Ruma Rajbhandari, MD MPHNick Simon’s InstituteGlobal Health Equity

ResidencyBrigham and Women’s

HospitalHarvard Medical School

Introduction to Healthcare Quality Improvement in Resource-Poor

Settings

A 6-month-old boy with severe respiratory distress presented to X Hospital in Nepal. Previously, the boy had been seen by untrained private practitioners in the community three times over four days. At presentation to X hospital, the child was evaluated by a health assistant who provided an initial course of antibiotics. Despite the child's ill appearance, supportive treatment including intravenous fluids and supplemental oxygen were not provided until discussion with the Medical Director three hours later. Later that evening, the electric nebulizer and oxygen concentrator became unusable after the hospital lost power owing to a blackout of the public electric grid and malfunctioning of the hospital’s backup generator. The regulator for the backup oxygen canister could not be found. At this juncture, without the ability to provide oxygen, the medical team recommended transfer. Unfortunately, the family refused transfer due to the high costs of other health facilities. That evening, after not being examined for over two hours by on-call staff, the child was found unresponsive. Cardiopulmonary resuscitation was not initiated for over ten minutes as the midwife managing the ward did not know the procedure and the bag valve mask was not at the bedside. Following fifteen minutes of unsuccessful resuscitation, the child was declared dead.

Outline of presentation Definition of quality in health careQuality improvement in resource poor settingsQuality improvement tools that can be used in

resource-poor settings with successful examples from different parts of the worldQuality improvement committeeDevelopment of standards and checklistsClinical auditsPatient exit interviewsMorbidity and & Mortality conferencePDSA cycles

What is quality?

[Crossing the Quality Chasm: A New Health System for the 21st Century (2001), Institute of Medicine (IOM), United States of America]

Quality gap

Quality gap

JAMA 284(23):2994-2995, 2000.

Six domains of health care qualitySafetyEffectivenessEfficiencyPatient-centerednessTimelinessEquity[Crossing the Quality Chasm: A New Health System

for the 21st Century (2001), Institute of Medicine (IOM), United States of America]

Definition of QualityDefinition of Quality

Meeting the needs and exceeding the expectations of those we serve

Delivering all and only the care that the patient and family needs

Using the framework of clients’ rights and staff needs Clients’ rightsInformation Access Informed choice Safe services Privacy and

confidentiality Dignity, comfort,

and expression of opinion

Continuity of care

Needs of health care staff

Facilitative supervision and management (clear job expectations, feedback, motivation)

Information, training, and staff development (skills and knowledge)

Supplies, equipment, and infrastructure (organizational and environmental support)

Facilitative Supervision for Quality Improvement Curriculum, 2008

USAID, the ACQUIRE Project

Quality improvement in resource-poor settingsSince the 1980s, quality improvement (QI)

research and implementation have taken steps towards reducing the “quality chasm” that exists in developed-country settings.

Quality improvement in resource-poor settings has not been given much attention.

Increasing funds for resource-poor setting to scale-up health services and programs (e.g. number of AIDS patients on ARVs) Focus on quantity of services provided

The quality of many of the resultant services has often times been low or poorly understood

Why should I care about Quality?

“We are already too busy. We don’t have time to think about quality”

“We don’t have enough money to think about quality”

“Our patients aren’t interested in quality”“This is Nepal. Your fancy ideas about quality

aren’t going to work here”

Basic quality improvement toolsQuality improvement tools that can be

used in a resource-poor district hospital setting:1. Quality improvement committee2. Development of standards and

checklists 3. Clinical audits 4. Patient exit interviews5. Morbidity and & Mortality conference 6. PDSA cycles

Examples of successful QI programs in resource poor settingsNepal Safe Motherhood Program (QI

committee, checklists, clinical audit, patient exit interview)

Nyaya Health, Achham (M&M, PDSA cycle)

Partners in Health, Rwanda (PDSA cycle)

Nepal Safe Motherhood Project (NSMP) ExperienceQoC (Quality of Care)

approachInfection Prevention

and Maternity Teams composed the QI committee

Monthly Assessment using checklists which defined a standard of care

Quarterly reviewSemi-annual

assessment and review

Hospital-based QI committee

• Should focus on quality improvement in the district hospital e.g. Infection Control, Maternity, Inpatient, OPD/ER

• Members: All hospital staff including doctors, nurses, health assistants/paramedics, support staff, store keeper, pharmacy personnel

