The Need for Quality Improvement : Challenges and Options

Indira Narayanan, MDConsultantMCHIP

Two Golden Truths

2

• Mere PRESENCE of skilled birth attendants does not guarantee quality newborn care

• Mere TRAINING of skilled birth attendants (even if competency based) does not guarantee quality newborn care

EVOLUTION OF SKILLS OF PROVIDERS IN 10 HZ(DRC) (At end of training all providers scored at least 80% ( most near 100%) when

evaluated with checklists)

AMTSL ENC RESUSC. PP CARE EXAM NB MINOR INF MAJOR INF0

10

20

30

40

50

60

70

80

90

100

72

92

62

74

62

91

49

8386

61

8388

61

75

9497

78

94 9296

84

Aug/Sept 09 (n= 47) Feb/May 10 (n= 24) Juin/Sep 10 (n=36)

PERC

ENTA

GE

Providers who gained skills through interaction with trained health workers gained similar competence

AMTSL ENC RESUSC. PP CARE EXAM NB MINOR INF

MAJOR INF

0

20

40

60

80

100

72

92

6274

62

91

49

83 86

61

83 88

61

75

94 97

78

94 92 9684

Aug/Sept 09 (n= 47) Feb/May 10 (n= 24) Juin/Sep 10 (n=36)PE

RCEN

TAG

E

AMTSL ENC RESUSC. PP CARE EXAM NB MINOR INF

MAJOR INF

020406080

100 8495

5467

57

94

40

Aprl/May 10 (n= 19)

PER

CEN

TAG

E

Supervision is not always in the job description of hospital staff Self learning and mentoring cultures limited Supervisors are in govt. offices - limited clinical skills, poor

motivation for visits to peripheral centers – want incentives Supervision often considered long after training Peripheral centers are scattered and not sufficiently staffed Clinical competence needs support of commodities +referral

system – inadequate cases necessitates more mannequins Some NB indicators are not in HMIS –therefore not collected Baseline / end-line surveys are costly

23

Maintaining and improving quality of care through supervision: Challenges

Possible options to improve quality: Before training

Policies Follow HBB guidelines for adapting Advocate early for key indicators to be in HMIS

–can serve as benchmarks for assessing quality of care /results• Drying/stimulation/warmth – regular part of ENC• Airway Clearing• Ventilation• Outcome

Plan for having key Information in delivery registers – case sheets/partographs more likely to be lost/ misplaced

Possible options to improve quality

Before Training (Cont’d) Develop consensus on major issues with existing

programs Plan/get in place

• Equipment, supplies and mannequins. Allow time for procurement in planning program activities

• Resources for M & E – commence with additional columns/note books - plan use of benchmarks

During training course Use terminologies that are widely understood in the

country including peripheral health workers Brainstorm+ develop plans for quality+ M & E Brainstorm on how to get help for resuscitation

Possible options to improve quality During and after training

During training and evaluation including in OSCE 2 Monitor method of placement of mask to get a

better seal Monitor (a) the health worker looks for appropriate

chest expansion and (b) the facilitator verifies expansion

After training, while individual assessment through visits is ideal, it is time consuming and does not permit many workers to be covered, especially in peripheral centers. Additional methods of supervision include Internal supervision for larger centers/hospitals Group supervision for health centers with few staff.

Explore innovative methods such as use for m Health for both M & E and quality of care

Late acquisition of equipment and insufficient number of cases may have resulted in decrease in competence at the

first supervisory visit –improved with further support

Group supervision: more workers are targeted (5 S1 compared to 12 S2 and 13 S3) – USAID/BASICS)

Pretest (N:19) Oct 08

Post test (N:18)

Suivi 1 (N:5) Dec 08

Suivi 2 (N:12) Fev 08

Suivi 3 (N:13) Mar 08

0102030405060708090

100

66.3

95.57

68.81

88.22 90.98

Compétences en Réanimation des agents de santé de Betioky (Madagasdcar)

Pour

cent

age

des

moy

enne

s de

not

esSkills of Betioky (Madagascar) health workers on resuscitation

techniques

Perc

enta

ge o

f ave

rage

scor

es

Follow-up 1 (N=5) Dec 08

Follow-up 2 (N:12) Feb 08

Follow-up 3 (N:13) Mar 08

Group supervision (modified collaborative approach): Advantages

More agents are covered in a shorter time Agents help and motivate each other Fruitful exchanges on problems encountered in practice and

possible solutions Opportunity for supervisors to provide suggestions for

improvement to the group Easier to take decisions, define priorities, try solutions (PDSA) Useful for reviewing skills relating to cases that are infrequent

such’ birth asphyxia’ or an sick newborn in health centers) Rotating sites can be useful to inspect other centers Facilitation by NGO’s helpful

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Two Golden Rules

Training alone not enough. We must consider : Capacity building for

provision of documented good quality HBB care

Definition and documentation of the results

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