Improvement Collaboratives

36
Quality Improvement Quality Improvement Collaboratives Collaboratives GH Mini University GH Mini University October 27, 2006 October 27, 2006 James Heiby James Heiby Medical Officer Medical Officer GH/HIDN/HS GH/HIDN/HS

Transcript of Improvement Collaboratives

Page 1: Improvement Collaboratives

Quality Improvement Quality Improvement CollaborativesCollaboratives

GH Mini UniversityGH Mini UniversityOctober 27, 2006October 27, 2006

James HeibyJames HeibyMedical OfficerMedical Officer

GH/HIDN/HSGH/HIDN/HS

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Session OutlineSession Outline

Measuring how good health care isMeasuring how good health care is Established approaches for improvingEstablished approaches for improving Continuous Quality Improvement modelContinuous Quality Improvement model How the collaborative methodology How the collaborative methodology

modifies CQImodifies CQI Results so far in developing countriesResults so far in developing countries Issues with the collaborative methodologyIssues with the collaborative methodology DiscussionDiscussion

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A scenario:A scenario: A mother brings her 8 month old girl to a A mother brings her 8 month old girl to a

MOH clinic in rural AfricaMOH clinic in rural Africa She is very thin, has a high fever, labored She is very thin, has a high fever, labored

breathing, and is not breast feedingbreathing, and is not breast feeding 4 years earlier, you were on a team that 4 years earlier, you were on a team that

designed a health project that was designed a health project that was implemented in this regionimplemented in this region

Project supplies basic drugs/supplies Project supplies basic drugs/supplies The health worker enters the exam room The health worker enters the exam room

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A Systems View of QualityA Systems View of Quality Inputs/structure: The resources deemed Inputs/structure: The resources deemed

necessary to provide health carenecessary to provide health care Drugs, equipmentDrugs, equipment Competent providerCompetent provider Guides, job aids, recording formsGuides, job aids, recording forms

Process: The activities of providing health care Process: The activities of providing health care are carried out correctly are carried out correctly Compliance with clinical standardsCompliance with clinical standards Interpersonal elementsInterpersonal elements Systems to support patient care efficientlySystems to support patient care efficiently

Outcomes: The results of the health care process Outcomes: The results of the health care process meet expectationsmeet expectations Mortality, morbidityMortality, morbidity Completed immunizationsCompleted immunizations

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Impact of an EBG for Impact of an EBG for Diarrhea in malnourished Diarrhea in malnourished

children in Dhakachildren in Dhaka(Ahmed, et al, Lancet, 1999)(Ahmed, et al, Lancet, 1999) Following Following

standardized standardized clinical protocol:clinical protocol: Mortality 9%Mortality 9% Oral fluids only 60%Oral fluids only 60% Antibiotics used Antibiotics used

18%18%

Following usual Following usual practice at practice at ICDDR,B Hospital:ICDDR,B Hospital: Mortality 17%Mortality 17% Oral fluids only 29%Oral fluids only 29% Antibiotics used Antibiotics used

40%40%

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How well do providers follow How well do providers follow evidence-based guidelines?evidence-based guidelines?

How do programs know about this?How do programs know about this? What do we find when we look?What do we find when we look? What are the trends for the future?What are the trends for the future?

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JHU Uganda Performance JHU Uganda Performance According to Standards According to Standards

Survey (2001)Survey (2001) National sample, 30 health centersNational sample, 30 health centers 81 indicators grouped into indices; 81 indicators grouped into indices;

published MOH standardspublished MOH standards IMCI assessment: 47%IMCI assessment: 47% IMCI treatment: 35IMCI treatment: 35 Malaria treatment: 70Malaria treatment: 70 Antenatal care: 35Antenatal care: 35 Family Planning: 44Family Planning: 44 STI STI 14 14

Moderate variation among districtsModerate variation among districts

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How do programs traditionally How do programs traditionally try to improve compliance with try to improve compliance with

EBGs?EBGs? What approaches are widely used?What approaches are widely used? How are these approaches working?How are these approaches working? What have we learned about What have we learned about

improving compliance?improving compliance?

