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, 2013
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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

Scaling up effective coverage

Building health systems capable of continuously improving and sustaining quality care is essential for achieving and sustaining effective coverage of high impact interventions for every mother and child

The Issue of Quality in Health Care

Every system is perfectly designed to achieve exactly the results it achieves (Batalden & Stolz 1993)
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What do We Mean by Quality Health Care? Care that is.. Safe: does not harm patients Effective: Adherent with evidence-based standards (delivery of high-impact interventions) Client centered: respectful of patient needs, values & preferences Equitable: does not vary in quality because of personal characteristics (gender, ethnicity, SES, etc) IOM, 2001, Crossing the Quality Chasm

Commercial aviation vs health care: Comparative Risks Adverse event

1:300

1:10,000,000

How skilled are SBAs?

Harvey et al. Bulletin of the WHO, 2007
100%

75%

50%

25%

0% Knowledge Neonatal resuscitation Manual removal of placenta Nicaragua Bimanual uterine compression Rwanda

Benin

Ecuador

Jamaica

Kenya

A framework for continuously improving quality of care

Achieving effective coverage of impact newborn interventions: What does it take?

INPUTS Supportive policy

PROCESSES
Reliable delivery of effective interventions Effective organization of care processes Safe (not harmful) Respectful

RESULTS
Mortality & morbidity

Available, motivated, competent staff

Essential commodities available Standards & robust measures

Incidence of complications
Case fatality Negative patient experience of care Low utilization of care

HMIS

Crossing the Implementation Divide

Improvement Principles: Understanding health care in terms of processes and systems Team-work (all relevant actors, all system levels) Regular measurement of quality measures (adherence with 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 meeting their 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 capture quality of post-partum care: ENC & AMTSL

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Delivering integrated RMNCH packages at critical leverage 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 for mothers and newborns: Niger 28 maternities Average 2,100 births per month
Indicator Dec 2005 (baseline) 0% 2006 2007 July Sept 2008 99.5%

% births AMTSL applied

34%

98%

% births BF within one hour % compliance ENC standards (composite) % compliance AMTSL standards (composite) Postpartum hemorrhage (PPH) rate (#PPH cases/# births) Total # births
Number of maternity facilities 16

23% 17% 27% 2.1%

44% 35% 51% 0.6%

98% 96% 98% 0.4%

99% 99% 100% 0.2%

28,937 28

40,510 33

12,284 39

Accelerating effective coverage of high impact intervention packages

Multiple teams from different sites & system levels work together intensively to test, share and implement changes to reliably deliver high quality care for every patient in a common clinical or public health area

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Shared learning accelerates implementation

What changes are robust and effective across teams?

Learning Session

Site-level summary

QI team representative

Collaborative coach or manager

Which changes really yield improvements?

QI team site

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Examples of local changes in processes of care to improve integrated post-partum care for mothers and newborns
Equipped ready Newborn Corner every delivery room Stocked bedside cooler with pre-filled oxytocin

Regular breast feeding support

Regular post-partum monitoring of mother & newborn first 24 hours Pre-discharge physical mother & newborn

Synthesizing Learning: National Workshop Niger

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Extending learning from Niger Mali: Improving ENC , 41 health centers Kayes & 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
100
90 80 70 60 % compliance to ENC norms 50 40
Training in AMTSL and QI Baseline results restitution + Niger EONC Collaborative Experience sharing Baseline assessment

Learning Session 2

Coaching visits LS1 + Key Niger successful changes sharing

30 20
10 0
O N D J F M A M J J A S O N D J1 2 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 criteria 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

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Months

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 Maternities Luwero & Masaka Districts, Nov 2010 Aug 2012
% 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
100

80

Jan 12: 2nd Learning session

Jul12: 3rd Learning session

Percentage

60

Jun 11: TEO stock outs

40

Dec 10: Introduction of ENC registers

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Mar 11:Training health workers in QI 1st Learning session

Nov10: Training MNCH district coaches on ENC

0 Nov-10

Feb 11: Training health workers in ENC

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

Nov- Dec- Jan- Feb- Mar- Apr- May- JunAug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- JunAugJul-11 Jul-12 10 10 11 11 11 11 11 11 11 11 11 11 11 12 12 12 12 12 12 12
% of newborns who received 3 components of ENC # of Sites Reporting % of newborns put to the breast within 1 hour of birth # of Sites Reporting % of newborns examined by skilled provider at 4 to 7 days after birth # of Sites Reporting 3 9 1 8 0 8 24 20 18 18 9 18 26 22 21 21 8 21 49 24 34 24 17 24 51 28 40 28 17 28 71 32 47 32 13 32 78 34 55 34 18 34 74 34 59 34 19 34 70 34 66 34 22 34 68 34 59 34 22 34 60 34 64 34 20 34 72 34 73 34 21 34 60 34 68 34 16 34 65 34 73 34 21 34 66 34 73 34 24 34 74 34 79 34 22 34 80 34 91 34 18 34 66 34 75 34 19 34 64 34 67 34 16 34 60 34 63 34 28 34 78 34 84 34 30 34 86 34 88 34 25 34

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Uganda: Improvement Team Meeting

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Stepping up from a measuring to a managing information system: tracking MNH quality measures at facility, regional and national levels in Ecuador
Demonstration phase (2003-2008): 84 facilities, 47,036 annual deliveries,12 provinces

Spread phase (2009): 59 additional facilities; 114,152 additional annual deliveries in 5 new provinces.
National Coverage 2009:
143 (of 152 MOH) facilities attending approximately 163,000 deliveries (92% national deliveries) in 17 of 24 provinces

Lessons Learned: Enabling environment for continuous Improvement

Leadership and engagement key stakeholders essential(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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Achieving & sustaining effective coverage of Best Buys..

Comprehensive improvement approaches 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