quality improvement in reproductive, maternal, newborn and child health

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Quality Improvement

RHMNCH

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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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


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


Sustainable Response

Objective 4 of the National MNH Implementation Plan, 2016

QI embedded in county health strategic plans

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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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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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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


Use of conceptual frameworks to define QI Approaches

The Model for Improvement


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


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


Use of simple Problem Identification Tools

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Focus a lot more on the means, not ends

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QI Focus


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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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?


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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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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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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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


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)


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


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


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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C/S: Decision to Incision – Kitui

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0102030405060708090

100

Axis Title


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


Scale or spread – Use of QI champions and Learning Session


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


Invest in Coaching in Quality Improvement


In QI

“Don’t Eat the whole Elephant”

Introduce one concept at a time


Sharing through Learning Sessions

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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


Thank You

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quality improvement in reproductive, maternal, newborn and child health

Health & Medicine