Dr. Nigel Livesley, USAID ASSIST Project

1

Making changes in the health facility: skills for improving the care of mothers and

babies

Nigel Livesley, MD, MPH

India Project Director USAID ASSIST Project

South Asia Regional Director University Research Co.

USAID Applying Science to Strengthen and Improve Systems

Three useful ideas


Degrees of implementation (Fixsen DL et al 2005)

Paper implementation The new idea remains in paper form

Process implementation The superficial processes associated with a new idea are

put in place

Performance implementation The new idea actually leads to improved benefit



Paper implementation The new idea remains in paper form

Guidelines and standards


put in place People are trained Monitoring of quality of care


Decreased mortality and morbidity



Paper implementation (90% of efforts) The new idea remains in paper form


put in place



Improving health service delivery organisational performance in health systems. Pallas et al. International Health 4 (2012) 2029

Leadership and management (supervision)

Organisational structure Standards and guidelines

(accreditation) Knowledge and skills enhancement Incentives Process re-engineering Organisational culture

PresenterPresentation NotesTo highlight that there are many ways to improve quality of care. Talk about how we focus a lot on the first column, not so much on the 2nd but that the 2nd is also important.


People mean different things when they say quality improvement

1. Management approach for front line workers to improve processes (Juran)

2. Organizational development approach based on systems and complexity theory (Deming)

7


People mean different things when they say quality improvement

1. Management approach for front line workers to improve processes (Juran)

2. Organizational development approach based on systems and complexity theory (Deming)

3. Specific interventions that come out of definition 1

4. Quality assurance=quality improvement 5. Anything that can improve quality of care

8


Implementation at a single facility Focusing on what didnt work Lessons for implementation

Implementation at large scale ASSIST overview Selected results

Integrating into existing government systems Chamba district, India General approach


Maternal mortality in a Delhi hospital in 2013 5854 deliveries

Pt. Age of the patient

Time of death after delivery

Cause

1. 22 96 hrs PPH

2. 20 20 hrs PPH

3. 21 6 hrs PPH

4. 22 4 hrs PIH

5. 21 24 hrs PPH


Women assessed only twice in six hours after delivery

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Jan-wk1 Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3 Ju-wk1 Ju-wk3

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Average number of times vitals recorded within first 6 hrs of birth


What changes could the team make?


How can higher levels support change?


First idea: management directive

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Change idea: Letter from medical superintendent instructing labour and delivery room staff to assess women 6 times in the first 6 hours. Week 4, January 2014


Success!

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Letter from superintendent Week 4, January 2014


Success! Or is it?

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Massive overcrowding in labour room

Tools: Leadership Standards Incentives


What feedback should you give to the team?


Success! Or is it?

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Massive overcrowding No action to address crowding for 1 week


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A Letter from the Boss doesnt affect systemic issues


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A Letter from the Boss doesnt affect systemic issues

Not testing the letter led to a week of problems


Addressing overcrowding

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Clarified that women should be discharged to ward Made some changes in efficiency of assessment


Sustained improvement!

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Sustained improvement! Or is it?

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What are we trying to accomplish?

Doing assessments or identifying and managing women in danger?


0.16% of women identified with complications

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Number of women with danger signs identified in PNC ward



0.16% of women identified with complications

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Lots of change in assessment; not much improvement in care


What changes could the team make?


How can higher levels support change?


Improving ability to identify and management women with complications

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What the team did differently:



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What the team did differently: Identified the root cause of

poor assessment



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poor assessment Used small scale tests to

learn what works



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poor assessment Used small scale tests to

learn what works Focused on the aim


Women with complications are now 12 times more likely to be identified early

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New system of care Observation room Partnering with patients


Sustained improvement and NO MATERNAL DEATHS in post partum ward

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Jan Feb March April May June July Aug Sept Oct

% of women identified withcomplications and managedappropriately

number of times women were assessed in first 6 hours


Sustained improvement and NO MATERNAL DEATHS in post partum ward

0.0%

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1.0%

1.5%

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2.5%

3.0%

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Jan Feb March April May June July Aug Sept Oct

