1

Participants manual

Training programme for quality improvement for maternal & newborn health 1st QI training workshop for health care providers

www.prrinn-mnch.org

2

ACKNOWLEDGEMENTS In the first place we thank Dr Jan Hofman from Health Partners International (HPI) for

conceptualising and writing the initial and the revised Quality Improvement (QI) facilitators

guide and this QI participants manual, which is based on his extensive experience in

conducting QI training for health care providers.

We thank him and Dr Joanna Raven from the International Health Group at the Liverpool

School of Tropical Medicine (LSTM), who jointly designed the initial concept of the QI

training programme, which Dr Hofman further developed during the course of its use in

Nigeria.

A special word of thanks goes to Dr Adetoro Adegoke, who together with the author of this

facilitators’ manual piloted the QI training programme in Nigeria during its first year, and to

Dr Danladi Abubakar, the national consultant who has been co-facilitating the QI workshops.

We thank the QI trainers, who reviewed in March 2014 the first version of the QI facilitators

guide, which was prepared in May 2012, after it had been used for 2 years to conduct QI

training workshops in the three northern states. They include: Dr Danladi Abubakar, Mrs

Furera Atiyaye Barnes, Mrs Dada Yusuf Bate, Mrs Esther Beko, Dr Maidugu Bwala, Dr Elijah

Kehinde, Dr Abubakar Kullima, Dr Ibrahim Lawal Magaji, Dr Adebola Owadunni, Dr

Abdulmajeed Oyeniyan, Dr Musa Sarki, Dr Bashir Abdullah Umar.

We also thank the members of the management team of the PRRINN-MNCH programme for

recognising the importance of quality of care for improving Maternal Newborn and Child

Health (MNCH) in Northern Nigeria and for including a QI component in the PRRINN-MNCH

programme.

Our gratitude is also extended to the representatives from the State Ministries of Health in

the target states of the PRRINN-MNCH programme (Katsina, Yobe, Zamfara) for their

support to the QI initiative in the PRRINN-MNCH programme and their valuable contributions

to the QI workshops so far. These include representatives from the State Health Services

Management Boards, the State Primary Health Care Management Boards and Primary

Health Care Directors and Maternal and Child Health Coordinators at Local Government

area (LGA) level.

We also thank the PRRINN-MNCH staff who gave logistical and administrative support to

the PRRINN-MNCH QI workshops.

We are grateful to the authors of the WHO publication “Beyond the Numbers: reviewing

maternal deaths and complications to make pregnancy safer” and the WHO staff who

contributed to this document, which has been a great inspiration for the current QI training

programme, which is designed around the recommended QI methods recommended by

WHO in this publication.

We thank the participants of the QI workshops and the members of the health facility QI

teams, from whom we have learned a lot concerning the implementation of QI activities in

Northern Nigeria, which has helped to give the QI training programme its current shape.

Finally we thank UK Aid of the UK Department for International Development (DFID) and the

Norwegian Government, who funded the PRRINN-MNCH programme. Without their financial

support this QI training programme and manual would not exist.

3

ABBREVIATIONS ANC Ante Natal Care

ARV Anti Retro Viral

BEmNC Basic Emergency Obstetric and Newborn Care

CBA Criteria Based Audit

CEmONC Comprehensive Emergency Obstetric and Newborn Care

CQI Continuing Quality Improvement

CS Caesarean Section

DFID Department For International Development (UK)

EmONC Emergency Obstetric & Newborn Care

ENC Essential Newborn Care

FANC Focused Ante-Natal Care

FGD Focus Group Discussion

FMOH Federal Ministry Of Health

FP Family Planning

HF Health Facility

HIV Human Immuno-deficiency Virus

HMIS Health Management Information System

HPI Health Partners International

LGA Local Government Area

LSS Live Saving Skills

LSTM Liverpool School of Tropical Medicine

MCH Maternal and Child Health

MD Maternal Death

MDG Millennium Development Goals

MDR Maternal Death Review

MMR Maternal Mortality Ratio

MNH Maternal & Newborn Health

MNCH Maternal Newborn and Child Health

NPHCDA National Primary Health Care Development Agency

NGO Non Governmental Organisation

PAC Post Abortion Care

PHC Primary Health Care

PMTCT Prevention of Mother to Child Transmission (of HIV)

PNC Post Natal Care

PNDR Peri Natal Death Review

4

PRRINN Partnership for Revitalising Routine Immunisation in Northern Nigeria

QI Quality Improvement

RH Reproductive Health

SBA Skilled Birth Attendance

SHSMB State Health Services Management Board

SMOH State Ministry of Health

SPHCMB State Primary Health Care Management Board

SRH Sexual and Reproductive Health

TBA Traditional Birth Attendant

ToR Terms of Reference

TQM Total Quality Management

VCT Voluntary Counseling and Testing

WHO World Health Organization

5

TABLE OF CONTENTS

i ACKNOWLEDGEMENTS ......................................................................................... 01

ii ABBREVIATIONS ..................................................................................................... 02

iii TABLE OF CONTENTS ............................................................................................ 04

1. INTRODUCTION ............................................................................................. 05

2. PURPOSE AND APPROACH OF THE TRAINING ................................................ 08

3. STRUCTURE AND CONTENT OF THE QI WORKSHOPS .................................. 10

4. CONTENT OF THE 1ST QI WORKSHOP .............................................................. 12

5. REFERENCES ....................................................................................................... 27

ANNEXES

I. TASKS FOR AFTER THE 1ST QI WORKSHOP .................................................... 29

II. INTERVIEW GUIDES …......................................................................................... 30

III. PERFORMANCE ASSESSMENT TOOL ............................................................... 35

6

1. INTRODUCTION

Nigeria has some of the highest rates of maternal, neonatal and child mortality in the world.

These mortality rates show wide disparities between the north and the south. Although the

national IMR and U5MR are 75 and 157 per 1000 live births respectively, rates in the North

West geopolitical zone, for example, are 91/1000 (IMR) and 217/1000 (U5MR) respectively.

Maternal mortality ratios in the North are far above the national figure of 545/100,000 and

are unacceptably high (NDHS, 2008). A population-based study of maternal mortality in

Northern Nigeria over the 1990’s found a Maternal Mortality Ratio (MMR) of 2,420 deaths

per 100,000 live births (Adamu, 2003), while a household survey conducted by the PRRINN-

MNCH programme in 2011 in four northern states reported a MMR of 1,271 maternal deaths

per 100,000 live births (Doctor, Findley, Afenyadu, 2011).

At least 80% of all maternal deaths result from five complications that are well understood

and can be readily treated: haemorrhage, sepsis, eclampsia & pre-eclampsia, obstructed

labour and complications of abortion. We know how to prevent these deaths – there are

existing effective medical and surgical interventions that are relatively inexpensive. Most

obstetric complications cannot be predicted and occur suddenly and unexpectedly – prompt

access to good quality Essential (or Emergency) Obstetric Care (EmOC) and Newborn Care

(NC) is essential.

Key strategies to reduce maternal and newborn mortality are, increasing access to skilled

attendance at birth for all pregnant women and to Essential (Emergency) Obstetric Care

(EmOC) for those mothers who experience life-threatening complications during pregnancy,

childbirth and the post-partum period, while Essential Newborn Care (ENC) is crucial to save

newborn lives. Also increasing access and utilization of Family Planning (FP) services and

Focused Antenatal Care (FANC) are important to reduce maternal mortality, as is prevention

of unsafe abortion. To increase access and utilisation of these services health facilities which

provide such services must be available and accessible. This requires functioning health

systems which ensure that sufficient professional staff is available to provide these services

and that they have the necessary knowledge and skills as well as the enabling environment

to do so. This includes adequate infrastructure, equipment, drugs and other medical

supplies. In addition to this, communities need to be sensitised on Maternal Newborn & Child

Health (MNCH) issues and mobilised to ensure that women are supported to use essential

health services and socio-cultural determinants which affect maternal and newborn health

are addressed.