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The Basic Principles of Continuous The Basic Principles of Continuous

Quality Improvement (CQI)Quality Improvement (CQI) The delivery of modern health services The delivery of modern health services

is complex and dynamicis complex and dynamic It is feasible to study the process of It is feasible to study the process of

health care and find ways to improve ithealth care and find ways to improve it Our hypotheses about how to improve Our hypotheses about how to improve

health care should be tested before we health care should be tested before we accept themaccept them

Regular health workers can do most of Regular health workers can do most of this workthis work

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Basic Principles, continuedBasic Principles, continued

Improvement work consumes health Improvement work consumes health resources, and should be accountableresources, and should be accountable Benefits should exceed the costsBenefits should exceed the costs Current investments areCurrent investments are

Extremely smallExtremely small Primarily the time of health staffPrimarily the time of health staff

The benefits of successful improvement The benefits of successful improvement work grow as it is:work grow as it is: Extended into the futureExtended into the future Spreads geographicallySpreads geographically

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How do we change the system? The Model for Improvement

What are we trying to

accomplish?

What change can we make that will result

in an improvement?

How will we know that a change is an

improvement?

PLAN

DO

STUDY

ACT

1.

2.

3.

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Standards for Neonatal Resuscitation will be Standards for Neonatal Resuscitation will be Applied at Each DeliveryApplied at Each Delivery

Percentage of deliveries in which neonatal resuscitation guidelines were applied correctly

0

20

40

60

80

100

120

%

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Mpumalanga TB Data: Case Mpumalanga TB Data: Case finding per quarter finding per quarter

(Data from 30 clinics: 10 per district)(Data from 30 clinics: 10 per district)

240 238289

516 502472

524

0

100

200

300

400

500

600

1st Qtr02

2nd Qtr02

3rd Qtr02

4th Qtr02

1st Qtr03

2nd Qtr03

3rd Qtr03

QI started

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Salima: Improving Patient Salima: Improving Patient Compliance - MalariaCompliance - Malaria

ProblemProblem High rate of malariaHigh rate of malaria

“re-attendants”“re-attendants” Cause AnalysisCause Analysis

Discarded drugs Discarded drugs 23% of patients re-23% of patients re-

attendants (n=761)attendants (n=761) 84% of patients 84% of patients

“forgot” “forgot” instructions (n=43)instructions (n=43)

InterventionsInterventions DOT dose of SPDOT dose of SP Blood smear for all Blood smear for all

re-attendants re-attendants Educate the Educate the

community on community on importance of importance of following treatment following treatment instructionsinstructions

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Result: Decreased Result: Decreased Re-attendant Malaria PatientsRe-attendant Malaria Patients

22.7

7.3 7.1

3.31.9

0.5

0

5

10

15

20

25

Feb. March April May June July% r

e-a

tte

nd

an

t m

ala

ria

pa

t

DOT implemented

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Why isn’t everyone doing this?: Evaluation of Why isn’t everyone doing this?: Evaluation of Zambia QA ProgramZambia QA Program

Findings from a field evaluation one year after the end of Findings from a field evaluation one year after the end of USAID assistance, based on a sample of 25 clinicsUSAID assistance, based on a sample of 25 clinics

Motivation for doing additional work: many teams stopped Motivation for doing additional work: many teams stopped after first problemafter first problem

Poor choice of problem, few clinical issuesPoor choice of problem, few clinical issues Inefficiency: minimal spread of innovations among teamsInefficiency: minimal spread of innovations among teams Documentation weakDocumentation weak Slow pace of improvementSlow pace of improvement Training costs high relative to improvementsTraining costs high relative to improvements Leadership among senior MOH management lackingLeadership among senior MOH management lacking

What does the field of modern quality improvement have to What does the field of modern quality improvement have to offer that might address these problems?offer that might address these problems?

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The Improvement The Improvement Collaborative MethodologyCollaborative Methodology

Traditional QI teams and methodsTraditional QI teams and methods Organized around a specific topicOrganized around a specific topic Many teamsMany teams Technical experts provide a model of Technical experts provide a model of

care feasible for the system, with care feasible for the system, with indicatorsindicators

High level sponsorsHigh level sponsors Frequent communications among teamsFrequent communications among teams Wide experience in developed countriesWide experience in developed countries

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Value Added of Multiple Teams Value Added of Multiple Teams Working on a Single Problem:Working on a Single Problem:

More rapid progressMore rapid progress Each team learns from work of the others: Each team learns from work of the others:

don’t re-invent the wheeldon’t re-invent the wheel Peer group provides motivation for QI workPeer group provides motivation for QI work facilitates spread of improvements--more facilitates spread of improvements--more

efficientefficient Pressure for better, quantitative recordsPressure for better, quantitative records Can focus on priority issuesCan focus on priority issues Framework for scaling upFramework for scaling up

