Social and Behavior Change, Provider Behavior, and Quality of Care
CORE Group Meeting May 19, 2016
Chelsea Cooper On Behalf of:
MCSP Quality Team
2
• Growing global body of QI approaches, but evidence still needed (esp around effective & sustainable approaches)
• Under-focused area of SBC – need for more applications of SBC lens, as much of QoC work has behavioral and interpersonal dimensions
• Improve health outcomes by providing respectful and technically sound services, delivered according to standards known to maximize health impact.
• Client and community perceptions of quality can affect utilization of services.
Why Quality and Provider Behavior?
3
• health care delivery occurs as part of an interaction between a health care provider and the client and community;
• provider performance is affected and motivated by a wide range of factors in the provider’s immediate environment;
• the health system is responsible for providing inputs and processes that service providers need to deliver quality services, including infrastructure, supervision, and management
Underlying Considerations
4
Quality Aims for MCSP
High quality care is: Effective: Adherent with evidence-based standards Safe: does not harm patients Timely: care provided when needed People centered: Respectful of patient needs, values & preferences Coordinated: services for a single client are coordinated across time and levels of care Institute of Medicine, 2001, Crossing the Quality Chasm
A Framework for Continuously Improving Quality of Care
Conceptualizing Quality:
Moving beyond Inputs and building blocks…. (Source: Donabedian)
6
1. What is done
2. How it is done
• Patient health status/outcomes
• Change in health behavior
• Patient perception and experience of care
• Human resources
• Infrastructure • Materials
(i.e. vaccine) • Information • Technology
Structure (inputs)
Process
Outcomes
7
STANDARDIZATION FOCUSED PROBLEM-SOLVING
OPEN PROBLEM-SOLVING
PROCESS REDESIGN
GOVERNANCE
PURPOSE Regularity Improvement towards target
Find solutions to complex problems
Optimize flow of activities
Whole organization involvement
PROCESS SDSA PDSA PDSA Reengineering Systemic improvement
TOOLS Process mapping, check-lists, assessment tools
Root-cause analysis, team implementation
Appreciative enquiry, collective solutions
Process-mapping, quality function deployment
Education, clinical audit, risk management, openness, research
POTENTIAL BEST FIT
New programs, no best-practices in place, multiple issues
Need to address key specific issues
Multiple complex issues with limited evidence (e.g. community)
Need for efficiency and value-added gains
Multi-level system improvement
EXAMPLES SBM-R, accreditation, certification, 5-S, check-list
TQM/CQI (Kaizen), Six Sigma, BSC, Health/QUAL, “collaboratives”
PDQ, Citizen Voice and Action, Community Score Card
Lean, reengineering
CCM, Clinical governance, REC-QI, RAPID
Adapted by Edgar Nocea from S. Hacker, B. Jouslin de Noray, and C. Johnston, European Quality, European Quality Publications, Ltd; London; 2001
Ilustrative Taxonomy of Quality Approaches
MCSP QI Principles
• Measurable clear aims focused on important health outcomes for which high-impact interventions exist
• Prioritization of needs, values and desires of clients • Engaging health worker hearts and minds to improve care –
Motivation; leadership, QI, clinical, management skills
• Focus on understanding and overcoming critical gaps (bottlenecks) in local care processes and health systems
• QI team work - representatives all system functions
• Change management strategy driven by local actors
• Real-time use of data (i.e. tracking process and outcome measures.)
• Regular shared learning to accelerate improvements at scale
8
9
SBC(C) and Quality of Care
In terms of….
• Provision of care
• Experience of Care
WHO Quality of Care Framework for Childbirth
Source: BJOG 2015
11
Identified QI Implementation Interventions
12
The implementation interventions identified were then consolidated into 11 categories as follows:-
1. Leadership of quality 2. Planning, designs and policies for implementation or scale-up 3. Financial strategies to support improvement 4. Assessment and provision of resources 5. Engaging women, families, communities in their care 6. Education and training for clinical and system activities 7. Supportive supervision of clinical and system activities 8. Adaptive designs for implementation or scale up 9. Data to support improvement 10. Learning communities for accelerating improvement 11. Governance of quality
Lessons from MCHIP
Guinea SBM-R • Three urban health
facilities already implementing SBM-R for MNH/FP.