• Leaders: doctors, nursing-in-charge

Quality of Essential Obstetric Care: Monitoring Tools/Checklists

Q1.   Accessibility and availability of services Indicator: 1 1. BEOC facility is providing the following services 24

hours a day Q1.1.0 Injectable oxytocic Y N Q1.1.1 Injectable antibiotics Y N Q1.1.2 Injectable sedatives/ anticonvulsant Y N Q1.1.3 Injectable anti-hypertensives Y N Q1.1.4 Plasma expanders Y N Q1.1.5 Instrumental delivery ( Forceps/ Vacuum ) Y N Q1.1.6 Manual Removal of Placenta Y N Q1.1.7 D&C Y N Q1.1.8 MVA/Post Abortion Care Y N

Q1.2 Indicator: 2 CEOC facility is providing the following services 24 hours a day

Q1.2.1 All of the above Y N Q1.2.2 Caesarean Section Y N Q1.2.3 Laparotomy Y N Q1.2.4 Blood Transfusion Y N

How to use the checklist toolsSECTION 7PERFORMANCE STANDARDS FOR INFECTION PREVENTION

Health Facility:____________________ Date of visit: _______________ Evaluator_______________

PERFORMANCE STANDARDS VERIFICATION CRITERIA Y / N NA

1. The various departments and clinic has available running water

Observe during the visit whether there is running water in:The sinksThe washbasinsThe toilet tanks for personnelThe toilet tanks for clients

2. The hospital area is clean. Observe whether there are no dust, trash or waste in the following areas:

External area Waiting room Hallway Examining rooms Emergency rooms Laboratory Sterilization area Toilets Storeroom Utilities areas

How to use the checklist tools: scoring

TOTAL STANDARDS: 10

TOTAL STANDARDS OBSERVED:

TOTAL STANDARDS ACHIEVED:

PERCENTAGE (STANDARDS ACHIEVED / OBSERVED) %

Monthly Action PlansQuality Improvement Tools

Action Plan

Facility: ___Gulmi District Hospital____________ Prepared By: ___Nursing-in-charge______________ Date: ____Feb. 24th, 2011______________

TOOL # GAP CAUSE INTERVENTION /

ACTION RESPONSIBLE SUPPORT DEADLINE

SBA:Infection prevention

No running water in admission/ER

room

No pipe/no faucet/no

sink

Will obtain bucket with a tap to be refilled daily by

support staff

1. Nursing-in-charge will obtain bucket from store room

2. Support staff will be assigned duty of making sure bucket is refilled daily`

Need support of store room, nursing and support staff

1 week (March 3,

2011)

Clinical AuditsAn audit is a systematic and critical

analysis of the quality of medical care. It includes “the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient” (Crombie et al 1997).

Too often assumptions are made that best practices are followed.

Audits permit clinicians to learn how often best practices are really followed and under what circumstances.

Criterion-based clinical audit cycle

Step 1: Establish criteria of good

practice and define cases

Select topics: e.g. Management of major obstetric complications

Step 5: Re-evaluate

practice and give feedback

Step 4: Implement changes in practice

where indicated. E.g. skills up-dates, clinical

guidelines

Step 3: Feedback

findings and set local

standards

Step 2: Measure current practice:

-Staff questionnaire

-Case-note review-Registers

(Monitoring Quality of Care in Maternity Services, 2004, FHD, MoH)

Example of an audit cycle: PPHWorking Definition of Post-partum

hemorrhage (PPH): Severe bleeding from the genital tract after delivery, which requires treatment with IV fluid and/or blood transfusion. PPH could be due to retained placenta, ruptured uterus or from vaginal/cervical lacerations.

Standards and Criteria for best practice:Standards Criteria

1. Massage the uterus to get it to contract

1. Patient’s uterus was massaged

2. Control bleeding with IM (Oxytocin 10U) or IV (ergometrine 0.2mg) oxytocic drug.

2. Patient was given oxytocin (10U IM) or ergometrine (0.2mg IV)

3. Take blood for Hb, grouping and cross-matching.

3. Hb was measured and recorded blood was type and matched and recorded

Patient exit interviewsHelp to identify patient’s perceptions of

quality of care at the hospital Help to identify problem areas that may

have been overlooked by hospital staffChoosing the right people to conduct such

interviews, ensuring anonymity of answers

Client exit interview formatS.No. Questions Response

1. How did you get to this facility?

Tick response[ ] Walk [ ] Bus [ ] Own transport[ ] Ambulance [ ] Carried in a doko/ dola/ stretcher [ ] Other

