Dr. Ziaul Matin Health Specialist, UNICEF

8 April 2015

Using 5S-CQI-TQM Approach For Improving Quality of Newborn Care In Bangladesh

Outline

Background of Quality Improvement Initiative Different QI approaches for MNCH services 5S-CQI-TQM Approach for QI Applying 5S-CQI-TQM approach for Quality

Improvement of Newborn Care Findings from 11 hospitals under 5S-CQI-TQM Challenges and Way forward

2

Context and Background

Substantial efforts have been taken so far to improve MNH services

There are still concerns regarding the quality and safety of services

Poor quality leads to medical errors, waste Currently the quality of services in the

hospitals is unsatisfactory and lead to client/consumer dis-satisfaction and mistrust

3

Context and Background

The basic characteristics of service delivery in our hospitals are characterized by: Long waiting time Overcrowding Unhygienic and disorganized work environment Wastage

Many of our hospitals ignore the non-healtrh expectations of the people: Dignity Basic human needs Prompt attention for care and treatment Communication Confidentiality

4

Lot of problems in The Hospital

5

Current Efforts of the MoHFW for QI MoHFW has incorporated Quality Improvement programme in the Health

Sector Programme 2011-16 5S-CQI-TQM approach scaled up in 97 facilities BFHI/WFHI (21 hospitals) accredited Development of National Strategic Framework for QI Development of National Health Care Standards and guidelines for 5S-CQI-

TQM Regulatory framework for the private sector/ NGO hospitals/

clinics/laboratories Introduction of standard waste management system Development of guidelines and national standards of clinical care following

WHO guidelines/protocols Regional quality assurance system for family planning services etc. Other agencies/NGOs adopted different approaches for QI- SBMR, ISO,

COPE etc. 6

Partnership and collaboration in QI MoHFW: Implementation through DGHS, DGFP and HEU (QIS) Partner Agencies: WHO, UNICEF, JICA, GIZ, USAID, MCHIP, SC, FHI

Policy advocacy QI Strategic Planning Resources Knowledge management on QI Technical assistance on 5S-CQI-TQM Capacity building South-South collaboration

icddr,b; CIPRB: Assessment, monitoring and mentoring, HMIS, MPDR Professional bodies and Academia: SOP development, Strategic

planning, mentoring/monitoring Technical agency: Supply Chain Mangement, equipment maintenance, NGOs: BRAC, Engender Health, others

7

Improved Outcome of MNCH/FP/N Services

Step 1: 5 S Step 2: KAIZEN

Step 3: TQM

Work environment Problem solving Quality services & customer satisfaction

Competency Based

Training SBM-R

Regional Roaming QI

Teams

Joint Supervisory

Visits (Supportive Supervision)

MPDR MNCH/FP/N Clinical services at facility & community

MaMoni HSS Projects Integrated QI Approaches

PresenterPresentation Notes5S: Sort, Set, Shine (clean), Standardize, Sustain. KAIZEN: Continuous Quality Improvement (Japanese) TQM: Total Quality Management SBM-R: Standard Based Management and Recognition RRQIT: Regional Roaming Quality Improvement Team MPDR: Maternal & Perinatal Death Review JSV: Joint Supervisory Visits.

TQM Approach

What is 5S?

Sort Remove un-necessary items from your work place and reduce clutter

Set Organize everything needed in proper order for easy operation

Shine Maintain high standard of cleanliness

Standardize Set up the above 3 Ss as norms in every section of your work place

Sustain Train and maintain discipline of the personnel engaged

11

Quality Improvement Process

12

KA

IZEN

LEA

DER

SHIP

Wat

er Tru

nk

Root

14

Implementation Steps of 5S-CQI-TQM

Advocacy and sensitization workshop at facility

Assess situation/ baseline

Develop WIT Action Plans and monitoring framework

Implement WIT Action Plans; track progress; Monitoring by QIT

15

Formation of QIT/WITs

5S-CQI-TQM

16

5S Activities: Implementation

Work Improvement Team

[3 - 5 persons]

Quality Improvement

Team [5 - 15 persons]

Top management

Work Improvement Team

[3 - 5 persons]

Work Improvement Team

[3 - 5 persons]

Taking leadership & support for 5S activities. Learn and practice 5S principles by him/herself