However, increasing availability and access to skilled attendance at birth, EmONC, FANC

and FP services is not enough to reduce mortality rates. In order for such services to be

effective in reducing maternal & neonatal mortality and morbidity and in attracting clients and

patients and increase utilisation of essential MNCH services, we must ensure adequate and

acceptable quality of care. This can be achieved by introduction of Quality Improvement (QI)

processes at MNCH facilities, which can make a significant impact on pregnancy outcomes

and service utilisation.

Confidential enquiries into maternal deaths and analysis of findings from facility-based

maternal death reviews in various countries have shown that across the world a

considerable proportion of MD cases result from avoidable factors and sub-standard care. In

the latest edition of “Why Mothers Die 2000-2002: Sixth report of the confidential enquiries

into maternal deaths in the UK” it was reported that 67% of direct maternal deaths in the UK

7

were the result of sub-standard care and 47% of these were considered to be major, where

a different treatment might have prevented the death. The 3rd report of confidential enquiry

into maternal deaths in South Africa 2002-2004 found that 36.7% of maternal deaths were

clearly avoidable within the health care system (Moodley & Pattinson, 2006). In another

study in West Africa it was found that 69% of direct maternal deaths were the result of sub-

standard care (Bouvier-Colle, 2001).

The previous figures indicate that in order to reduce maternal and perinatal mortality it is

important to improve quality of MNH care within health facilities. The World Health

Organization (WHO) advises, to go beyond the numbers in order to reduce maternal

mortality and recommends several methods to improve quality of care of MNH services

(WHO, 2004). These include facility and community-based maternal and peri-natal death

reviews, criteria-based audit, working with standards and confidential enquiries into maternal

and perinatal deaths. Several studies have demonstrated that maternal and perinatal death

reviews, followed by remedial action, can improve quality of care and reduce maternal and

perinatal mortality (Pattinson, 2009).

Against this background the Partnership for Reviving Routine Immunisation in Northern

Nigeria and Maternal Newborn and Child Health (PRRINN-MNCH) programme initiated in

2010 ongoing QI processes in the EmONC facilities which were supported by the

programme.

The PRRINN-MNCH programme was launched in September 2008 to support Nigeria in the

achievement of the Millennium Development Goals (MDGs) related to MNCH in Northern

Nigeria. This 5 year programme, which was funded by UK Aid from the UK Department for

International Development (DFID) and the Norwegian Government, sought to contribute

towards the reduction of maternal, neonatal and child morbidity and mortality in 3 northern

states: Katsina, Zamfara and Yobe. The programme was implemented by a consortium of

organisations and institutions with expertise in MNCH. The MNCH programme linked up with

the earlier initiated Partnership for Revitalizing Routine Immunization in Northern Nigeria

(PRRINN). The PRRINN-MNCH programme was managed by Health Partners International

(HPI), Safe the Children UK and GRID Consulting, with technical support from a range of

partners including Johns Hopkins Bloomberg School of Public Health and Liverpool

Associates in Tropical Health/Liverpool School of Tropical Medicine (LATH/LSTM). One of

the outputs in the PRRINN-MNCH programme was to improve the delivery of MNCH

services (including RI) via the strengthened PHC system.

In order to initiate ongoing QI processes in the PRRINN-MNCH supported EmONC facilities

in the 3 target states, the programme organised a series of QI workshops for representatives

from these health facilities. The purpose of these QI workshops was, to build capacity to

improve quality of care of MNCH services in an ongoing manner by establishment of QI

teams and introduction of QI methods. Different approaches and methods for QI were

introduced and the EmONC facilities have formed QI teams, which are leading the QI

processes in the health facilities.

The QI training programme has been developed and initiated with technical support from

staff of the Maternal & Newborn Health (MNH) Unit of the Liverpool School of Tropical

Medicine (LSTM), assisted by a Consultant Obstetrician from the Federal Medical Centre in

Gusau, Zamfara state. To build in-country capacity, health staff from the Primary Health

Care offices of target LGAs as well as from the State Ministries of Health (SMOH), State

Primary Health Care Management Boards (SPHCMB) and State Health Services

8

Management Boards (SHSMB) also attended the QI workshops and teams of QI master

trainers have been trained and mentored in each of the PRRINN-MNCH supported states.

They are now able to deliver the QI training package in their states.

To facilitate institutionalisation of QI in the three states a QI orientation package for senior

policy makers has been developed and in February 2014 a QI orientation workshop was

organised in Kano for senior policy makers from the three target states as well as from the

Federal Ministry of Health (FMOH) and the National Primary Health Care Development

Agency (NPHCDA). A 4 day QI training package has been developed for health programme

managers at state and LGA level and in March/April 2014 in each of the three states a QI

training will be held for selected health programme managers from the target LGAs and

SMOH.

In March 2014 the initial QI training package and the training manual from 2012 have been

revised by a group of experienced QI trainers, including the author of the manual and the

national QI consultant from the FMC in Gusau. It was decided to redesign the QI workshops

into a series of three instead of four workshops so that the whole programme can be

delivered within a period of one year, with about 3 months intervals between workshops.

This is the training manual for participants of the 1st QI training workshop, which covers the

content of this workshop.

2. PURPOSE AND APPROACH OF THE QI TRAINING

2.1 Purpose of the QI training

The purpose of the QI training programme is to initiate ongoing QI processes in health

facilities, whereby in a continuing process these facilities identify quality of care problems,

analyse the root causes and come up with interventions to address these problems and

improve quality of care with the ultimate aim to reduce maternal, peri-natal and child

mortality and morbidity and increase client, patient and staff satisfaction.

2.2 Expected Outcomes

It is expected that health care providers and health service managers who participate in the

QI workshops will:

Become aware of the importance of quality of care for the reduction of maternal,

newborn and child mortality and reduction of morbidity;

Become more knowledgeable about the meaning of quality, quality of care and

approaches and methods which can be used to improve quality of care of MNCH

services;

Be able to assess quality of care in health facilities, considering different

perspectives, aspects and dimensions of quality of care, analyse root causes and

develop interventions to assess the identified quality of care problems and monitor

and evaluate their effectiveness in improving quality of care.

Be able to initiate, organise and conduct facility-based maternal and peri-natal death

reviews as well as to develop standards for quality of care for various health services,

develop criteria for audit of MNCH service provision and conduct criteria-based audit;

9

Establish QI teams in their health facilities, which will be responsible for assessing

quality of care, initiating and monitoring QI activities and evaluating their

effectiveness in improving quality of care.

2.3 Approach

The QI training consists of a series of 3 workshops, each lasting between 2 and 4 days. The

workshops are conducted at 3 month intervals. In this way participants gradually build up

their knowledge and skills for QI. Moreover, each subsequent workshop starts with a recap

of the key issues covered during the previous workshop, reinforcing the earlier acquired

knowledge. In between these workshops participants apply the knowledge and skills

developed during the workshops within their own health facilities, assessing quality of care,

identifying quality of care problems, analysing the root causes, and initiating QI activities.

The workshops are facilitated by at least 2 workshop facilitators, who have technical

knowledge about and experience with MNCH and QI methods for MNCH. The workshop

facilitators will be assisted during workshops by an administrative assistant, who is

responsible for all logistical and administrative arrangements.

Within health facilities QI teams are formed, which are responsible to lead the QI activities in

their facilities. These QI teams report to the Management of the health facility.

Within 2 weeks after each QI workshop, the members of the QI teams who attended the

workshop must organise a QI step-down training for the other members of the health facility

QI team. In this they will be supported by one of the QI trainers from the state.

To support the health facility QI teams and institutionalise QI processes it is important that

these teams receive regular supportive supervision, which should start already after the first

QI workshop and continues in between the various QI workshops.

A separate 4 day QI training programme has been developed to train health programme

managers who are involved in QI and who are to supervise the health facility QI teams.

These include LGA Primary Health Care (PHC) directors and Maternal & Child Health (MCH)

coordinators, state-level QI desk officers, MCH coordinators from the SMOH, SPHCMB or

SHSMB, and members of the state-level QI committee or from the state supportive

supervision teams.

