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Context in Improvement Science:
Rapid Scale Up of High Impact Interventions for Improved Child Survival in Ghana -Reflection from 202 Public Hospitals
Sodzi Sodzi-Tettey, MD, MPH
Director, PFA!PFHS Webinar
October 23rd 2015
Introduction
Design
The 9 Hospital Prototype
Results – Prototype - Scale
Reflections – Scale & Sustainability
350
18580
4030
0
50
100
150
200
250
0
100
200
300
400
500
600
700
800
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
U5
an
d N
eon
atal
Mo
rtal
ity/
1
,00
0 L
ive
Bir
ths
MM
R/1
,00
,00
0 L
ive
Bir
ths
Maternal MortalityRate
U5 Mortality Rate
Neonatal Mortality
Source: World Bank http://data.worldbank.org/indicator/SH.STA.MMRT (1990 figure is from UNDP http://www.undp-gha.org/mainpages.php?page=MDG%20Progress)
AIM:Assist and accelerate Ghana’s efforts to achieve
Millennium Development Goal 4 (66%
reduction in Under-5 mortality to 40/1000 live births by 2015)
through the application of quality improvement methods
Funded by the Bill & Melinda Gates Foundation
COLLABORATORS :
• Ambitious Aims• Systems View • Core Metrics with Feedback • Rapid Cycle Tests of local
ideas
DESIGNQI Team Members at a Meeting at
OLGH, Asikuma
• Multidisciplinary
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
PlanAct
DoStudy
Source: Associates for Process Improvement
Change package of process improvements that had been shown to be effective in similar contexts
Assessment and Design
Period
Learning Session 1
© Institute for Healthcare Improvement
Learning Session 2
ACTIVITY PERIOD
Repeated improvement
cycles:
Learning Session 3
12 -24 months
Intensive support from project staff & DHMT
ACTIVITY PERIOD
Repeated improvement
cycles:
Improvement Collaborative Network
Health Facilities
Reducing Under 5 Deaths in NCHS Hospitals
Delay in Seeking Care
Reliable use of Protocols
Delay in Providing Care
We documented our theory of what leads to U5 deaths in hospitals - Driver Diagram
1o Drivers 2o Drivers
Mobilizing Community
Cultural Barriers
Referral from 1o facility
Financial Barriers
Attractiveness of services
Emergency response Syst.
Outpatient services
Staff Issues
Admission Process
Process Measures
Staff Knowledge and Skills
Availability of Drugs, supplies and equipment
Access to Protocols
Outcome
Average cervical dilatation of women in labour arriving at Hospital
Average time of 1st encounter with hospital after onset of symptoms for children U5
Average Time critically ill U5 identified in hospital to
time first treatment is commenced
Percentage adherence to selected protocols
Average stock out for antimalarial, blood and oxygen
Knowledge of 1o caregiver
Average Time spent by woman in labor from registration until assessment by midwife of doctor
Institute for Healthcare Improvement, 2013Slide 8
Start-up:
months
1 – 8
Total Pop’n:Under 5 Pop’n:
Nov 2007
Wave 1:
months
9 – 22
350,000
60,000
Jul 2008
Wave 2:
months
23 – 63
5 million500,000
Sept 2009
Wave 1R:
months
58 – 89
11 million1.7 million
Aug 2012
Start Small, Scale up Rapidly with Change Package
No of. QI Teams: 30 258 350 369>1,046
Jan 2013
Wave 3:
months
24 – 89
11 million1.7 million
Oct 2009
Wave
4:
months
63 – 89
22 million3.3 million
*Referral project launch
41 Referral Teams
Pareto Principle
Roughly 80% of the problems are caused by only 20% of the contributors
Results give credibility & enhance buy in
Is there standardized data to measure the effect of specific changes tested and implemented?
Are processes improving?
Is process improvement influencing outcome?
Are you focusing on key processes?
What adaptations in design can be made?