% of women identified withcomplications and managedappropriately

number of times women were assessed in first 6 hours

Tools: Leadership Standards Incentives Process redesign Organizational culture


Lessons learned

1. Standards and instructions from management dont fix all problems

2. Small scale testing is necessary for solving some problems

3. Focus on the right aim 1. so what?


General principles for problem solving

Subject knowledge

Context knowledge

Change method


ASSIST overview

USAID Applying Science to Strengthen and Improve Systems (ASSIST) is a five-year project of the Office of Health Systems of the USAID Global Health Bureau designed to: Improve health and social services at scale Strengthen host country capacity to improve care Learn and share knowledge about improvement

globally


ASSIST has worked in 24 countries

PresenterPresentation NotesRashad


Scale of USAID ASSIST Activities, FY13-FY14

4,339 facility based improvement teams

994 community based improvement teams

222 government and implementing partners

124 million catchment population


ASSIST India

349 improvement teams

12-17,000 deliveries per month 30% of deliveries in 27 High Priority Districts


If ASSIST-supported sites in India were their own country, they would rank 88th out of 180 countries in the world in total deliveries, just behind Azerbaijan and the Netherlands

109 110 110 113 116 117 118

123 126

131 137 138 140

144 145

154 156 156 157 158

179 180 181 184

193 194

Turkmenistan

Cuba

Serbia

Sweden

Czech Republic

Greece

Mauritania

Belgium

El Salvador

Kyrgyzstan

State of Palestine

Nicaragua

Lao People's Democratic Republic

Libya

Congo

Jordan

Central African Republic

Israel

Liberia

Paraguay

Tunisia

ASSIST India supported sites

Netherlands

Azerbaijan

Eritrea

Tajikistan

Births per country in 2010 (1000s of births)

ASSIST India supported sites

PresenterPresentation NotesNigel


What we do

Support team-based problem solving at facility and community level

Support peer-to-peer learning between networks of teams

Support government to incorporate these approaches into their systems


Seven steps to support team-based problem solving

Decide what problem you want to fix Get a team together to fix it Identify the causes of the problem Develop a simple measurement system Come up with some possible solutions Test the solutions on a small scale Implement the effective solutions


Support networks between teams based on peer-to-peer learning

QI team

site

Site-level summary QI team

LearningSession

representative

Site-level testing of changes and analysis of results

QI team

site

QI team

site

QI team

site

QI team

site

QI team

siteQI team

site

QI team

site

Collaborative-level sharing and synthesis of best practices

QI team

site

QI team

site

Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care

PresenterPresentation NotesA variation of modern QI is what we call collaborative improvementthat builds on the efforts of individual QI teams but links them in important ways that heighten the impact of their efforts. This approach was originally developed by the Institute for Healthcare Improvement about 15 years ago and has been used extensively in the US and other developed countries. How does it work? Just like the Uganda team example, it starts with individual teams testing changes and analyzing their results (using time series charts to assess whether their changes led to improvement). But now other teams are also working on the same issues at the same timeThese teams get together periodically to share their changes and results so they can learn from each other. This periodic sharing, known as learning sessions, also has the effect of inducing teams to compete against each other in a friendly way to get the best resultsFor the collaborative as a whole, the results are validated, consolidated and synthesized. This facilitates rapid gains across all teams because the consolidation of best practices out of the work of all teams helps all teams to move forward, faster.So, collaborative improvement is simply multiple teams simultaneously testing changes, using common indicators and peer learning about what are the most effective changes to improve the same area of care.


Continuum of care

District Hospital

Community Health Centre

Primary Health Centre

Sub-centre

Community

- Active management of 3rd stage of labor - Essential newborn care - Improving ANC - Improving PNC

- Improving ANC (BP, Hb, weight, counseling) - Early registration - Identification of danger signs - Identification of severe anemia - Promotion of institutional delivery

- Management of anemia - Neonatal resuscitation - PPH management - Management of pre/ -- eclampsia - Prevention and control of infection - Other

Routine care Complication care

Aims


Improving routine care for over 15 000 pregnancies and deliveries per month

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Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14