The QI training programme focuses on MNCH, but the principles of QI can also be applied to

other aspects of health care.

10

3. STRUCTURE AND CONTENT OF THE QI WORKSHOPS

3.1 Structure of the QI Training Programme

The QI training is delivered in a series of three QI workshops. After the 1st QI workshop the

health facilities establish QI teams at their health facilities, which are responsible for

identifying and analysing quality of care issues and for improving quality of care and will lead

the QI activities in the health facility. In between the workshops the QI teams will apply the

knowledge and skills acquired during the workshops within their own health facility by

identifying quality of care problems, analysing the root causes, using the QI methods which

have been explained during the workshops, and initiating, monitoring & evaluating activities

to improve quality of care.

Each subsequent workshop starts with a recap of the key issues discussed during the

previous workshop, followed by sharing of experiences with QI. At the end of each workshop

participants discuss and agree on the next steps for the way forward after the workshop.

3.2 General Content of the QI Workshops

The first QI workshop will make participants familiar with the concepts of quality and quality

of care and they will learn why quality of care is important for MNCH. During the workshop

the different dimensions and perspectives of quality of care are explored, as well as the

different aspects of quality of care from a health systems perspective. General approaches

to improve quality of care are discussed as well as specific QI methods which have been

used to improve quality of MNH services. Participants are encouraged to form QI teams in

their health facilities, which will be responsible for quality of care. The composition and roles

& responsibilities of these QI teams are discussed. Finally methods and tools to assess

quality of care are presented. At the end of the workshop participants are asked to inform

other staff at their health facility, particularly the Management, about the proceedings of the

workshop, to establish a health facility QI team, conduct a QI step-down training for other

members of the health facility QI team, and carry out an assessment of quality of care in

their health facility.

The 2nd QI workshop, after a recap of the content of the previous workshop, starts with

sharing of experiences. Each QI team presents what they have done since the 1st workshop,

what quality of care problems they have identified, as well as their root causes, what they

have done to address these issues, what was achieved, what challenges they faced in

improving quality of care and what lessons they have learnt. The main content of the 2nd QI

workshop includes facility-based Maternal Death Review (MDR) and Peri-Natal Death

Review (PNDR) as well as how to measure quality of care and how to monitor and evaluate

QI activities. With a case scenario participants are introduced to the “three delays model”,

which is used as an analytical framework for MDR and PNDR. It is explained how MDR and

PNDR can help to understand why mothers and babies are dying and to identify

weaknesses in the provision of MNH care, which have to be analysed and translated into

action in order to address the shortcomings in care. The concept, principles, advantages and

limitations of these methods are explained and participants conduct a MDR and PNDR in

small groups, using case scenarios, in order to better understand the process. Data

recording and reporting forms for facility-based MDR and PNDR are presented and

11

reviewed. The rest of the workshop is spent on two main issues: 1) How to measure quality

of care; 2) How to monitor & evaluate QI activities.

The 3rd QI workshop also starts the 1st day with a recap of the content of the previous

workshop, sharing of experiences and discussion of issues arising. In particular, workshop

participants share their experiences with initiating and conducting MDR and PNDR.

Workshop participants are asked to bring cases of maternal and perinatal deaths which have

been reviewed and some of these will be presented and discussed on the 2nd day of the

workshop. The next workshop topic is, working with standards to improve quality of care,

explaining how to set and use standards. The workshop participants develop and formulate

in small groups minimum standards for various aspects of MNCH services, which are further

discussed in a plenary session. After this the QI method of Criteria-Based Audit (CBA) is

introduced. During small group work participants explore what aspects of service delivery

and care can be audited and how to develop criteria for audit, which will form the audit

checklist. They also carry out two practical criteria-based audit exercises in small groups.

In the following chapters the content of the 1st QI workshop will be presented in detail.

12

4. CONTENT OF THE 1ST QI WORKSHOP

The duration of the 1st QI workshop is 2 days.

4.1 Workshop Objectives

The objectives of the 1st QI workshop are as follows: Explore and define the concepts of quality and quality of care;

Explain why quality of care is important for MNCH;

Describe different perspectives and dimensions of quality of health care and explain

the three health system levels;

Contextualise how quality can be improved;

Learn how to assess quality of care in health facilities;

Agree on recommended composition, roles and responsibilities of health facility QI

teams;

At the end of the workshop, participants will be able to:

Initiate a process of identifying quality of care problems and initiating quality

improvement activities in health facilities.

Establish health facility QI teams.

4.2 Workshop Programme

DAY 1:

08.30 am Registration

08.45 am Welcome address and opening prayer

09.00 am Introductions, ground rules

09.30 am Objectives and programme of the workshop

09.45 am Pre-test

10.00 am What is quality and quality in health care?

10.30 am Tea/coffee break

10.50 am What is quality in the context of maternal & newborn health?

11.00 am General historic background to QI: the wider picture

QI champions and success stories

11.15 am Importance of quality of care

11.45 am Models of quality of care

12.15 am Group exercise: Perceptions of quality

13.00 pm Prayers and lunch

14.00 pm Feedback from group exercise

15.00 pm Is this quality? Reviewing photographs

15.30 pm Prayers + tea break

16.00 pm End of day evaluation and closing prayer

13

DAY 2:

08.00 am Registration

08.15 am Recap of day 1

Outline of programme of day 2

08.45 am Role plays: Good and bad quality of ANC

09.15 pm Identifying aspects of good and bad quality of ANC (group work)

09.45 am Presentation of findings from group work

10.30 am Tea/coffee break

10.50 am How to improve quality of care?

- Approaches

11.15 am How to improve quality of care

- QI methods to improve MNCH care

11.45 am Methods and tools to measure quality of care

12.15 pm Group photo

12.30 pm Prayers and lunch

13.30 pm Introduction to QI teams

Group exercise: QI teams

14.15 am Feedback from group work

15.15 pm Presentation of quotes related to QI

15.30 pm Next steps for the way forward after the workshop

- Tasks to be done in next months

- Explanation of quality of care assessment

- What to prepare for the next QI workshop

15.45 pm Post-test and filling in of workshop evaluation form

16.30 pm Handing out of certificates

Closing remarks and prayer

14

4.3 Detailed Workshop Content

What is Quality?

During the first workshop exercise participants explore the meaning of “quality”. This is done

by buzzing in pairs or threes for 5 minutes. They are asked to think about the meaning of

quality by thinking about when they last bought an item, such as clothes, shoes, furniture, a

bicycle, motorcycle, refrigerator, food, a radio or TV. Why did they buy that particular item

and why from that particular shop?

Aspects of quality which may come up are: durability, reliability, reputation, recognized

brand, prompt service, consumer friendly, competent and helpful shop attendant, availability

(desired product is in stock), affordability, right price (value for money), high standard,

attractiveness of item, comfort, pleasant environment, convenient opening hours of shop.

What is Quality in Health Care?

Workshop participants explore the meaning of quality in health care. This is again done by

buzzing in pairs or threes.

Aspects of good quality health care may include: warm and cordial welcome, friendly staff,

competent staff, prompt service, affordable services, proper history taking and examination,

making a correct diagnosis, right treatment, clear treatment instructions, availability of drugs

and equipment, good health outcomes, information & advice given, clean environment.

Aspects of bad quality health care may include: negative attitudes and bad behaviour of

staff, long waiting times, staff not around or coming late, lack of privacy (e.g. no curtains

around delivery beds), no skilled staff, no drugs (patient has to buy elsewhere), lack of

equipment, dirty environment, poor health outcomes.

Definitions of Quality in Health Care

Over time different definitions have been developed for quality of care in a health care

setting. Defining and therefore measuring quality of care has initially tended to focus on

biomedical outcomes. An earlier definition indicates this: “the application of medical science

and technology in a manner that maximises its benefit to health without correspondingly

increasing the risk” (Donabedian, 1980).