22.37.8
UCL
LCL0
50
100
Jan
-08
Ma
r-0
8M
ay-0
8Jul-
08
Se
p-0
8N
ov-0
8Jan
-09
Ma
r-0
9M
ay-0
9Jul-
09
Se
p-0
9N
ov-0
9Jan
-10
Ma
r-1
0M
ay-1
0Jul-
10
Se
p-1
0N
ov-1
0Jan
-11
Ma
r-1
1M
ay-1
1Jul-
11
Se
p-1
1N
ov-1
1Jan
-12
Ma
r-1
2M
ay-1
2Jul-
12
Se
p-1
2N
ov-1
2
De
ath
s p
er
10
00
A
dm
issio
ns
Under 5 Deaths per 1000 Admissions in Our Lady of
Grace Hospital, Breman Asikuma, (Jan 2008 - Dec 2012),
U-Chart
Rate
17.4
8.8
UCL
LCL0
20
40
60
Jan
-08
Ma
r-0
8M
ay-0
8Jul-
08
Se
p-0
8N
ov-0
8Jan
-09
Ma
r-0
9M
ay-0
9Jul-
09
Se
p-0
9N
ov-0
9Jan
-10
Ma
r-1
0M
ay-1
0Jul-
10
Se
p-1
0N
ov-1
0Jan
-11
Ma
r-1
1M
ay-1
1Jul-
11
Se
p-1
1N
ov-1
1Jan
-12
Ma
r-1
2M
ay-1
2Jul-
12
Se
p-1
2N
ov-1
2
Death
s p
er
1000
Ad
mis
sio
ns
Under 5 Deaths per 1000 Admissions in St. Francis Xavier Hospital, Assin Foso, (Jan 2008-
Dec 2012), U-Chart
Rate
25.817.5
UCL
LCL0
20
40
60
Jan
-08
Ma
r-0
8M
ay-0
8Jul-
08
Se
p-0
8N
ov-0
8Jan
-09
Ma
r-0
9M
ay-0
9Jul-
09
Se
p-0
9N
ov-0
9Jan
-10
Ma
r-1
0M
ay-1
0Jul-
10
Se
p-1
0N
ov-1
0Jan
-11
Ma
r-1
1M
ay-1
1Jul-
11
Se
p-1
1N
ov-1
1Jan
-12
Ma
r-1
2M
ay-1
2Jul-
12
Se
p-1
2N
ov-1
2
De
ath
s p
er
10
00
A
dm
iss
ion
s
Under 5 Deaths per 1000 Admissions in St. Martins de Porres Hospital, Eikwe, (Jan
2008 - Dec 2012), U-Chart
Rate
18.4 8.0
UCL
LCL0
20
40
60
Jan
-08
Ma
r-0
8M
ay-0
8Jul-
08
Se
p-0
8N
ov-0
8Jan
-09
Ma
r-0
9M
ay-0
9Jul-
09
Se
p-0
9N
ov-0
9Jan
-10
Ma
r-1
0M
ay-1
0Jul-
10
Se
p-1
0N
ov-1
0Jan
-11
Ma
r-1
1M
ay-1
1Jul-
11
Se
p-1
1N
ov-1
1Jan
-12
Ma
r-1
2M
ay-1
2Jul-
12
Se
p-1
2N
ov-1
2
De
ath
s p
er
10
00
A
dm
iss
ion
s
Under 5 Deaths per 1000 Admissions in Margaret
Marquart Hospital, Kpando, (Jan 2008 - Dec 2012), U-Chart
Rate
44.4
25.815.6
UCL
LCL0
20
40
60
Jan
-08
Ma
r-0
8M
ay-0
8Jul-
08
Se
p-0
8N
ov-0
8Jan
-09
Ma
r-0
9M
ay-0
9Jul-
09
Se
p-0
9N
ov-0
9Jan
-10
Ma
r-1
0M
ay-1
0Jul-
10
Se
p-1
0N
ov-1
0Jan
-11
Ma
r-1
1M
ay-1
1Jul-
11
Se
p-1
1N
ov-1
1Jan
-12
Ma
r-1
2M
ay-1
2Jul-
12
Se
p-1
2N
ov-1
2
Death
s p
er
1000
Ad
mis
sio
n
Under 5 Deaths per 1000 Amdissions in Catholic
Hospital, Battor, (Jan 2008 -Dec 2012), U-Chart
Rate
23.3
UCL
LCL0
20
40
60
1…
3…
5…
7…
9…
1…
1…
3…
5…
7…
9…
1…
1…
3…
5…
7…
9…
1…
1…
3…
5…
7…
9…
1…
1…
3…
5…
7…
9…
1…
Death
s p
er
1000
Ad
mis
sio
ns
Under 5 Deaths per 1000 Admissions in Mathias Hospital,
Yeji, (Jan 2008 - Dec 2012), U-Chart
Rate
13.5
Weak management support Poor team dynamics High Attrition of core QI team
members Challenged reporting of process
measures
Driver
Area of
Clinical/
Community
Care Change Concept
Package
# Description of Successful Change Ideas
Delay in
Seeking
Care
Care–seeking
behaviour
Targeted health
education
1A Targeted health education on early care-seeking using
interactive platforms
1B Community engagement and education via durbar or place
of worship
Referral
Engaging
primary
providers
1C Engagement with health providers (both traditional and
allopathic)
Prompt
Diagnosis and
Treatment
Triage
2A
Triage system for screening and emergency treatment of
critically ill children
Separate U5 OPD services from adult OPD service
Prioritize U5 outpatient care
Prioritize U5 inpatient care
Delay in
Providing
CareFast Track
Non-
Adherence
to
ProtocolsAdherence to
Protocols
Training/
Coaching/
Mentoring
3A
Training staff on protocols followed by regular coaching and
mentoring which include ad hoc testing on site with
immediate feedback.
