Monitoring data to drive countrylevel improvement: lessons learned in Ecuador and ways forward

Dr. Jorge Hermida Regional Director, LAC programs The USAID ASSIST Project, University Research Co., LLC Global Newborn Health Conference JOHANNESBURG, SOUTH AFRICA. April 2013

The place of quality of care indicators in the QI process

How do we improve processes of care? The Model for Improvement

We use indicators to identify deficiencies and set our aims

1.

What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement?
3

We develop indicators to assess if process changes result in improvements Indicators help us monitor improvements over time and assess sustainability

PDSA Cycle
PLAN

2.

3.

ACT

DO

STUDY

A system to manage EONC quality based on indicators

National MOH MNCH team
Analyze indicators by province Supervision to provincial offices

Provincial MOH MNCH person

Analyze EONC indicators by facility Supervision following indicators Aggregate indicators and report to central MOH

County Hospital
QI team

Provincial referral Hospital

QI team Clinical records audit Analyze EONC indicators Implement PDSAs to improve processes Report indicators to provincial MOH office

Ambulatory care facilities

QI team

QI team

QI team

A user-friendly information system for continuous quality improvement at facility, provincial and central levels, Ecuador
Facility Provincial Central

Quality standards Data from sample of clinical records Enter data on data base Indicator Runchart Analysis and action Runchart Analysis and action Runchart Analysis and action Aggregation of data from facilities at provincial level Aggregation of data from facilities at national level

NORMS, QUALITY STANDARDS AND DATA SOURCES FOR QUALITY MEASUREMENT

The perinatal clinical record is the main source of data for quality indicators Indicator
1 2 % Antenatal care in compliance with standard. % deliveries with partograph correctly used

% deliveries with an abnormal partograph where a decision was made

% deliveries with AMTSL

4 5 6 % postpartum care in compliance with standard.. % of immediate newborn care in compliance with standard. % deliveries attended by a doctor or midwife. % of newborns attended by a doctor or midwife % of cases of preeclampsia, eclampsia care in

2y3 8f 8d 6 7a 7b 4 8a y 8b

7A 7B 8A 8B

compliance with standard.

% of cases of Hemorrhage care in compliance with standard.. % de cases of sepsis care in compliance with

8C 8D 8F

standard.
% preterm deliveries treated with corticosteroids for fetal lung maturation % premature rupture of membranes care in

compliance with standard.

Measuring compliance with standards: auditing records

QI team members meet once a month and audit records, following a standard procedure QI team: doctors, nurses, auxiliary nurses QI team enters numerators and denominators in an Excel spreadsheet that produces runcharts

Data base for entering numerators and denominators at facility, provincial or central levels

 QI teams identify deficient processes based on indicators Building on their own experience, literature and lessons learned, QI teams decide to test interventions. QI teams assess the impact of the intervention using indicators

Using indicators to identify deficiencies and to trigger improvement interventions at the facility
WHAT ARE WE TRYING TO ACCOMPLISH ? HOW WILL WE KNOW A CHANGE MADE AN IMPROVEMENT ? WHAT SPECIFIC, CONCRETE CHANGES CAN WE MAKE TO THE PROCESS ?

Continuous Quality Improvement teams at work:

Plan

Act

IMPLEMENT AND TEST THE INTERVENTION

Do

Study

Percentage of Premature Rupture of Membranes (PROM), managed in accordance to standards, 97 hospitals and health centers. Ecuador, 2008- 2011
100 90 80
PERCENTAGE

70 60 50 40 30 20 10 0
%

E F M A M

J J 2008

A S O N D E F M A M

J J 2009

A S O N D E F M A M

J J 2010

A S O N D E F M A M

J J 2011

A S O N D

0.0 0.0 0.0 5.0 25. 10. 15. 22. 26. 42. 41. 53. 58. 33. 28. 81. 72. 54. 60. 57. 71. 69. 65. 72. 64. 64. 65. 61. 66. 68. 76. 70. 75. 73. 85. 73. 66. 77. 71. 81. 73. 64. 77. 77. 71. 73. 60. 85. Num 0 0 0 1 4 14 17 29 33 31 33 22 93 57 67 203 68 68 90 86 105 115 88 95 112 107 115 115 105 99 125 122 88 87 78 84 130 108 115 120 119 94 103 103 87 79 40 30 Den 18 12 16 20 16 129 107 129 123 73 79 41 159 168 239 70 94 125 150 150 146 165 134 132 175 165 176 187 157 144 163 174 116 146 134 114 195 140 160 148 163 146 133 133 121 107 66 35

 Reporting made mandatory by Ministerial decree One person of QI team in charge of sending the monthly report Report sent mostly by email using Excel spreadsheet Supervisory visits to facilities late in reports Indicators used in maternal and newborn mortality audit process

Monitoring and reporting indicators from facilities to provincial MOH offices

Monitoring quality indicators for facilities in a region through runcharts

QAP, 2004

Aggregated data and analysis at provincial level

Percentage of deliveries in which the newborn was provided with essential standardized care (11 standard activities) Fourteen hospitals in 2003, scaled up to 89 hospitals in 2006
100 90 80
PERCENTAGE

70 60 50 40 30 20 10 0
JlAg Sp Ot Nv Dc En Fb Mr ABMy Jn Jl Ag Sp Oc 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 03 2003 2004 2005 2006 % 25 70 64 54 64 75 70 65 70 68 72 74 78 81 84 89 87 84 74 84 82 83 82 84 86 87 90 86 87 86 84 82 84 88 85 85 88 87 89 93

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Weight Height Cephalic perimeter Apgar score Registration of need for HBB/action Physical exam Vitamin K 1 mg Ocular disinfection drops Skin-to-skin contact Immediate and exclusive breastfeeding 11. Baby and mother together in ward

Using regional indicators at central MOH to monitor national progress

100 90 80
PERCENTAGE

Percentage of preterm deliveries in which dexamethasone was administered for fetal lung maturation. 97 hospitals and health centers, Ecuador, 2008 to 2011

70 60 50 40 30 20 10 0
%

E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D 2008 2009 2010 2011

Antonio Recalde, MOH staff in charge of national database

0.0 0.0 0.0 0.0 0.0 10. 32. 30. 47. 64. 63. 81. 64. 63. 71. 84. 89. 86. 75. 72. 82. 85. 84. 85. 82. 83. 85. 76. 89. 87. 93. 92. 91. 92. 90. 95. 81. 90. 90. 93. 88. 92. 92. 92. 90. 90. 92. 97. Num 0 0 0 0 0 20 45 61 86 65 65 57 159147151 49 137136188191153205200218237222267236273255253247246218151285222331362321252275250213158161 88 83 Den 18 12 16 19 12 189140202181101102 70 247233212177153158248262185240238254286265314307305291272267269246238299271367402343286296270230175178 95 85

 Integrating QI indicators system with regular MOH Management Information System Linking QI indicators with MOH system to reimburse costs for services Developing an ongoing system to monitor quality of data at provincial and local levels Introducing mHealth Stepping-up from a measuring system to a managing one

Challenges ahead