An important distinction between the quality of the actual care and the expected quality of

care based on standards is made in this definition: quality of care is “proper performance

(according to standards) of interventions that are known to be safe, that are affordable to the

society and that have the ability to produce an impact on mortality, morbidity and disability”

(Roemer & Montoya-Aguilla, 1988). In addition to biomedical outcomes, this definition adds

safety and affordability as aspects of quality care.

Some definitions are more inclusive and now address user and provider satisfaction, social,

emotional, medical and financial outcomes as well as aspects of equity and performance

according to standards and guidelines.

Wilson and Goldsmith (1995) describe quality of care as: “the sum of its four components:

technical quality (measured by patients’ health status improvement), resource consumption

(measured by the costs of care), patient satisfaction (measured by patient perception of the

DAY 1

15

subjective or interpersonal aspects of care), values (measured by the acceptability of any

trade-offs that must be made among the three previous outcomes)”.

More recent definitions of quality of care include one by the Institute of Medicine (2001): “the

degree to which health services for individuals and populations increase the likelihood of

desired health outcomes and are consistent with current professional practice”. This

definition makes it clear that quality of care is a means of closing the gap between the

desired and actual health outcomes.

Quality of Care in the Context of Maternal & Newborn Health

Defining quality of maternal health care poses some extra challenges. Pittrof et al (2002)

pointed out that maternity care has 4 specific aspects:

• Most users of maternity services are well. Basic essential care should therefore be

provided to all pregnant women and their babies. It should be evidence based and cost

effective.

• Some users will develop conditions requiring a higher level of maternity care.

8-15% of women will develop complications, and although screening of women may

ensure that some women receive a higher level of care, we cannot predict who. Providing

higher-level care should not interfere with providing minimum care to the entire

population. Availability of good quality EmOC is important to provide tis special care.

• Maternity care is aimed at least at two recipients – the mother and baby. Outcomes

for both mother and baby are important and advantages and disadvantages for both need

to be counterbalanced.

• As childbirth is a culturally and emotionally sensitive area, non-biomedical outcomes

may be more important than for other areas of health care. Satisfaction depends on

values given to specific medical outcomes which vary between cultures and individuals.

Defining quality in the context of maternal health, Hulton et al (2000) incorporated the

concept of both effective and timely access, and of reproductive health rights: “quality of care

is the degree to which maternal health services for individuals and populations increase the

likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes

that are both consistent with current professional knowledge and uphold basic reproductive

rights”.

The authors recognise the importance of two components of care: quality of the provision of

care and quality of care as experienced by users. The use of services and outcomes are the

result not only of the provision of care but also of women’s experience of that care. Provision

of care may be deemed of high quality against recognised standards of care but

unacceptable to the woman and her family. Conversely, some aspects of care may be

popular with women but may be ineffective or harmful to health.

Pittrof et al (2002) proposed the following definition of quality of maternity care: “high quality

of care maternity services involves providing a minimum level of care to all pregnant women

and their newborn babies and a higher level of care to those who need it. This should be

done while obtaining the best possible medical outcome, and while providing care that

satisfies women and their families and their care providers. Such care should maintain

sound managerial and financial performance and develop existing services in order to raise

the standards of care provided to all women”.

16

Historic Background to Quality Improvement (QI): the bigger picture

Although QI seems a new concept in Nigeria, in fact QI is not new. The current QI movement

has its origins in the 1950s in the manufacturing industry, particularly in Japan. Quality was

seen as an important management issue, which requires a systematic approach in order to

reduce failures in the production process and reduce costs. QI will reduce total costs by

avoiding costs of doing things wrong and thus increases profitability. Quality problems are

seen as systematic due to management rather than individual errors of workers. Also the

importance of satisfying the needs and expectations of the customer was recognised and

even exceeding these expectations as Demings promoted, who stressed the need to stay

ahead of the customer and to anticipate needs and demands.

K Ishigawa F Nightingale I Semmelweis Socrates A Feigenbaum E Demmings

Pioneers of this quality revolution in Japan were Edwards Deming and Joseph Juran. Other

leaders in QI were Walter Shewhart, Armand Feigenbaum (who introduced the concept of

Total Quality Management), and Philip Crosby. Deming perceived quality as “satisfying the

customer”, focusing on the needs of the customer. He sees QI as controlling and managing

systems and management processes to solve problems. Juran defines quality of a product

or service as “fit for purpose or use”. Fit for purpose has 5 major dimensions: 1) quality of

design; 2) quality of conformance; 3) quality of availability, including reliability and

maintainability; 4) safety; 5) quality in use by the customer. Quality is primarily judged by the

user or customer. Crosby defines quality as “conformance to requirements”, which need to

be defined and specified clearly. Feigenbaum emphasized the importance of prevention of

poor quality rather than detecting it after the event. He also argued that quality should be an

integral part of day-to-day work.

In the 1950s the Japanese industry was at the forefront of embracing QI concepts in order to

increase efficiency, reduce wastage and costs as a result of errors, and increase profitability.

Japanese gurus in QI were Kaoru Ishikawa and Genichi Taguchi.

Much later, after the successes in the manufacturing industry, in the 1980s and 1990s the

principles of QI were also introduced in the health sector by people like Avedis Donabedian,

Donald Berwick, and Heather Palmer. Also the USAID funded Quality Assurance project has

done recommendable work to apply the QI concepts in the health sector. The Harvard

Medical Practice study in 1991 raised concern about quality of care by revealing that

adverse events as a result of errors occur in 4% of hospitalizations, of which 14% are fatal. A

study by the US Department of Health and Human Services in 2009 found that 70% of such

errors are preventable. This triggered an interest in QI tools to prevent errors or undesired

variation as have been used elsewhere, such as in the aviation sector. Also the need for

Government cuts in health budgets raised concerns that this may jeopardise quality of care.

We also must recognise that there were already pioneers in the health sector who tried to

solve quality of care problems long before the QI movement which took off after the 1980’s.

17

Examples are Florence Nightingale, the founder of modern nursing, and the Hungarian

physician Ignaz Semmelweis, whose work in the 1840s demonstrated that hand washing

could drastically reduce the number of women dying after childbirth. Perhaps we could even

consider the ancient Greek physician Hippocrates, who lived between 460 and 377 BC and

is considered the father of modern medicine, as a QI pioneer in QI.

WHO also recognizes the importance of quality in health systems. WHO distinguishes six

essential building blocks which make up the health system. We need these building blocks

to support health care services to be effective. The 6 building blocks will only lead to

expected improved health outcomes when access, coverage, safety and quality of health

services are ensured. If the quality of the services and the building blocks is inadequate we

will not achieve the desired health outcomes. Universal coverage to ensure access to

services is also required to achieve the desired outcomes for the whole population.

Further reading: Ghobadian A, Speller S (2006). Gurus of quality: a framework for

comparison. Total Quality Management; 5 (3): 3-69.

Why is Quality of Care Important?

During the workshop, in groups of two or three participants are asked to discuss why quality

of care is important and why should we be concerned about quality of care.

Quality of care affects health care in the following ways:

Outcome:

Quality of health care will affect if and how well the woman and newborn recover. This is not

just about reducing mortality, but also morbidity (illnesses and disability)

Patient satisfaction:

Quality of care determines how satisfied is the woman and her family are with the care that

she received. When information spreads, this will in turn affect other people’s perceptions of

the services and create a bad reputation.

Health worker satisfaction:

When health workers know they provide good quality services and they receive positive

feedback it creates job satisfaction and motivates staff in their work.

18

Health seeking behaviour:

If quality is poor, this will affect people’s confidence in the services and also affect behaviour,

such as compliance to treatment and advice. If quality of care is poor women and families

will choose other facilities or other health care providers such as traditional healers and they

may be reluctant to use health services, even when this is necessary, such as in case of an

emergency or serious condition.

Utilisation of services:

Women and families will talk with others and this will affect their perceptions of the health

facility. Clients and patients will not use any services, even essential ones, if they perceive

the quality as poor. The result may be that a woman does not receive antenatal care or will

not benefit from a skilled attendant during child birth. This may have a negative impact on

the health status of women in the population.

