On-site clinical and management mentoring: Driving sustainable

quality improvements in EmONC  

Nepali- German Support to the Health Sector Programme Valerie Broch Alvarez, Sept. 2016

Why still the focus on MNC?

539  

281  229  

170   190  

258  

0  

100  

200  

300  

400  

500  

600  

1996   2006   2009   2012   2014   2015  

Trends in maternal mortality, 1996-2015

50  

39  33   33  

23  

0  

10  

20  

30  

40  

50  

60  

1996   2001   2006   2011   2014  

SDG  target  –  12  SDG  target  -­‐  70  

Trends in neonatal mortality, 1996-2014

1.  Nepal’s policies focused on access – quality was overlooked 2.  Gaps in comprehensive quality of care: Met need for EmONC

(from 22% in 1998 to 41% in 2009) not adequately addressed 3.  Centralized pre-service training, limited in-service supervision and

re-training 4.  Lack of Midwives

 

Ø  To address inefficiencies in current training and clinical practice - tailor made CD

Ø  To retain HW in their communities

Ø  To encourage greater continuity of care with focus on processes and organizational aspects (logistics, infrastructure, equipment etc.)

Ø  To strengthen the HS, through better networking between public/public, public/private HFs and communities within each district – referral system strengthening

Why mentoring for QoC?

Mentoring for Improving MNHC

GDC support - improve care delivery with emphasis on EmONC through:

Ø  On-site training/mentoring at the HF level Ø  Developing capacity of the existing district supervisory

structure

Ø  Initiation of a systems focus on a combined clinical and management mentoring of health centre teams

Ø  Use of data for continuous quality improvement Ø  Strengthening of effective referral systems for obstetric

emergencies

 

Clinical and management mentors (10)

CEONC                  BEONC                        BC  

Health facility mentoring: Implementation

District           10 9

Districts CEONC

25 24 BEONC HP-BC

Referral  system  strengthening  

321 322 Clinical Management

516 2/5d-4/6w Visits Frequency

Results: SBA-level clinical mentoring

   #  

   MNC  QI  Tool  (#  standards)    

#  Mentees   Average  %  standards  met   %    Improvement  

(D/B)  Baseline  

(B)  Endline  (E)  

Average  difference  (D=  E-­‐B)  

1   InfecMon  prevenMon   128   45.6   85.6   40.0      88%  2   Antenatal  care   119   44.2   84.5   40.3      91%  3   ComplicaMons  of  pregnancy   147   37.9   80.3   42.3   112%  4     Normal  Delivery  and  Immediate  

Newborn  Care  116   42.5   82.3   40.6        95%  

5   Postpartum  care  (PNC)   112   23.9   81.7   57.8   138%  6   Newborn  care   141   31.2   77.6   46.5   149%  7   ComplicaMons  of  labour  and  

delivery  122   32.9   81.2   49.3   147%  

8   Assessment  of  newborn  with  a  problem  

137   39.6   76.9   37.4   94%  

Average % of standards met, baseline and endline

49.6  

59.2  

59.5  

58.1  

62.8  

46.1  

72.7  

49.2  

80.0  

95.6  

77.3  

81.9  

85.7  

78.6  

92.1  

76.4  

Tool  1:  CommiJee  structure  and  funcNon  

Tool  2:  Policies  and  guidelines  

Tool  3:  Facility  management  and  support  

services  

Tool  4:  Financial  management  

Tool  5:  Human  resource  management  

Tool  6:  Hygiene,  IP  and  waste  management  

Tool  7:  InformaNon  management  and  HMIS  

Tool  8:  TransportaNon  and  communicaNon  

Baseline   Endline  

Results: Management mentoring

Average % of standards met, management tools (N=45)

Tools # of

standards Average  %  of  standards  met  

Round 1 Round 2    Tool 1-1: Infection prevention* 16 46.4 (10) 72.1 (7) Tool 1-2: Caesarean section 5 31.7 (12) 82.0 (10)    

Tool 1-3: Laparotomy for ectopic pregnancy 10 - 72.0 (10)     B-Lynch suture - Introduced    

Tool 1-5: Condom tamponade (UBT) 5 Introduced 86.2 (13)    Tool 2-1: Blood transfusion 14 36.8 (8) 58.0 (7)    

Tool 3-1: Pre-anesthetic check-up (PAC) 9 61.3 (12) 92.0 (7)    Tool 3-2: Local anesthesia 6 63.8 (6) 61.7 (7)    Tool 3-3: Spinal anesthesia 11 57.0 (12) 84.3 (7)    Tool 3-4: Ketamine anesthesia 6 - 47.7 (8)    Tool 4-1: OTTM Operation theatre techniques and management

10 58.0 (10) 82.9 (7)    

Notes: *Infection prevention is assessed for the hospital, not for individual mentees Round 1: September 2015–February 2016; Round 2: May–June 2016 Round 1 and Round 2 scores are average scores for all mentees assessed in the respective round. Numbers in parentheses are ‘N’ of mentees assessed for each tool in the corresponding round.

   

Results: CEONC-level clinical mentoring

Average % of standards met by tool for Rounds 1 & 2

Ø Difficult to ensure locally-driven process when funding comes from EDP but essential to drive real change

Ø Staff transfers and vacancies limit effectiveness, both of mentors and mentees

Ø Referral system needs to be fully functional to gain maximum benefit

Ø  Learning may be limited in low case load locations and few opportunities to continue practising new skills

Ø Mentoring should be one element of continuous professional development (CPD)

Ø  The real cost-effectiveness of mentoring versus other forms of supportive supervision is not yet known

Lessons learned and challenges

Conclusion and outlook

Ø Mentoring improves both clinicians and managers mentees’ motivation, confidence and adherence to MNCH protocols

Ø Mentoring checklists enable evidence-based feedback and continuous QI

Ø Mentorship integrates in-service training and systems improvement into routine care delivery

Ø  Incorporation of the concept into NHSS (2015–2020) Ø  Institutionalization of the mentorship approach for

continued QoC into the system – focus of next phase  

THANK YOU!