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Collaborative Improvement Model as Adapted by QAP

Country andProvince Selection

Orientation of Country

Leader Teams

BaselineAssessment

IdentifyCountryTeam

CQI Teams

FinalizeTechnical Content/Change Package

A D

P

S

A D

P

S

A D

P

S

Conclusion of Collaborative

Ongoing exchange of experiences:-- Website/Extranet-- Coaching visits-- Periodic meetings of teams-- Telephone calls

ExpertMeeting

LEARNING SESSION 2

LEARNING SESSION 3

LEARNING SESSION 4

LEARNING SESSION 1

PreparatoryPreparatory

Stage at local

Stage at local

levellevel18-24 months

Monthly reporting on indicators

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RwandaRwanda Malaria Collaborative Malaria Collaborative OverviewOverviewGeographical Scope

• 4 districts (Gisenyi, Kibungo, Muhima, Ruhengeri)

• 23 teams and sites•19 health centers•4 district hospitals

Progress• baseline study in 2 districts completed Nov 2002

• quality improvement (QI) changes and indicators proposed by level of care

• 70% of sites used flowcharts to analyze their problems

• QI changes made and results monitored

• Mortality impact in both simple and severe malaria

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Exampless of Findings from Exampless of Findings from Initial Assessment (2 district Initial Assessment (2 district

sample)sample) no children were (case) managed no children were (case) managed

according to norms according to norms only 29% of children treated only 29% of children treated

according to norms according to norms mothers wait an average of 3 days mothers wait an average of 3 days

before going to health centre before going to health centre 31% of health centres have had 31% of health centres have had

stock-outs during the 30 days stock-outs during the 30 days before assessmentbefore assessment

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Key ChangesKey Changes For malaria in children 0-4 yearsFor malaria in children 0-4 years Decision to seek care within 24 Decision to seek care within 24

hourshours Diagnosis and treatment at health Diagnosis and treatment at health

centers and hospital according to centers and hospital according to national standardsnational standards

No stockouts of drugs or supplies No stockouts of drugs or supplies at districtat district

Appropriate and successful Appropriate and successful referral of serious casesreferral of serious cases

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MeasuresMeasures Numbers of children treated in health Numbers of children treated in health

centerscenters Numbers of severe cases treated in district Numbers of severe cases treated in district

hospitalhospital Number of deaths due to malaria in hospitalNumber of deaths due to malaria in hospital Hospital case fatality rate for child malaria Hospital case fatality rate for child malaria

cases cases Percent of children treated according to Percent of children treated according to

national norms in HC and hospitalnational norms in HC and hospital Error rate of lab tests on quality control Error rate of lab tests on quality control

exercisesexercises Stockouts of drugs or supplies at HC/hospStockouts of drugs or supplies at HC/hosp

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RWANDA MALARIA COLLABORATIVE: RWANDA MALARIA COLLABORATIVE: IMPROVEMENTS IN CARE-SEEKING BY MOTHERS (19 IMPROVEMENTS IN CARE-SEEKING BY MOTHERS (19

HEALTH CENTERS)HEALTH CENTERS)

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1000

1500

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% children age 0-5 presenting with malaria who were taken to consultation within 24h

53 56 63 66 69 78 79 82 81 79 77 76

a) Number of children under 5 years admitted with signs of malaria

1505 1384 1450 1538 1705 2295 2160 2264 2244 2262 2144 1777

J A S O N D J F M A M J 2004 2005

%

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Changes tested by the teamsChanges tested by the teams CHWs motivated and included in CHWs motivated and included in

teamsteams CHWs organized their own meetingsCHWs organized their own meetings Bonus for CHW performanceBonus for CHW performance Educational materials distributed in Educational materials distributed in

community churchescommunity churches Presentations at community meetingsPresentations at community meetings Discount on clinic fee for bringing child Discount on clinic fee for bringing child

within 24 hourswithin 24 hours

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RWANDA MALARIA COLLABORATIVE: RWANDA MALARIA COLLABORATIVE: IMPROVEMENTS IN CASE MANAGEMENT OF IMPROVEMENTS IN CASE MANAGEMENT OF

CHILDREN < 5 YEARS (19 HEALTH CENTERS)CHILDREN < 5 YEARS (19 HEALTH CENTERS)

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% children age 0-5 with malaria who were managed according

to norms at health centres

43 60 73 79 85 88 90 91 91 92 92 93

# cases of malaria analysed in the month 385 393 390 391 396 398 394 399 393 381 346 310

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

%

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Changes tested by the Changes tested by the teamsteams