Timing of presentation at health facility:

Patients come late, because they are reluctant to use services if they have no confidence in

them. They only come for emergencies or when the condition has deteriorated to a

desperate level and by the time they arrive in the hospital it is too late to save the mother or

baby’s life.

Willingness to pay for care:

If people do not see the value of the care they receive, they are not willing to pay for poor

care and will not use facilities which charge fees. They prefer to spend money on other

things.

If we are seriously concerned about quality of care it will help us achieve many things:

• Higher standards of care, better outcomes and reduced mortality and morbidity.

• Satisfied patients;

• Staff satisfaction – if I feel like I have provided good care, then I feel happy, and this

motivates me to continue to provide good care and improve care.

• Improved relationships between colleagues – work together as a team, motivate

each other to provide good quality of care;

• Improved relationships between staff, patients and communities – staff are

responding to needs of patients and communities, better communication.

• Increased use of facilities and earlier use of facilities

• Increased use of services may lead to an increase in funds, such as more income

from user fees and more likely financial support from donors. This may help improve

the quality even further as a result of affordability to purchase equipment, send staff

for training, and maintain the facility and improve working environment.

Poor quality health services may result in waste of money, time and even lives.

Models of Quality of Care

Quality of care can be viewed from different perspectives (Ovretveit, 1992):

1. the view of patients, clients, potential users and the community at large;

2. the view of health care providers;

3. the view of health planners, managers and programme coordinators.

19

Quality of care has different aspects or elements, such as effectiveness (in curing or

preventing diseases, reducing mortality, morbidity and disability), technical competency,

interpersonal relations, equity, safety, patient centredness (responsiveness to client’s and

patient’s needs and expectations), timeliness and continuity and efficiency.

Technical competence

This refers to knowledge, skills and actual performance of health care providers, managers

Interpersonal relations

This refers to relationships between health care providers and clients, managers and

providers, health team and community. Good interpersonal relations create trust and

credibility.

Inadequate communication can negatively affect effectiveness of care, such as poor

compliance with recommendations and poor care and treatment as a result of

miscommunication and misunderstanding.

Patient centredness

This refers to being responsive to the needs and expectations of clients, patients and the

community at large, it includes ‘user-friendly’ services and convenient lay-out of facilities,

respect for clients’ and patients’ cultural values, beliefs and practices, involving clients and

patients in decision making and ensuring privacy and confidentiality.

Equity

This means that services are provided fairly and with consideration for those who need the

services most.

Effectiveness

Services when provided correctly produce the desired results and have good health

outcomes.

Efficiency

This means producing the greatest benefits within resources available and not wasting

resources needlessly.

Safety

We must ensure that in providing treatment and care we take safety precautions to avoid

doing harm to our patients, ourselves and others. This includes a safe environment, safe

procedures and treatments and infection and accident prevention measures.

Timeliness and continuity

This refers to accessibility and continuity of care, including avoiding delays in accessing and

receiving care and availability of 24/7 obstetric care. Access to care includes geographic

access (availability of transport, distance from home, travel time to health facility), financial

access (ability and willingness to pay for services) and organisational access (hours of

service, waiting time, human resources, emergency referral system).

Amenities

Refers to aspects of services not directly related to clinical effectiveness, but which enhance

the client/patient’s satisfaction and likelihood to return.

20

Dimensions of the Health System:

Quality of care is also related to different dimensions of the health care system and can be

measured at these different points in the system. The quality of resources, quality of

management, quality of health care activities and quality of outcome - all of which constitute

quality of care, can be measured (Donabedian, 1980).

It is important to focus on all three dimensions of the health system as health outcomes are

dependent on the structural aspects and processes of the health system.

Structure: refers to the characteristics of the resources in the health delivery system (what

has to be in place to provide services), for example number of qualified staff, functioning

equipment, number of road worthy vehicles, policy guidelines, and management systems.

These may be easy to measure but are not always informative unless they are related to the

process and outcome.

Process: examining the process of care embodies what is actually done to and for the

patient and how it is done. Collection of this data depends on having good systems of

recording and reporting. Process measures include things such as waiting time, being given

a clear diagnosis, examining the patient properly, prescribing the correct treatment,

interpersonal communication.

Outcome: measurement of the effect or outcomes of care is generally still more difficult to

carry out and is less frequently done. Outcome measures include for example mortality,

patient satisfaction, coverage, and attendance levels.

Is this Quality?

After the more theoretical discussion of concepts of quality and quality of care, workshop

participants get a chance to look at some real life examples on pictures. They are asked to

comment on what they see in terms of quality of care.

21

What is Good and what is Bad Quality Antenatal Care?

In order to apply the concepts of quality of care which have been discussed the previous

day, the workshop participants explore the aspects of quality of antenatal care. This started

off with two role plays. The first role play shows an example of good antenatal care. The

second role play demonstrates bad antenatal care. Afterwards workshop participants were

divided in 3 groups for group work on what constitutes good quality antenatal care:

Group 1 discusses and lists aspects from the health care provider perspective which are

related to structure;

Group 2 discusses and lists aspects from the health care provider perspective which are

related to process;

Group 3 discusses aspects from the client’s perspective, in terms of what the client expects;

How to Improve Quality of Care?

QI is a continuous process, it uses a systematic approach, and it requires teamwork and

commitment. QI is sometimes called quality assurance, which is defined as “a systematic

and planned approach to improve and maintain quality of care”. It has three key aspects:

Defining quality: this means setting standards for desired quality levels.

Measuring quality: this means, assessing actual quality of care and compare it with

desired standards.

Improving quality: this means planning and implementing interventions.

Four main approaches to QI

Our broad approach to improve quality of MNCH services has four main strategies:

1. Create a culture of quality

2. Identify champions to lead the process of quality improvement

3. Establish health facility Quality Improvement (QI) teams

4. Institutionalise QI in the Ministry of Health

DAY 2

Figure 1: The Quality Assurance Triangle

(Source: quality Assurance project, 2000)

22

Creating a culture of quality means changing health workers’ mind set at all levels of the

health care system by creating awareness on the importance of quality of care and

positioning quality of care as a cross-cutting issue, which guides health workers in their daily

work. It involves all staff. This culture has to be created not only at health facility level, but at

all levels in the MOH. This requires advocacy and should lead to ownership of QI by the

MOH. QI must be embedded in the daily routines of health workers. This culture of quality

includes awareness of the needs and expectations of patients and clients and considering

these when providing services and care, whereby health workers are enabled to see patients

and clients as consumers of services, which are responsive to their needs and expectations.

It also means promoting more respectful attitudes to patients and clients and commitment of

health care providers to improve and maintain quality standards of health care. In a culture

of quality identifying shortcomings in care and service provision are seen as structural

failures of the system rather than individual errors. So nobody is to blame and better

management is expected to solve the problems within a culture with concern for quality.

These shortcomings in quality of care are also seen as opportunities to improve quality of

care in a constructive way, avoiding a culture of fault finding and blame, whereby individual

people are accused or penalised. Instead through a teamwork approach identified quality of

care problems are analysed and addressed by finding and implementing solutions for the

problems.

Champions are people who have demonstrated an interest in quality of care and are

committed to actively pursue the improvement of quality of care. They provide inspiring

leadership, drive the process of QI and motivate people for continuing QI. Champions with

leadership skills for QI can be identified among policy makers, health planners and

managers as well as health care providers, such as doctors, nurse-midwives and CHEWs.

At each health facility at least one champion has to be identified who will lead the QI team

and directs the QI process at the health facility. Champions for QI are also needed at LGA

and state level.

Health facility Quality Improvement (QI) teams are instrumental in putting in place

continuing QI processes at health facility level and translating quality improvement into

action. They take charge of quality of care by identifying and analysing quality of care

problems, finding solutions to solve them and planning and implementing interventions to

address the problems and improve quality of care. They will also monitor the QI activities

and evaluate progress and effectiveness. The health facility QI teams are multi-disciplinary

in composition, preferably consist of not more than 8-10 members and meet regularly. They

report to the Management of the health facility. QI committees can also be established at

LGA or state level, but their roles will be different.