2. How long does it take to travel to the health facility?

30 minutes, 1 hour, 2 hours, >3 hours

3. What did clinic staff tell you about your health conditions?

e.g. BP, Physical exam, Baby’s condition, Blood and urine test, Others

4. What advice did she/he give you? Did you fully understand what you were told? What were you told?

5. How long did you wait for treatment?

30 minutes, 1 hour, More than 1 hour

Morbidity and mortality conferences (M&M)Simple, effective practice in hospitals throughout the

worldIdentifies key problems in clinical careHelps to improve quality of the hospital and its

departmentsNyaya Health’s unique M&M program

M&M conference as a hospital-wide quality improvement strategy in resource-limited settings

All staff at the hospital participate (including non-clinical staff)

Carried out weekly at staff meetingsStaff review recent clinical cases using root cause

analysis of morbidity and mortality, identifying systems failures and opportunities for future improvement.  

Seven domains of causal analysisClinical operations – concerns with patient flow or processing

in clinical departments, lab, radiology, or pharmaceutical operations

Supply chains – challenges in obtaining reliable supplies of quality medicines or equipment

Equipment – issues in the functioning, quality, or availability of equipment and medical devices

Personnel – factors pertaining to training, professionalism, management, or collaboration

Outreach – issues in recruiting patients into timely and appropriate care through community engagement

Societal – issues of gender, caste, economic, or other social status

Structural – factors related to infrastructure such as roads, telecommunications, educational or healthcare facilities

Example of M&MCase selection: An 8-month old boy presents with severe pneumonia,

subsequently survives a complicated hospital course, and is discharged. The Medical Director chooses the case as one with many lessons and opportunities for future improvement.

Case write-up/Team input by Medical Director Case conference: Staff not familiar with management of pediatric sepsis and

severe respiratory distress. The ambulance driver and nurses explain that problems arose due to the sharing of oxygen tanks between the ER and the ambulance.

Recommendations: Training needed to review pediatric sepsis and resuscitation protocols. Additional oxygen tanks are needed.

M&M summary write-up by Medical Director. Recommendation implementation: Two weeks later, physicians conduct a review

of clinical protocol and skills. The Hospital Administrator and procurement staff obtain new oxygen tanks, regulators, and masks from the capital city; however, due to supply chain difficulties, this procurement takes over two months.

Table 1: Cases from Bayalpata Hospital's Moribidity and Mortality Conference†

Sex Age Primary

diagnosis Primary Assessments and Recommendations

F 20 yr Intrauterine fetal demise

Laboratory staffing is insufficient at times of high patient volume. Additional training for nurses and mid-level practitioners should be conducted by lab personnel to enable lab task-shifting during times of high patient volume.

There is a lack of trained ultrasonographers at the hospital. Management should investigate options for off-site intensive training for a staff member.

F 19 yr Retained placenta

Some mid-level practitioners and nurses are unfamiliar with basic resuscitation protocols. On-site protocol review should be conducted by the senior physicians.

Limited pharmacy staffing leads to problems at times of high patient volume. The pharmacist should conduct task-shifting workshops for medicine dispensing and stocking for nurses and mid-level practitioners.

M; M

6 yr; 12 yr

Botulism poisoning

Clinicians are not in contact with private pharmacies in the villages. Management should develop a list of contact information and meetings should be set up at the hospital for relationship-building.

M 28 yr Suicide attempt

There is a lack of mental health services in our catchment area. Medical Director and management should develop emergency referral list and crisis-line with psychiatrists in the capital.

Pharmacy lacks any type of anti-depressant medications. Management should procure at least two different medicines and identify long-term suppliers.

Staff feedbackANM: Staff members “get ideas from other staff

[about how to manage patient care], learn from each other, and encourage each other [to work better].”

Data Manager: “Non-clinical staff get [an understanding] of how clinical operations function at the hospital.”

Staff physician: Staff “think in retrospect critically about the cases and realize the shortcomings that might not have been apparent while managing the case.” … “We learn the value of team effort in managing patients.” … “It is not just a review of a particular case, but a review of our hospital: what the problems are, what is missing, and what can be done [to improve].”

The model for improvement: PDSA cycle

Plan

DoStudy

Act

Examples of hospital based quality improvement in other countries

Rwanda, Partners in HealthVital signs and medications given were not

being recorded regularly (only 50% of the time)

Aim of QI project: Record vital signs and meds given 100% of the time for 5 days

Identified barriers to goalTeam work: how to get around barriersSpot checks monthly

Fig 1 Quality improvement protocol.

Kotagal M et al. BMJ 2009;339:bmj.b3488

©2009 by British Medical Journal Publishing Group

Fig 2 Percentage of vital signs monitored.