CM training during weekly staff CM training during weekly staff meetingsmeetings

Regular review of medical recordsRegular review of medical records Flow charts, other provider job aidsFlow charts, other provider job aids Improved patient registrationImproved patient registration Reorganization of servicesReorganization of services Started triage Started triage Extended lab availabilityExtended lab availability

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Niger Pediatric Hospital Niger Pediatric Hospital Improvement CollaborativeImprovement Collaborative

Proportion of Pneumonia, Malaria and Diarrheal Disease Cases Managed According to WHO Standards

Jan 04 - Aug 05 (14 Nigerien District Hospitals)

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Jan-

04M

arM

ay Jul

Sep Nov

Jan-

05M

arM

ay

Jul

Per

cen

tag

e o

f C

ases

Pneumonia

Malaria

Diarrheal Disease

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Equipe de PMTCT de Equipe de PMTCT de KicukiroKicukiro

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KICUKIRO Health Facility:Percentage of partners tested

0102030405060708090

Months - 2003

Changes tested:-Home visits and meetings by couples involved in the PMTCT program-Home visits by health providers -IEC on responsible paternity

LS1 LS2

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Gihundwe Health Facility: % of partners tested

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Jan Feb Mar Apr May June July Aug Sept Oct Nov

Months - 2003

Send invitation letters to partnersReinforce counselling

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Rwanda PMTCT—Data Exported Rwanda PMTCT—Data Exported from Extranetfrom Extranet

% of Partners Tested (16 initial sites)

0

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0.8

1

1.2

Butare

Byumba

Gikonko

Kicukiro

Gihundw e

Gisenyi

Muhima

Kanombe

Kabgayi

Kacyiru

Muhura

Nyagatare

Ruhengeri

Ruli

Kibuye

Kigeme

Percentage of partners of prenatal care women who were tested for HIV

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Evolution of the Evolution of the CollaborativeCollaborative

Expected duration of 9-18 monthsExpected duration of 9-18 months Leaders schedule final meeting based on Leaders schedule final meeting based on

results: teams using a package of results: teams using a package of improvementsimprovements

Expansion (or Spread) Collaborative:Expansion (or Spread) Collaborative: high performers can each lead a new efforthigh performers can each lead a new effort change package requires minor adaptationchange package requires minor adaptation Rogers’ Rogers’ Diffusion of InnovationsDiffusion of Innovations

Potential for multinational sharing of best Potential for multinational sharing of best practicespractices

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Late Majority

Early Majority

Early Adopters

Tradition-alists

Innovators

Successful Collaboration-Successful Collaboration-Identify and Make Use of Identify and Make Use of

the “Early Adopters”the “Early Adopters”

2% 13% 35% 35% 15%

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Active Management of the Active Management of the Third Stage of LaborThird Stage of Labor

IND. # 4: Partos vaginales atendidos en los H. del País en los que se administró 10UI. de Oxitocina intramuscular dentro del minuto después del nacimiento del bebé y se registró en la HCP. Ecuador, Honduras y Nicaragua. J ulio/03 a Diciembre/05

0

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ECUADOR 0 15 14 17 22 32 37 37 40 38 41 37 48 51 59 58 56 55 49 53 63 64 57 68 65 69 73 70 69 71

HONDURAS 92 99 100 99 100 96 94 95 100 96 98 93 95 99 98 99 98 94 99 100 100 100 100 100

NICARAGUA 69 76 86 86 88 92 93 93 94 99 92 95 94 97 98 99 96 97 99 99 98 100 98 99 97 97 98 98

Jl-03

Ag Sp Ot Nv Dc En Fb Mr AB My Jn Jl Ag Sp Oc Nv Dc En Fb Mr Ab My Jn Jl Ag Sp Oc Nv Dc

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Some issues for discussionSome issues for discussion

How to maximize learning from this How to maximize learning from this experience (17 USAID supported experience (17 USAID supported collaboratives to date)collaboratives to date) Documenting and analyzing implementationDocumenting and analyzing implementation What’s working and what needs to be fixedWhat’s working and what needs to be fixed How to make this approach more cost-effective and How to make this approach more cost-effective and

simpler simpler Connecting collaboratives to the Connecting collaboratives to the

institutionalization of improvementinstitutionalization of improvement Leadership: countries, donors, othersLeadership: countries, donors, others Obstacles to wider useObstacles to wider use