Institutionalising QI in the Ministry of Health is important to ensure general oversight and

policy guidance. The SMOH plays also an important role in Monitoring & Evaluation of QI

activities in the state and in providing technical and material support to QI at LGA and health

facility level.

The Ministry of Health has to provide leadership in QI, which includes:

Providing policies and guidelines for QI;

Including QI in annual health plans and budgets;

Coordination of QI initiatives and activities;

Monitoring & evaluation of quality of care and QI;

Providing technical, supervisory and material support to QI teams and QI activities;

23

Methods to Improve Quality of MNCH care

The following methods are useful to improve quality of MNCH services.

Maternal death reviews: - Facility based - Community based (verbal autopsy)

Maternal Death Surveillance and Response (MDSR);

Confidential enquiries into maternal & perinatal deaths;

Near miss reviews;

Peri-natal death reviews and child death reviews;

Setting and using standards of care;

Criteria-based audit;

Development and use of clinical protocols;

Supportive supervision;

Performance-based financing

Maternal, perinatal or child death reviews

Knowing the numbers of maternal, perinatal or child deaths only tells us about the magnitude

of the problem, but does not help us to solve the problems and reduce mortality. To do that,

we need to understand why patients are dying and go “beyond the numbers”. If we

understand why they are dying we can try to do something about it.

Maternal, perinatal or child death reviews are methods that help us to understand why

patients died. They all use the same approach of reviewing cases of deaths in health

facilities, or even in the community, in order to get the full story and to find out what went

wrong and why the person died. Besides identifying the cause of death, the review focuses

on the underlying contributing factors, including critical shortcomings in care. During these

reviews the review team tries to find out what went wrong, what should have been done or

what could have been done better. The contributing factors are discussed and analysed in-

depth to discover the root causes. If we understand why the person died, we can try to find

solutions to solve the problems and undertake action to address them. The deaths are seen

as failures of the health system to save these lives rather than mistakes of individuals. These

reviews are an opportunity to improve the quality of care and should always lead to action to

address these critical shortcomings in the care provided and the organisation of services.

The result of the discussion is an action plan, which should be implemented. The action plan

also needs follow-up to see whether the problems have been solved and the situation has

improved.

Near miss reviews

Near miss reviews follow the same principles as the above-mentioned death reviews, but

cases of patients who almost died are reviewed. These are called near-miss cases of

maternal deaths.

Near-miss cases are more common than maternal deaths so if health facilities have not

experienced any maternal deaths they can review near-miss cases in stead. Also from these

cases important lessons can be learnt. An interesting feature of near-miss reviews is that the

patient herself can give her view on her management in the health facility and express how

she experienced it, which adds an extra dimension to the review. She can also explain what

happened before she reached the hospital. Near-miss reviews may be less threatening

Definition of maternal, perinatal or child death reviews

“A qualitative in-depth investigation of the causes of and

circumstances surrounding maternal, perinatal or child deaths”.

24

because nobody can be blamed for mistakes which possibly caused a death. Near-miss

reviews create an opportunity to identify positive aspects of care, which saved the woman’s

life, besides identifying aspects of sub-standard care.

Confidential enquiries into maternal and perinatal deaths

In some countries data on maternal and perinatal deaths are analysed by a team of experts

for a whole region, state or the country as a whole. The results influence health policy and

strategic planning.

Maternal Death Surveillance & Response (MDSR)

This involves continuous surveillance of maternal deaths, similar to and linked to infectious

disease surveillance. The HMIS for surveillance is linked with QI processes. MDSR builds on

experience with facility- and community-based MDR and combines counting of maternal

deaths with reviewing them and undertaking action to prevent future deaths. It is advisable

that maternal death becomes a notifiable event.

Criteria based audit

This is a QI method which aims to assess performance of health care providers or health

care services by evaluating (auditing) selected aspects of service delivery, care or treatment.

Performance is assessed by using a checklist with specific assessment criteria which are

based on standards. This audit can be done by reviewing medical records or by observing

health workers while they are performing certain tasks. For each criterion an assessment is

made whether it was performed according to the standards or not.

Performance-based financing

This is an approach by which health care providers are, at least partially, funded on the basis

of performance. A contractual relationship exists between health care provider and health

care financer and remuneration occurs on the basis of achievement of performance targets.

It has the potential to improve quality of care by creation of financial incentives.

The QI methods listed on page 21 will be discussed in more detail in subsequent QI

workshops. For more background information it is recommended to read the following

publications:

Lewis G. (2003) Beyond the numbers: reviewing maternal deaths and complications

to make pregnancy safer. British Medical Bulletin; 67: 27-37.

WHO. (2004) Beyond the numbers: reviewing maternal deaths and complications to

make pregnancy safer. Geneva, WHO.

Definition of a near-miss

“A woman who nearly died but survived a complication that occurred during pregnancy, child birth or within 42 days of termination of pregnancy.”

“The most single important condition for success in quality assurance is the

determination to make it work. If we are truly committed to quality, almost any

reasonable method will work. If we are not, the most elegantly constructed of

mechanisms will fail”

(Donabedian, 1996)

25

Methods and Tools for Assessment of Quality of Care

A combination of quantitative and qualitative methods is used. Quantitative methods involve

counting and produce numbers and figures. Qualitative methods collect narrative information

on people’s opinions, perceptions and experiences related to health services.

Quality Improvement Teams

Quality of care is everybody’s concern and everybody has a role to play, but to ensure that

quality of care will improve in a continuous process somebody has to take the overall

responsibility for QI in the health facility. Otherwise nothing may change. To make things

happen it is useful to have a special health facility QI team, which is responsible for looking

into quality of care issues and which takes the lead in improving quality of care. Therefore

the QI teams are multidisciplinary, involving different cadres of staff and various

departments, including subordinate staff. Besides doctors, nurses, midwives and CHEWs, it

is important that there is a representative from the health facility administration in the team,

such as the officer in-charge or the hospital secretary. Also key departments should be

represented. On the other hand we must avoid that the team becomes too big; between 6

and 12 members works fine. In bigger health facilities, such as hospitals, it may be useful to

have also QI teams at department level. For small PHC facilities with few members of staff

there is no need to form a QI team and everybody can take part in monthly special QI

meetings in which quality of care issues are discussed. The workshop participants are

advised to establish QI teams in their health facilities.

Since quality of care is also affected by community issues, such as poor outcomes because

of late presentation or poor health seeking behaviour, and because it is important for the QI

teams to know the perceptions and concerns of the community about the quality of care, it is

important for the QI team to collaborate with the facility health committee, which forms the

Roles of QI teams:

Identify quality of care issues in the health facility.

Analyse the root causes of the quality of care problems

and discuss possible solutions.

Prepare action plans and initiate QI activities.

Monitor and evaluate QI activities.

Organise maternal & perinatal death reviews

26

link with the community, and have a member of the FHC in the QI team or have regular

meetings with them.

To improve quality of care, it is important that HF QI teams receive support from

management and higher levels of the health sector to ensure that necessary resources for

quality services are available. When structural quality of care problems are identified, such

as lack of resources, QI teams contact relevant authorities with requests for support, either

directly or through the HF management, the FHC or through influential community members.

Besides health authorities, the community through its leaders can also provide support to

improve quality of care by mobilising additional resources or sensitising the public.

Next Steps for the Way Forward after the Workshop

1. Brief management and staff of the health facility on what you learnt during this workshop.

2. Establish a QI team in your facility.

3. Organise QI step-down training to update QI team members on concepts of quality of

care and QI and the roles of the QI team.

4. Identify quality of care issues from different perspectives (see annex 2):

- Interviews with health care providers

- Interviews with managers

- Interviews with women

5. Assess quality of MNCH services in the health facility, using the performance assessment

tool (see annex 3).