Oxytocin

Vitamin K

Hb checked

Newborns breastfed in first hour


Improving routine care for over 15 000 pregnancies and deliveries per month

0%

10%

20%

30%

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100%

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14

Oxytocin

Vitamin K

Hb checked

Newborns breastfed in first hour

Tools used: - Standards - Process re-engineering - Culture change


Improvement in recording and drug management

50

Refrigerator Room temp Oxytocine


Improved organization and cleanliness

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52

After building improvement skills on routine care, teams

move on to complications care


Delivering baby on mothers abdomen

1,9

Immediate drying11,11

Delayed cord clamping0,9

Sterile cord clamping11,11

Avoid prelacteals11,11

Breast feeding within 1 hourof birth

9,11

Inj. Vit K to all newborns10,10

Kangaroo Mother Care0,0

No. of Facilities practising before training

Practice of ENC in 11 facilities in Delhi

PresenterPresentation NotesBefore= Yellow/ black+orange glow, with leader linesAfter = White box+red font, without leader linesSame for before and after yellow box with red font with glow



1,9






9,11




No. of facilities practising after 1 month

Improvement after mentorship/process improvement support




1,9






9,11




No. of facilities practising after 1 month

Tools used: - Skills building - Process re-

engineering - Culture change

Tools for improvement



Availability of mucous suckers6.9

Availability of masks & bag11,11

Ready to use masks & bag5,9

Tubing for Oxygen10,11

Oxygen source8,11

Functional NB care unit11,11

Use of NB care unit10,9

Practice of checking beforeevery delivery

0,4

Practice of cleaning/disinfectingafter every use

1,9

No. of facilities having before training

NR equipment readiness


Availability of mucous suckers6.9

Availability of masks & bag11,11

Ready to use masks & bag5,9

Tubing for Oxygen10,11

Oxygen source8,11

Functional NB care unit11,11

Use of NB care unit10,9

Practice of checking beforeevery delivery

0,4

Practice of cleaning/disinfectingafter every use

1,9

No. of facilities having before training No. of facilities having 1 month after training

Tools used: - Skills building - Process re-

engineering - Culture change

Improvement after mentorship/process improvement support


Perinatal mortality all ASSIST supported sites 10 000 15 000 deliveries per month

Baseline mortality 2.35% Current mortality 2.07%

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Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15

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Transfer of improvement skills into government

systems


India: Timeline of activities in Chamba District

In December 2013, ASSIST supported 5 facilities in Chamba to set up QI teams

In May 2014, the District Chief Medical Officer requested ASSIST support the rest of the district

They began to achieve some impressive results

Impressive!

Nov 2013

Dec 2013

Jan 2014

Feb 2014

Mar 2014

Apr 2014

May 2014

PresenterPresentation NotesTESSIE


Timeline of activities in Chamba District

May 2014 Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014

In September 2014, ASSIST trained 38 new facilities and 10 government coaches

Going forward

Coaches will provide on-site coaching support to facilities

2 Block Medical Officers will oversee the work

Improvement reports will be included in monthly district meetings

District will organize quarterly peer-to-peer learning sessions

These 43 facilities cover 35% of the births in this district of 540,000 people

In July and August 2014, ASSIST worked with the district to plan scale up of activities.

ASSIST MOHFW


37 of 38 facilities supported by government coaches collecting and reporting data and showing initial signs of improvement

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Mar Apr May Jun Jul Aug Sep Oct Nov

Iron supplementation

Oxytocin at delivery

>2gm inc in Hb

ANC Hx and Px

PresenterPresentation NotesTESSIE


General principles of setting up a system for quality improvement

Facility and community-based improvement teams

Team support system Leadership component



Facility and community-based improvement teams Team-based QI ID problems that need to be solved at other levels

Team support system Leadership component




Team support system Support QI skills development Spread good ideas between teams Support multi-level problem solving

Leadership component




Team support system Support QI skills development Spread good ideas between teams Support multi-level problem solving

Leadership component Set goals Encourage problem identification and solving Fix problems at their level Encourage learning


For more information and resources please visit:

www.usaidassist.org

Or contact

[email protected]


Baseline perinatal mortality in Jama CHC Dumka District, Jharkhand

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Improvement team working on neonatal resuscitation and partograms

Changes in perinatal mortality in Jama CHC, Dumka District, Jharkhand


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deaths in hosp deaths in ref


Baseline 2.4% babies died in hospital 2.4% babies died after referral

After improvement work 1.7% babies died in hospital 1.0% babies died after referral

Perinatal mortality including when mothers and babies are referred to other facilities


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Baseline mortality 4.8% Intervention mortality 2.7%

Improved management and decreased referrals of moribund babies


How does performance compare between facilities with improvement aims and those without improvement aims?

