Hill: Crossing the Implementation Divide - Improving Quality of Newborn Services

7/28/2019 Hill: Crossing the Implementation Divide - Improving Quality of Newborn Services

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Crossing the Implementation Divide:

Improving Quality of Newborn Services

Kathleen Hill, M.D., M.P.H.

Deputy Director USAID ASSIST Project

USAID Health Care Improvement Project

University Research Co. LLC

Global Newborn Health Conference

April, 20131


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What is the Problem?

The reality is straightforward. The power of

existing interventions is not matched by the

power of health systems to deliver them to

those in greatest need, in a comprehensive

way, and at an adequate scale.

Margaret Chan

Director General

World Health Organization


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Scaling up effective coverage

Building health systems capable

of continuously improving and

sustaining quality care is essential forachieving and sustaining effective

coverage of high impact interventions

for every mother and child

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Every system is

perfectly

designed to achieve

exactly the results it

achieves

(Batalden & Stolz1993)

The Issue of Quality in Health Care


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Commercial aviation vs health care:Comparative Risks Adverse event

1:300 1:10,000,000


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How skilled are SBAs?

Harvey et al. Bulletin of the WHO, 2007

0%

25%

50%

75%

100%

Knowledge Neonatal resuscitation Manual removal of

placenta

Bimanual uterine

compression

Benin Ecuador Jamaica Kenya Nicaragua Rwanda


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A framework for continuouslyimproving quality of care


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Achieving effective coverage of impact newborn

interventions: What does it take?

INPUTS PROCESSES RESULTS

Reliable delivery of

effective

interventions

Effective organization

of care processes

Safe (not harmful)

Respectful

Mortality & morbidity

Incidence ofcomplications

Case fatality

Negative patient

experience of care

Low utilization of care

Supportive policy

Available, motivated,competent staff

Essential

commodities available

Standards & robustmeasures

HMIS


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Crossing the Implementation Divide

Improvement Principles: Understanding health care in terms ofprocesses and

systems

Team-work (all relevant actors, all system levels)

Regularmeasurement of quality measures (adherencewith standards) for action

Focus on patient needs

(client-centered)

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Regularly measuring quality ..Despite challenges it is possible

Improvement teams (e.g. DHMT, service delivery) set

improvement objectives based on high impact interventions

(content) and regularly measure prioritized content

indicators to determine whether (or not) they are meetingtheir objectives

Teams adapt medical records and registers as necessary

to measure and regularly track prioritized content indicators

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Adapting local medical records to capturequality of post-partum care: ENC & AMTSL


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Delivering integrated RMNCH packages at criticalleverage points along the RMNCH continuum(Bernadette Daelmans, WHO)

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Improving Care Where Patients Receive Care

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Improving a post-partum package of care formothers and newborns: Niger 28 maternitiesAverage 2,100 births per month

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Indicator Dec 2005(baseline)

2006 2007 JulySept

2008

% births AMTSL applied 0% 34% 98% 99.5%

% births BF within one hour 23% 44% 98% 99%

% compliance ENC standards

(composite)

17% 35% 96% 99%

% compliance AMTSL

standards (composite)

27% 51% 98% 100%

Postpartum hemorrhage

(PPH) rate (#PPH cases/#

births)

2.1% 0.6% 0.4% 0.2%

Total # births 28,937 40,510 12,284

Number of maternity facilities 28 33 39


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Accelerating effective coverage of high impactintervention packages

Multiple teams from different sites & system

levels work together intensively to test, share and

implement changes to reliably deliver high qualitycare for every patient in a common clinical or

public health area


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Shared learning accelerates implementation

QI team site

Which changesreally yield

improvements?

What changes are

robust and effective

across teams?

Collaborative coach

or manager

Site-level summaryQI team

Learning

Session

representative

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Examples of local changes in processes of careto improve integrated post-partum care formothers and newborns

Stocked bedside cooler

with pre-filled oxytocin

Regular breast feeding

support

Equipped ready

Newborn Corner

every delivery room

Regular post-partum monitoring of

mother & newborn first 24 hours

Pre-discharge physical mother &

newborn


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Synthesizing Learning: National Workshop Niger

E t di l i f Ni M li


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Training in

AMTSL and QI

LS1 + Key Niger

successful changes sharing

Coaching visitsBaselineassessment

Baseline results restitution

+ Niger EONC Collaborative

Experience sharing

Learning Session 2

Extending learning from Niger Mali:Improving ENC , 41 health centersKayes & Diema Districts, Oct 2010-Sep 2012

Percent of compliance to ENC norms in EONC collaborative target sites, Kayes

regional hospital, Kayes and Djema districts, October 2010 September 2012

O N D J F M A M J J A S O N DJ12

F M A M J J A S

# of complied criteria to norms 491 502 502 574 597 917 121 124 135 133 138 135 136 133 132 134 139 129 138 137 140 132 129 118

# of cri teria 126 126 128 131 127 136 139 142 142 141 142 137 137 133 132 135 139 129 138 137 141 132 129 124

% of compliance to ENC norms 39 40 39 44 47 67 87 88 95 94 97 99 99 100 100 99 100 100 100 100 100 100 100 96

# Sites 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 40 40 40

0

1020

30

40

50

60

70

80

90

100

% compliance toENC norms

Months21

I i dh ith PNC b t ti


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Improving adherence with PNC best practices:Herat Province Afghanistan; 9 Health Centers

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Uganda: Monthly Coaching /refresher training sessions

Masaka & Luwero Districts Uganda


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Uganda: Improving ENC & PNC, 34 MaternitiesLuwero & Masaka Districts, Nov 2010 Aug 2012

Nov10: Training MNCHdistrict coaches on ENC

Dec 10: Introduction of ENCregisters

Jun 11: TEO stock outs

Jan 12: 2nd Learningsession

Jul12: 3rd Learningsession

Feb 11: Training healthworkers in ENC

Mar 11:Training healthworkers in QI 1st Learning

session

0

20

40

60

80

100

Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12

Perc

entage

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11 Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12 Jul-12

Aug-12

% of newborns who received3 components of ENC

3 24 26 49 51 71 78 74 70 68 60 72 60 65 66 74 80 66 64 60 78 86

# of Sites Reporting 9 20 22 24 28 32 34 34 34 34 34 34 34 34 34 34 34 34 34 34 34 34

% of newborns put to thebreast within 1 hour of birth

1 18 21 34 40 47 55 59 66 59 64 73 68 73 73 79 91 75 67 63 84 88


% of newborns examined by skilledprovider at 4 to 7 days after birth

0 9 8 17 17 13 18 19 22 22 20 21 16 21 24 22 18 19 16 28 30 25


% Newborns who received 3 components of ENC, initiated early BF, and examined by a skilled provider

4-7 days after birth in 34 sites in Luwero and Masaka districts, Uganda, November, 2010 August, 2012

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Uganda: Improvement Team Meeting


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L L d E bli i t f


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Lessons Learned: Enabling environment forcontinuous Improvement

Leadership and engagement key stakeholdersessential(national, regional, district, facility, community)

High impact content is at the heart of rapidly improving

effectiveness of care

Building provider competence must be integrated as a

central component of improvement work

Initially improvement teams need support; then they become

the improvement experts

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A hi i & t i i ff ti


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Achieving & sustaining effective coverageof Best Buys..

Comprehensive improvementapproaches target all levels of a health

system to deliver and scale-up best buys

(vertical) and help strengthen health

systems (horizontal)

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Thn Thank You

Thank you

Hill: Crossing the Implementation Divide - Improving Quality of Newborn Services

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