6. Hold monthly QI meetings in your facility – discuss findings from interviews and quality of

care assessment, list the identified quality of care problems and develop action plans,

focussing on one or two problems at the time.

7. Ask LGA PHC director to organise quarterly cluster meetings.

8. QI trainers to organise follow-up visits to the health facilities for supportive supervision of

the QI teams, including support to the QI step-down training.

27

5. REFERENCES

1. Adamu YM, Salihu HM, Sathiakumar N, Alexander GR (2003). Maternal mortality in

Northern Nigeria: a population-based study. Eur J Ostet Gynecol Reprod Biol; 109: 153-

159.

2. Bouvier-Colle MH, Ouedraogo C, Dumont A, Vangeederhuysen G et al (2001). Maternal

mortality in West Africa: rates, causes and substandard care from a prospective study.

Acta Obstet Gynecol Scand; 80: 113-119.

3. Doctor HV, Findley SE, Afenyadu GY (2012) Estimating maternal mortality level in rural

northern Nigeria by the sisterhood method. Int J Population Research; volume 2012:

Article ID 464657.

4. Donabedian A (1988). The quality of care: How can it be assessed? JAMA; 260 (12):

1743-1748.

5. Ghobadian A, Speller S (2006). Gurus of quality: a framework for comparison. Total

Quality Management; 5 (3): 3-69.

6. Hulton HA, Matthews Z, Stones RW (2000). A framework for the evaluation of quality of

care in maternity services. University of Southampton.

7. Lewis G. (2003) Beyond the numbers: reviewing maternal deaths and complications to

make pregnancy safer. British Medical Bulletin; 67: 27-37.

8. National Population Commission, ORC Macro (2008). Nigeria Demographic and Health

Survey 2008. Abuja, National Population Commission Federal Republic of Nigeria.

9. Pittrof R, Campbell OMR, Filippi VGA (2002). What is quality in maternity care? An

international perspective. Acta Obstet Gynecol Scand; 81: 277-283.

10. Roemer MI, Montoya-Aguilla C (1988). Quality assessment and assurance in primary

health care. Offset publication 105. Geneva, WHO.

11. WHO. (2004) Beyond the numbers: reviewing maternal deaths and complications to

make pregnancy safer. Geneva, WHO.

12. Wilson L, Goldsmith P (1995) quality and its measurement. In: Wilson L, Goldsmith P.

eds. Quality management in health care. Sydney, McGrw-Hill: 229-258.

28

ANNEXES

29

ANNEX 1: TASKS FOR AFTER THE 1ST QI WORKSHOP

1. Establish a quality improvement team in your facility

Select members, chair person and secretary.

Decide on roles of QI team.

Meetings: how frequently, write minutes, keep minutes on file.

Reporting: who and how.

2. Assess perceptions of quality of care in your health facility

The purpose of this exercise is to explore perceptions of quality of care amongst

women, health care providers and managers in your facility.

o Interview at least ten women about their perceptions of quality of care

(see pages 2-4)

o Interview at least four (hospital) or two to three (PHC) health care workers

about their perceptions of quality of care (see pages 4&5)

o For the QI team of the General Hospital: Interview at least one manager

(medical director, hospital secretary) about his/her perceptions of quality of

care (see pages 4&5)

Analysis of findings from the interviews:

o What is quality from the different perspectives of women, health care providers,

managers.

o What constitutes good quality care.

o What problems are there in the quality of care being provided.

o What should be improved

Present these findings at your quality improvement team meetings in your facility:

o Discuss these findings.

o Identify the possible reasons for the quality of care problems.

o Develop an action plan based on these findings: what action should be taken

(activities), who should do what, dates by which this is done, what do you want

to achieve (objectives), how to monitor that these actions have taken place and

objectives have been achieved.

Prepare a presentation for the next quality improvement workshop of the findings

from the interviews after analysis, the quality of care problems identified, the results

of the discussion, the action plan, and possible achievements as well as challenges.

3. Assess quality of MCHC services in your health facility, using the performance

assessment tool.

4. Give feedback at next quality improvement workshop on what has been done

since the 1st QI workshop (prepare written notes or a power point presentation)

Who are the members of the QI team and their designation.

Number of meetings held and what was discussed.

Results of interviews and performance assessment.

Quality of care problems identified.

Activities planned and those that were successfully carried out.

Achievements and challenges

Lessons learnt from.QI.

30

ANNEX 2: INTERVIEW GUIDES

Guideline for interviews with women

Who do I Interview? Using the “interview guide with women”, interview at least ten women who have received antenatal, delivery or postnatal care services. When do I interview them? Interview these women as they are leaving the health facility. Where do I interview them?

Find a place that is quiet and away from the other patients and staff to ensure privacy.

Offer the patient/client somewhere to sit so that she feels comfortable during the interview.

Interview tool

Use the 2 page interview guide (questionnaire) on the next page.

Make 10 photocopies of the questionnaire and use one for each interview or use one questionnaire and the note taker writes the answers for each question on a separate blank sheet of paper for each interview.

Who conducts the interviews?

Two persons are needed: one to ask the questions, the other to note down the answers.

If possible, it is preferable that someone interviews the women who is not directly involved in their care.

Interview technique

Ask the woman if you may interview her.

Explain briefly why you are interviewing her. Read the explanation at the top of the interview guide.

One person conducts the interview, and one person takes notes.

Ask the questions on the interview guide in a clear way. If they find it difficult to answer the question, then rephrase or explain the question.

Try to get as much detailed information as possible and ask to explain the complaints or concerns about the quality of care. Let the client decide on their response. (Remember that it is the client’s perception of the service that we are exploring and not what you think their perception is! Do not try to influence the client's answer.)

Thank the woman for doing the interview. After the 10 interviews

Once you have completed the 10 interviews, then you need to summarise your findings from the interview using your notes and memory.

For each question list the responses from the different women.

If the same response comes up more than once, write up the response once and between brackets how many times it came up.

31

Interview guide with women

Explain the purpose of the interview: We are interested in understanding what users of our health services think about our facilities and services provided. This will help us improve our services to you and future clients. Feel free to give your personal opinion, whether good or bad. We appreciate your honesty and don’t blame you for negative criticism. Your answers are strictly confidential. We do not need to know your name. We thank you for your participation and honesty. Type of client/patient: …………………………………………………..................................... Date of interview: …….. / ……….. / …………….; Interview number: ………….. 1. What services have you received during this visit to this health facility? (encircle) ANC; Delivery care; PNC; FP clinic; Immunisation; Other (specify); ................. 2. Why did you come to this health facility?

……………………………………………............................................................................... ……………………………………………………………………………………………………..

3. Do you have any problems, concerns, complaints with regard to the following aspects of the services?

Problem/concern: YES or NO Explain:

Times of opening

Affordability and fees

Access of services

Transport to get to clinic

Waiting time

Buildings and space

Availability of drugs

Availability of equipment and supplies

Availability of staff

32

Behaviour of staff

Skills of staff

Care received

Understanding of treatment

Privacy

Cleanliness

4. What is important for you about a good health service for mothers during pregnancy, child birth and the period after child birth? …………………………………………………………………………………………………………………………………………………………….................................................................................. …………………………………………………………………………………………………………………………………………………………….................................................................................. …………………………………………………………………………………………………………………………………………………………….................................................................................. ……………………………………………………………………………………………………………

5. Are there any improvements or changes you would like to see in the way this health facility provides maternal and newborn health services?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Not at all Very much 6. Are you happy with the service you get here? 0 1 2 3 4 5 (Give a score from 0 – 5) 7 Is there anything else you would like to say about the services? ……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Many thanks for participating in this interview. This will help us to provide better care.