Train the hospital staff

Support implementation of 5S activities

Monitor & assess achievements of WITs Coaching the WITs

Implement 5S in respective work units/dept. Develop WIT Action Plans Conduct periodical monitoring Reporting to QIT

Improving Newborn Care in UICEF Supported 11 Hospitals with 5S-CQI-TQM

Medical College Hospital

District Hospital

Upazila Health

complex

Funding

Chittagong and

Mymensing

Bandarban, Coxsbazar, Kishorganj, Netrokona

GoJ

Moulavibazar, Narail

Kalia, Barolekha

DFATD (MNHI)

Tangail UNICEF/KOICA

2 7 2

Introducing the 5S-CQI-TQM approach Strategic planning and orientation

workshops organised in the targeted hospitals. QIT and WITs formed and QI plan was developed and has been implemented.

Training on Hospital Change Management through 5S-CQI-TQM approach was organised jointly with JICA in Sri Lanka during 2013.

Various QI activities such as clinical case review and continuous medical education sessions were supported.

Bi-annual and annual QI review workshop were organised by DGHS with joint support from UNICEF and JICA.

18

PresenterPresentation Notes

5S Activities (SORT) in Coxs Bazar District Hospital

19

5S Activities (SET) activities Nurses station in Newborn Care Unit

20

BEFORE 2011 AFTER 2014

3S: Shining

21

3S: Shining

22

4S: Standardize

23

Various QI activities (5S: Sustain)

24

CQI in SCANU Before

After

25

26

Renovation Works of SCANU in Mymensing Medical College Hospital

237 medical officers and around 580 nurses were trained in the Emergency Triage and Treatment for sick newborns (ETAT) at BSMMU and other institutes in 2013-2014

A visual learning tool explaining

Standard Operating Procedures for use and maintenance of selected essential newborn equipment was developed with technical support from BSMMU.

Strengthen Service Delivery Capacity Development of Human Resource

27

Strengthen Service Delivery SCANU Establishment

Renovation works of SCANU by the Public Works Department and Health Engineering Department under MoHFW

Quality assurance of the renovation works by Technical agency Procurement of Essential newborn care equipment Technical agency for installation, commissioning, user training and

maintenance of the equipment

28

Small CQI/KIZEN

29

Example of CQI/KIZEN Activity

30

Waste disposal at the Bandarban District Hospital, before 5S implementation - first monitoring visit in August 2013

CQI/KIZEN activity at Bandarban District Hospital, after 5S implementation (and after building waste disposal system0, fourth monitoring visit in April 2014

31

CQI In HMIS of Newborn Care

2011

2012

2013

Policy Advocacy Through Demonstrating Impact of Innovations For Improved Quality of Newborn Care in SCANU

32

Quality Improvement of services adopting TQM

approach

Competency based training and use of audio-

visual tools for skill development

Paper-based record keeping and reporting to Dashboard and individual

case-tracking through web-based MIS

Radar diagram showing overall quality of management of MNH and support services at selected hospitals during baseline assessment

(2011)

33

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Overall outlook

Provision of Responsive HealthServices

Infection Control and Wastemanagement

Out-patient Department:Maternal

Out-patient Department:Neonatal

Pharmacy Management

Emergency Management

Indoor Management: Maternal

Indoor Management: Neonatal

Pathology Management

Store Management

Diet and Kitchen Mangement

Human Resource Managementand Leadership

Maintenace of Equipments

Record Keeping

QA Activities

Bandarban DH

Barlekha UHC

Chittagoong MCH

Cox's Bazar DH

Kalia UHC

Kishoregonj DH

MoulviBazar DH

Mynenshigh MCH

Narail DH

Netrokona DH

Tangail DH

Radar diagram showing overall quality of management of MNH and support services at selected hospitals during end line assessment

(2014)

