan 2008-May 2013) U Chart - 29% Reduction

Rate

launch: Wave 3innovation

Wave 3 Scale up

UCL

LCL

0

10

20

30

40

50

60

Jan

-08

Ap

r-08

Jul-

08

Oct-

08

Jan

-09

Ap

r-09

Jul-

09

Oct-

09

Jan

-10

Ap

r-10

Jul-

10

Oct-

10

Jan

-11

Ap

r-11

Jul-

11

Oct-

11

Jan

-12

Ap

r-12

Jul-

12

Oct-

12

Jan

-13

Ap

r-13

Jul-

13

Oct-

13

Under Five Deaths per 1000 Admissions in OLoGH, Breman Asikuma (Jan 2008 - May 2013) U Chart - 86% Reduction

Rate

launch: Wave 3 innovation

wave 3scale up

20

MNH Referral Work

Table 2: Summary of change ideas being tested

Primary

Driver

Change Ideas Stakeholder Number of

teams

testing

Socio-

cultural

barriers

During early ANC period, health providers counsel and

conduct site visits of the health facility to orient women

and reduce their fears and anxieties about facility

delivery or possible referral to hospital. Staff show the

women a new delivery bed to motivate them to deliver

at the facility.

Health

professionals

NR = 1

Sub-district health committee members to promote

care-seeking for ANC, skilled delivery as well as male

involvement in ANC and skilled delivery care seeking.

Health

professionals &

community

NR = 1

Health staff announce at ANC and CWC that women can

register and leave their ANC cards at the facility if

carrying the card home is a barrier to early registration.

Staff and woman make a joint decision about keeping

ANC card at the health facility until such a time client is

comfortable keeping her card at home.

Health

professionals

NR = 1

Use existing community groups (mother to mother

support groups, TBAs, CBVs,) traditional leaders &

existing mechanisms/structures such as durbars, prayer

camps, FM station, community information centres for

reaching communities for health promotion on

importance of early ANC, Skilled delivery, early care

seeking, referral and other areas as needed.

Community and

Health staff

NR = 3

CR = 6

Form men fun club and use gospel rock shows to get men to listen to convincing messages.

Do intensive home visits to talk to men

Meeting with key opinion leaders, assemble man

CBVs reach out to men in their farms

Health staff &

community

CR = 1

Financial risk pooling for pre-financing emergency

transport (fueling of motorbikes for transporting

emergency maternal & newborns cases):

a. Contributions are collected from each house in a community. The motorbike owner pre-finances the fuel at the time of emergency and

Community NR = 1

CR = 1

21

Primary

Driver


teams

testing

Transport

&communic

ation

is reimbursed later from the emergency transport fund.

b. Monthly church collection to cater for those who cannot pay taxi fare

a. Engage chiefs, community leaders, social and religious groups to assume greater responsibility in liaising with motor-king, motor-bike and vehicle owners in the communities to make their motors or vehicles available for transporting maternal and neonatal referrals to health facilities. Disseminate to community members the willingness of motor and vehicle owners to volunteer this service using religious & other social gatherings.

b. QI teams contact transport owners directly and not through the community leadership.

Community &

health staff

NR = 9

CR = 2

District Director of Health Service facilitates finding

emergency transportation solutions by dialoguing with

NAS, district assemblies, private transport owners and

unions and community leaders; jointly identify local,

sustainable solutions for transport for health

emergencies (drivers, repairs, upkeep and maintenance,

etc).

Management &

leadership

NR = 1

Update list and contact numbers of taxi drivers, talk to

GPRTU leadership and share with them the current

response time to emergency calls, and hold a meeting

with the drivers to improve drivers’ response to

emergency calls.

Health staff &

community

CR = 1

Health staff, HEW or volunteer conducts follow up visits

to the homes of those referred to find out, if they

complied and what the feedback on final diagnosis is.

Health staff NR = 2

22

Primary

Driver


teams

testing

Transport &

communicat

ion

I.

During first ANC visits, ensure that all pregnant women

and their families develop and agree on a Birth

Preparedness Plan and Transport Plan, including

securing the necessary permissions for skilled delivery,

funds available for transportation and upkeep while in

health facility and preparedness for referral to hospital

should the need arise.

Health staff &

individual/family

NR = 2

CR = 4

Furnish all facilities in the district with the phone

numbers of the district ambulance service and selected

community drivers to call for means of transport for

MNH referrals.

Management &

leadership

CR = 1

Mobilize communal labour to do minor repairs of roads

linking community to the health facility, using local

resources.

Community CR = 1

Hospital health information officer collects completed

feedback forms, weekly, on all referrals received in the

various wards and sends to the DHMT to pass on to the

respective referring facilities. Facilities referring without

the necessary documentation are noted and feedback

given for them to improve.

Hospital & DHMT CR = 1

Procure low cost telephones (Vodafon landlines) for all

health facilities in the district to communicate with

referral facility when sending a case. Along with this,

phone numbers of facilities in-charges in the district is

compiled and shared with the district hospital.

Management &

leadership

CR = 1

I I . Inadequat

e clinical

skills &

manageme

nt

Organize periodic customer care orientation/training for

health care providers

Health Staff

CR = 1

Provider-patient communication: engage and

communicate directly with patients/family about the

Health staff NR = 2

23

Primary

Driver


teams

testing

condition being referred, allay their fears and get family

to accept for patient to go straight to the next level

while a family member goes back to the house to

prepare and meet at the referral facility.

Make feedback form available at the health facility and

train staff on how to complete it to improve giving

written feedback to lower referring facilities

Management

/leadership &

health staff

CR = 1

Governanc

e and

accountabi

lity

Support standardized systems for referral procedures by

removing barriers hindering staff’s ability to adhere. For

staff to accompany MNH clients to next level, provide

the following support:

Means of transport to the referral point

Negotiate fuel with the family if taking the H/C means

In-charge to provide staff with pocket money to support him/her while at referral point

Accommodation if needed

Management &

leadership and

health staff.

NR = 1

improvement collaborative report november 2012 to … · 2014-04-11 · wave. this second wave...

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