Kotagal M et al. BMJ 2009;339:bmj.b3488

©2009 by British Medical Journal Publishing Group

Fig 3 Percentage of drugs given as prescribed.

Kotagal M et al. BMJ 2009;339:bmj.b3488

©2009 by British Medical Journal Publishing Group

Developing improvement with PDSAs

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLANDO

STUDYACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

PLAN

DO

STUDY

ACT

Accumulatin

g inform

ation and kn

owledge

Accumulatin

g inform

ation and kn

owledge

Testing andTesting andrefining ideasrefining ideas

Implementing newImplementing newprocedures & systemsprocedures & systems- sustaining change- sustaining change

BrightBrightidea!idea!

Starting a QI ProjectMany of the tools we have talked about

(e.g. checklists, audits, M&Ms) help to identify quality gaps/chasms.

Need to prioritize among these gaps to decide which ones to address first

PDSA cycle is tool to actually start addressing a gapOnce gap identified, write down an AIM

statementConducting a series of PDSA cyclesMeasuring outcomes

Example of starting a PDSA cycle

Identifying a Problem and Focusing on a Problem

Doctors were not being called by the ANMs in a timely manner regarding obstructed labor and other problems during labor.

Doctors were not being called by the ANMs in a timely manner regarding obstructed labor and other problems during labor

ANMs are not recognizing problems during labor

Partograph is a useful tool to identify problems during labor. Are ANMs filling out partographs?

Very few deliveries (<25%) at Bayalpata Hospital had a properly recorded partograph.

How to Write an Aim StatementF (feasible)I (interesting)N (novel)E (ethical)R (relevant)M (measurable)T (includes a timeframe)

What?Where? Who?When?How?

Aim StatementIn the next two months, we will increase

the percentage of deliveries with a properly recorded partograph to >90% by working with ANMs and doctors at Bayalpata Hospital.

In the next two months, we will increase the percentage of deliveries with a properly recorded partograph to >90% by working with ANMs and doctors at Bayalpata Hospital.

In the next two months, we will increase the percentage of deliveries with a properly recorded partograph to >90% by working with ANMs and doctors at Bayalpata Hospital.

In the next two months, we will increase the percentage of deliveries with a properly recorded partograph to >90% by working with ANMs and doctors at Bayalpata Hospital.

PDSA cycle: Partograph recording 1. Graph of weekly tally of deliveries with

partographs posted in the delivery room.2. A class was given by staff nurse and doctor

to the ANMs on importance of partograph and how to record a partograph properly.

3. Subsequent recording of percentage of partographs properly filled out.

4. Staff nurse discovers that ANMs are now filling out the partographs (almost 100% compliance) but it’s not being filled out correctly.

Summarizing the PDSA cycle Improvement requires change to systems

PDSAs are a tool that help you bring about change in a practical, useful, manageable and managed way

Starting points: remember the three fundamental questions to guide change

Remember that you will never know whether the change is better unless you measure

Keep up the momentum and don’t forget to record what happens

SummaryQuality improvement in resource poor

settingsQuality improvement tools that can be used

in resource-poor settings with successful examples from different parts of the worldQuality improvement committeeDevelopment of standards and checklistsClinical auditsPatient exit interviewsMorbidity and & Mortality conferencePDSA cycles

Take home points about quality improvement workQuality improvement work does not always

require more resources/moneyHelps us identify systems issues at play

that bring about bad outcomesIdentifying problems does not mean laying

blame. We identify problems/errors so we can do better next time

Positive changes need to be continued—incorporated into the system and sustained.

A 6-month-old boy with severe respiratory distress presented to X Hospital in Nepal. Previously, the boy had been seen by untrained private practitioners in the community three times over four days. At presentation to X hospital, the child was evaluated by a health assistant who provided an initial course of antibiotics. Despite the child's ill appearance, supportive treatment including intravenous fluids and supplemental oxygen were not provided until discussion with the Medical Director three hours later. Later that evening, the electric nebulizer and oxygen concentrator became unusable after the hospital lost power owing to a blackout of the public electric grid and malfunctioning of the hospital’s backup generator. The regulator for the backup oxygen canister could not be found. At this juncture, without the ability to provide oxygen, the medical team recommended transfer. Unfortunately, the family refused transfer due to the high costs of other health facilities. That evening, after not being examined for over two hours by on-call staff, the child was found unresponsive with a thready pulse. Cardiopulmonary resuscitation was not initiated for over ten minutes as the midwife managing the ward did not know the procedure and the bag valve mask was not at the bedside. Following fifteen minutes of unsuccessful resuscitation, the child was declared dead.

QUESTIONS??THANK YOU!