34

0%10%20%30%40%50%60%70%80%90%

100%Overall outlook

Provision of Responsive HealthServices

Infection Control and Wastemanagement

Out-patient Department:Maternal

Out-patient Department:Neonatal

Pharmacy Management

Emergency Management

Indoor Management: MaternalIndoor Management: Neonatal

Pathology Management

Store Management

Diet and Kitchen Mangement

Human Resource Managementand Leadership

Maintenace of Equipments

Record Keeping

Bandarban DH

Barlekha UHC

Chittagoong MCH

Cox's Bazar DH

Kalia UHC

Kishoregonj DH

MoulviBazar DH

Mynenshigh MCH

Narail DH

Netrokona DH

Tangail DH

Sick Newborn Admission during 2013-2014

8007

7178

2947

99

1541

9960

7560

3785

138

2140

0

2000

4000

6000

8000

10000

12000

MMCH CMCH KDH BDH CDH

2013 2014

35

Measuring KIZEN/CQI

36

17.2 14.4

0.0

5.0

10.0

15.0

20.0

25.0

30.0

2013 2014

SCANU Case fatality rate in 2013 and 2014

19772

3405

27996

4041 0

5000

10000

15000

20000

25000

30000

Total Admission Total mortality

SCANU total admission in 2013 and 2014

2013 2014

Window for Policy Support of Strengthening National Capacity Building for QI

QI Secretariat at HEU, MoHFW

Divisional QI Committee

QI Assessor team

District/Upazila QI Committee

QIT/WIT

Lessons Learned

This initiative has demonstrated evidence of changes resulting from the QI interventions in a small unit of targeted hospitals and documented those changes and processes for knowledge and evidence generation.

This has facilitated the programme managers to adopt the 5S-CQI-TQM as a feasible and doable approach for improving the quality of maternal and newborn care services at Primary/Secondary/Tertiary level hospitals within the HSS framework..

This has led to useful learnings and strategic directions to the policy makers and programme managers to further scale-up any Quality Improvement Initiatives/ in Bangladesh.

Challenges

Poor institutional mechanism and organogram for QI Inadequate institutional capacity at national and sub-

national level for QI programme management Lack of effective coordination, harmonization and

integration among different programmes and agencies for Quality Improvement (QI)

Operationalize the national strategic framework and comprehensive Action Plan for QI

Shortage of human resources in number and skills Inadequate monitoring & supervision system Poor motivation of service providers for compliance

of clinical standards and protocols

Way Forward

Capacity building of Quality secretariat and Qi committees both at national and Sub-national levels

Develop a realistic implementation plan with costing based on the national strategic framework for QI

Bring synergy, harmonisation and effective partnership under different QI programmes

Scale-up 5S-CQI-TQM sequentially from MNCH to cover whole hospital services leading to TQM

Develop assessors team at divisional level and conduct periodic assessment of facilities

Integrate core sets of quality indicators in the DHIS 2 (web-based HMIS)to monitor the quality of care

Institute comprehensive QI/QA system at all levels of health facilities leading to formal accreditation and reporting mechanism

Systematic Approach For Total Quality Management (5S-CQI-TQM) Introduced in 11 Hospitals

After

Slide Number 1OutlineContext and BackgroundContext and BackgroundLot of problems in The HospitalCurrent Efforts of the MoHFW for QIPartnership and collaboration in QISlide Number 8TQM ApproachWhat is 5S?Slide Number 11Quality Improvement ProcessSlide Number 13Slide Number 14Implementation Steps of 5S-CQI-TQM5S Activities: ImplementationImproving Newborn Care in UICEF Supported 11 Hospitals with 5S-CQI-TQMIntroducing the 5S-CQI-TQM approach5S Activities (SORT) in Coxs Bazar District Hospital5S Activities (SET) activitiesNurses station in Newborn Care Unit3S: Shining3S: Shining4S: StandardizeVarious QI activities (5S: Sustain)CQI in SCANURenovation Works of SCANU in Mymensing Medical College HospitalSlide Number 27Slide Number 28Small CQI/KIZENExample of CQI/KIZEN ActivitySlide Number 31Policy Advocacy Through Demonstrating Impact of Innovations For Improved Quality of Newborn Care in SCANURadar diagram showing overall quality of management of MNH and support services at selected hospitals during baseline assessment (2011)Radar diagram showing overall quality of management of MNH and support services at selected hospitals during end line assessment (2014)Sick Newborn Admission during 2013-2014Measuring KIZEN/CQIWindow for Policy Support of Strengthening National Capacity Building for QILessons LearnedChallengesWay ForwardSystematic Approach For Total Quality Management (5S-CQI-TQM) Introduced in 11 Hospitals