• Six months • 34 performance standards.
Zimbabwe SBM-R • Adapted one year after SBM-R
was introduced for MNH • Implemented in 21 health
facilities • Three years 2011 to 2013 • 38 standards
13
Evidence of immediate positive influence on provider’s adherence to agreed performance standards.
No firm conclusions on SBM-R’s scalability and sustainability
Case Study: Respectful Maternity Care in Ethiopia
14
The Maternal Child Health Integrated Program in Ethiopia
• Service delivery interventions: Integrated Maternal & Newborn health (MNH) in 4 regions = 119 facilities (104 Health Centers, 12 hospitals) from 2011 – 2013
• Package of interventions centered on Quality Improvement Approach –Standards-Based Management and Recognition™ (SBM-R): Verifiable, objective standards to measure performance (RMC practices
integrated into quality standards) Providers & managers measure actual performance against standards &
identify gap filling to reach desired performance Competency-based skills training to ensure essential package of MNH
services Development of job aids, posters District health offices provided with small grants to support &
facilitate SBM-R
Integrated into existing training, supervisory support 15
Findings & Recommendations • Quality Improvement i.e. SBM-R intervention facilities
performed better in provision of RMC practice from observation (e.g. respectful reception, explaining every step, encouraging questions, woman allowed to give birth in position of choice, woman never left alone during labor, privacy ensured)
• No difference found between study groups on disrespect and abuse experienced
Recommendations: • Quality improvement approaches should look at integrating
RMC as part of MNH care • RMC needs to take clients’ views into consideration when
designing and promoting care; more attention to “experience” of care
16
Low Dose, High Frequency Training in Ghana (Jhpiego)
Traditional Approach • Off-site group-based training • 12-day BEmONC package • Limited number from each
facility
LDHF • “On-the-Job, on-site training” • Shorter training, repetition
(high frequency) • Local ownership, whole team
participation • Simulation and training with
low-cost models • Supportive use of technology • Mentorship, master mentors • On-site peer support and
practice post training
Reinforcement and reminders: mMentoring
• Text messages and quiz questions sent to all training participants
• Option to “opt out” • Messages are sent Monday – Friday • 16 thematic areas over 6 month period • PPCs receive mentoring phone calls
from Master Mentors • Master Mentors receive mentoring
phone calls from Jhpiego team
Performance of Master Mentors, 3 Regions, September 2014 – September 2015
79%
56%
91% 91% 95% 95%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Knowledge Assessment OSCE
Pre-training Post-training 1 year post intervention
Performance of Service Providers: 10 facilities, September 2014 – September 2015
84%
47%
94% 90%
93%
71%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Knowledge Assessment OSCE
Pre-training Post-training 1 year post intervention
Coming Soon: Age and Stage in Nigeria • Health workers will be supported with age- and
stage-specific counseling tools for each type of contact in a health facility with young people.
• Health workers will be oriented on adolescent development, best practices, and age-specific counseling skills to address adolescents’ needs.
• Young people will be actively engaged in quality improvement process through Partnership Defined Quality for Youth (PDQ-Y). Girls and boys will define and support a quality improvement process in collaboration with community leaders and health workers.
21
Takeaways
• Quality improvement is a behavior change intervention! • SBC(C) and QoC in terms of provision of care and experience
of care [further efforts needed around experience of care] • Need for further cross-fertilization between SBC and QoC
practitioners; apply SBC evidence, principles, processes
• Need for more focus on SBC(C) at point of service delivery • Consider respectful, client centered care approaches beyond
RMC • Explore opportunities to strengthen “change agency” role of
health workers • Pair QI efforts with HSS
22
For more information, please visit www.mcsprogram.org
This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not
necessarily reflect the views of USAID or the United States Government.
facebook.com/MCSPglobal twitter.com/MCSPglobal
Top Related