3B
Training postpartum women and other care givers on
hygienic cord care through demonstration, practice and
immediate feedback. Midwives and nurses teach,
3C
Mother-to-mother support group on food choices and
frequency of feeding while on admission under mentoring of
nurses.
Task-shifting 3D Empowering nurses to start acting on standard treatment
protocols before doctor arrives
Hospital Change Package
202H
68H
32H
9H
Drivers of Hospital Based Deaths
% of QI Teams Adopting at least one Change Idea (N=134)
Comments
Early Care Seeking 84.3 Three Change Ideas (H-1A, 1B, 1C)
Prompt Provision of Care 69.4 A Change bundle (H-2A)
Adherence to treatment protocols
69.4 Four Change Ideas (H-3A to 3D)
Change Idea H -1A H-1B
H-1C
H-2A
H-3A
H-3B
H-3C
H-3D
Proportion of teams testing this change Idea
58.2 23.1 3.0 69.4 43.3 1.5 2.2 22.4
15.9
10.9
0
5
10
15
20
25
Ja
n-1
2M
ar-
12
Ma
y-1
2Ju
l-1
2S
ep
-12
No
v-1
2Ja
n-1
3M
ar-
13
Ma
y-1
3Ju
l-1
3S
ep
-13
No
v-1
3Ja
n-1
4M
ar-
14
Ma
y-1
4Ju
l-1
4S
ep
-14
No
v-1
4
COLLABORATIVE (134 HOSPITALS) IN 7 REGION
Subgroup Center
7.7
5.0
0
2
4
6
8
10
12
14
Ja
n-1
2M
ar-
12
Ma
y-1
2Ju
l-1
2S
ep
-12
No
v-1
2Ja
n-1
3M
ar-
13
Ma
y-1
3Ju
l-1
3S
ep
-13
No
v-1
3Ja
n-1
4M
ar-
14
Ma
y-1
4Ju
l-1
4S
ep
-14
No
v-1
4
Collaborative (135 HOSPITALS IN 7 REGION
Subgroup Center
Pressure to start at scale
Sustainability
To superimpose new learning on old system or to redesign old system with new learning?
10 Regional Quality
Advisors
~ 3000 Site Visits
~ 4000 frontline workers
trained in LSs
July 2008
Wave 1 Launch.
Nov.12 PFA end
July 2010
NCE-1
(PNC
Policy)
Mar. 2014. Cost Extension. National Scale Up. August 2015 PFA! end2012 End of
Project - initial
May 2011. Referral Supplemental. May 2015, PFA! end
Nov. 2014. NCE2. Dec. 2015 PFA! end
• Tested Feasibility of PNC Policy• PFA!- Adapted National DQI Protocols Codesigned Referral Registers & Forms Adapted Community-Facility
Collaboratives Assisted to Accelerate Mortality
Reduction ~ 400 Improvement Coaches
Clinical Skills/Jhpieg
oDHIM
S
QI Projects 1. Ghana
Systems for Health
2. UNICEF’s Newborn Project
Adaptive designing may be the exception rather than the norm – decide early whether you want to work in a real health system or carry out an experiment
Attribution is the elephant in the room –extremely important but rarely openly acknowledged by partners and stakeholders
QI alone is not enough; Quality Planning, Quality Control & Quality Improvement integration is key
Rapid tests of change help to determine what works quickly in a cost-effective manner
Empowered teams adapting contextually-relevant changes can achieve rapid impact at scale
It takes strategic alignment with health system structures/ priorities and synergy between management and frontline workers to achieve impact at scale
Recommended