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Teams NOT TRYING to improve Hb measurement


Women attending clinics which are aiming to improve Hb measurement are now more likely to get their Hb measured

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Teams TRYING to improve Hb measurement

Teams NOT TRYING to improve Hb measurement


Antenatal care in Mandi, Himachal Pradesh

020406080

100

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Denominator: Number of ANCs conducted per week in Mandi, Himachel Pradesh (average = 45.6)


Antenatal care in Mandi, Himachal Pradesh

020406080

100

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Denominator: Number of ANCs conducted per week in Mandi, Himachel Pradesh (average = 45.6)

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Percentage of ANCs during which BP and Hb were measured in Mandi, Himachal Pradesh, July 2013-March 2014

% BP measured

% Hb measured


Mandi, Himachal Pradesh case study

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Number of high-risk pregnancies identified and percentage of ANCs during which BP and Hb were measured in Mandi, Himachel Pradesh

# high-risk identified % BP measured % Hb measured

18 high-risk pregnancies identified (1.4%)

39 high-risk pregnancies identified (12.3%)

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Making changes in the health facility: skills for improving the care of mothers and babiesNigel Livesley, MD, MPHIndia Project DirectorUSAID ASSIST Project South Asia Regional DirectorUniversity Research Co.Slide Number 2Degrees of implementation(Fixsen DL et al 2005)Degrees of implementation(Fixsen DL et al 2005)Degrees of implementation(Fixsen DL et al 2005)Improving health service delivery organisational performance in health systems.Pallas et al. International Health 4 (2012) 2029People mean different things when they say quality improvementPeople mean different things when they say quality improvementSlide Number 9Maternal mortality in a Delhi hospital in 20135854 deliveriesWomen assessed only twice in six hours after deliveryWhat changes could the team make?How can higher levels support change?First idea: management directiveSuccess! Success! Or is it? What feedback should you give to the team?Success! Or is it? Slide Number 19Slide Number 20Addressing overcrowdingSustained improvement! What feedback should you give to the team?Sustained improvement! Or is it? 0.16% of women identified with complications0.16% of women identified with complicationsWhat feedback should you give to the team?What changes could the team make?How can higher levels support change?Improving ability to identify and management women with complicationsImproving ability to identify and management women with complicationsImproving ability to identify and management women with complicationsImproving ability to identify and management women with complicationsWomen with complications are now 12 times more likely to be identified earlySustained improvement and NO MATERNAL DEATHS in post partum wardSustained improvement and NO MATERNAL DEATHS in post partum wardLessons learnedGeneral principles for problem solvingASSIST overviewASSIST has worked in 24 countriesScale of USAID ASSIST Activities, FY13-FY14ASSIST IndiaSlide Number 43What we doSeven steps to support team-based problem solvingSupport networks between teams based on peer-to-peer learningContinuum of care Improving routine care for over 15 000 pregnancies and deliveries per monthImproving routine care for over 15 000 pregnancies and deliveries per monthImprovement in recording and drug management Improved organization and cleanlinessAfter building improvement skills on routine care, teams move on to complications careSlide Number 53Slide Number 54Slide Number 55Slide Number 56Slide Number 57Perinatal mortality all ASSIST supported sites10 000 15 000 deliveries per monthTransfer of improvement skills into government systemsIndia: Timeline of activities in Chamba DistrictTimeline of activities in Chamba District37 of 38 facilities supported by government coaches collecting and reporting data and showing initial signs of improvementGeneral principles of setting up a system for quality improvementGeneral principles of setting up a system for quality improvementGeneral principles of setting up a system for quality improvementGeneral principles of setting up a system for quality improvementSlide Number 67Baseline perinatal mortality in Jama CHCDumka District, JharkhandChanges in perinatal mortality in Jama CHC, Dumka District, JharkhandChanges in perinatal mortality in Jama CHC, Dumka District, JharkhandPerinatal mortality including when mothers and babies are referred to other facilitiesImproved management and decreased referrals of moribund babiesHow does performance compare between facilities with improvement aims and those without improvement aims?Women attending clinics which are aiming to improve Hb measurement are now more likely to get their Hb measuredAntenatal care in Mandi, Himachal PradeshAntenatal care in Mandi, Himachal PradeshMandi, Himachal Pradesh case study

Documents

Dr. Nigel Livesley, USAID ASSIST Project