33

Guideline for interviews with health care providers and managers

Who do I Interview? Using the “interview guide with health care providers”, interview at least four health care providers (obstetricians, doctors, midwives, CHEWs) who are providing antenatal, delivery or postnatal care services and at least one manager, e.g. officer in charge of PHC or maternity. When do I interview them? Interview these health care providers and the manager at a convenient time. The interview should only take 10 or 15 minutes. Where do I interview them? Find a place that is quiet and away from patients and other staff to ensure privacy. Offer the health care provider somewhere to sit so that (s)he feel comfortable during the interview. Interview technique

Ask the health care provider if you may interview him / her.

Explain briefly why you are interviewing him / her. Read the explanation at the top of the interview guide.

One person conducts the interview, and one person takes notes.

Ask the questions on the interview guide. If they find it difficult to answer the question, then rephrase the question.

Try to get as much detailed information as possible.

Let the provider decide his/her response. (Remember that it is the person’s perception of the service that we are exploring and not what you think their perception is! Do not try to influence the client's answer.)

Thank the healthcare provider for participating in the interview.

After the interviews

Once you have completed the 5 interviews, then you need to summarise your findings from the interview using your notes and memory.

For each question list the responses from the different persons.

If the same response comes up more than once, write up the response once and between brackets how many times it came up.

34

Interview guide with health care providers and managers

We are interested in understanding what health care providers and managers think about quality of care, the care being provided in this facility and the problems with providing good quality care. This will help us improve the services provided to women and their families. Your answers are strictly confidential. We do not need to know your name. We thank you for your participation and honesty. Cadre of health care provider: ………………………........Date: …….. / ……….. / ………….. Designation: ………………………………………………... Interview number: ………….. 1. What does quality of maternal and newborn health care mean to you? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… 2. Does your facility provide quality MNH health services? Please give details about aspects of good quality care and services at your health facility . ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….. 3. What are weaknesses or shortcomings you have observed in the quality of care of MNH services in your health facility? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...................................... 4. What do you need or has to be done to improve quality of care in your health facility? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… 5. Is there anything else you would like to add about quality of care?

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Many thanks for participating in this interview. This will help us to provide better care.

35

ANNEX 3: PERFORMANCE ASSESSMENT TOOL

(answer “Yes” or “No” and score 1 for each Yes answer, unless otherwise indicated; for scores from 1-5: 1 = very bad; 2 = bad; 3 = satisfactory; 4 = good; 5 = very good)

A FOCUSED ANTENATAL CARE (FANC)

FANC: Structure Yes/No Score

A.1 Daily ANC during working days (score 1 for each ANC week day) / 5

A.2 Sheltered waiting area with adequate sitting arrangements (score 1 – 5) / 5

A.3 Provision of privacy during physical examination (score 1-5) / 5

Availability of essential resources (score 1 if available)

A.4 Sphygmomanometer (BP machine) available

A.5 Weighing scale available

A.6 Pinnard fetal stethoscope available

A.7 Measuring tape available

A.8 Examination couch available

A.9 ANC register (score: 0=no; 1= improvised; 2= official MOH HMIS) / 2

A.10 ANC cards or maternal health booklets available

A.11 Haematinics (Ferro & folic acid) available

A.12 Roster with allocation of topics for ANC health education available

A.13 At least 2 health workers available, of which one is a midwife

Total score for this section: / 27

FANC: Process (observe 3 interactions with

clients and for each point give a score 1 if yes) Yes/No Yes/No Yes/No Total

Score

A.14 Mother welcomed in cordial way

A.15 Examined for signs of anaemia during visit

A.16 Blood pressure measured during visit

A.17 Examined for presence of oedema of ankles/feet

A.18 Abdomen palpated to determine presenting part/lie

A.19 Foetal heart rate assessed during visit

A.20 Urine tested at booking visit

A.21 PCV tested at booking visit

A.22 Tested for HIV at booking visit

A.23 Mother tested for HIV during ANC

A.24 Findings of examination communicated to mother

A.25 Health education given (e.g. danger signs of pregn)

A.26 Haematinics provided

A.27 Tetanus vaccination given as required

Total score for this section: / 14

FANC: Outcome

Client satisfaction (conduct 2 exit interviews) Score 1 Score 2 Total Score

A.28 Satisfied with overall ANC care (score 1-5) / 10

A.29 Satisfied with waiting time (score 1-5) / 10

A.30 Satisfied with amount of privacy (score 1-5) / 10

A.31 Satisfied with health worker’s behaviour (score 1-5) / 10

A.32 Satisfied with information provided (score 1-5) / 10

Total score for client satisfaction: / 50

ANC utilization previous 3 months (check ANC register)

Month 1 Month 2 Month 3 Total

A.33 No of 1st ANC visits in previous month

A.34 No of re-visits in previous month

A.35 No of 4 or more visits in previous month

36

B INTRA- PARTUM CARE

Intra-partum care: Structure Yes/No Score

B.1 24/7 maternity care available

B.2 Running water in the labour ward or adequate hand washing facilities

B.3 Adequate electrical light source at night (solar, main grid)

B.4 Privacy in labour ward (curtains or screens around bed) (score 1-5) / 5

B.5 Floor of labour ward is clean (score 1-5) / 5

B.6 Labour ward is neat and tidy (score 1-5) / 5

B.7 Availability of essential resources (score 1 if available)

B.8 Sphygmomanometer (BP machine) available

B.9 Delivery bed available

B.10 Pinnard fetal stethoscope available

B.11 Stethoscope available

B.12 Examination couch available

B.13 Maternity register (score: 0=no; 1= improvised; 2= official MOH HMIS) / 2

B.14 Partograph forms available

B.15 Oxytocin available

B.16 Sterile gloves available

B.17 Number of midwives posted in maternity ward (score 1 for each midwife)

Total score for this section: / 30

Intra-partum care: Process

(observe partograph forms) Yes/No Yes/No Yes/No Total

Score

B.18 Partograph form filled in / 3

B.19 Active management of 3rd

stage practiced / 3

B.20 Blood pressure measured 4 hourly during labour / 3

B.21 FHR assessed at least hourly during labour / 3

B.22 Cervical dilatation adequately assessed (4 hourly) / 3

B.23 Aspect of liquor recorded / 3

B.24 Blood loss during delivery recorded / 3

B.25 Placenta examined and findings recorded / 3

Total score for this section: / 24

Intra-partum care: Outcome

Client satisfaction (conduct 2 exit interviews) Score 1 Score 2 Total Score

B.26 Satisfied with overall care during labour (score 1-5) / 10

B.27 Satisfied with skills of health worker (score 1-5) / 10

B.28 Satisfied with privacy (score 1-5) / 10

B.29 Satisfied with health worker’s behaviour (score 1-5) / 10

B.30 Satisfied with information provided (score 1-5) / 10

Total score for client satisfaction: / 50

Delivery outcome (check maternity register) Month 1 Month 2 Month 3 Total

B.31 No of deliveries in previous 3 months

B.32 No of maternal deaths in previous 3 months

B.33 No of stillbirths in previous 3 months

37

C EMERGENCY OBSTETRIC AND NEWBORN CARE (EmONC)

BEmONC: Structure Yes/No Score

C.1 24/7 BEmONC available

C.2 Special care or treatment room available

C.3 Emergency tray/ cupboard with emergency drugs available in labour ward

C.4 Magnesium sulphate available in labour ward

C.5 MVA set available

C.6 Vacuum extractor available in labour ward

C.7 Adult ambu bag & mask available in labour ward

C.8 Standard clinical EmONC protocols available in labour ward

C.9 No of health workers in maternity who have been trained in LSS-EmONC

C.10 Emergency transport system available (phone numbers of ETS drivers)

Total score for this section: / 10

CEmONC: Structure (in addition to BEmONC structure) Yes/No Score

C.11 Functional operating theatre available

C.12 At least 2 doctors available who can perform caesarean section

C.13 At least 2 anaesthetic nurses or anaesthetists available

C.14 Refrigerator available for storage of blood

C.15 Blood in stock for emergency transfusion

C.16 Blood donor register available in laboratory/blood transfusion unit

Total score for this section: / 6

EmONC: Process (observe in-patient records) Yes/No Yes/No Yes/No Total

Score

C.17 Every EmONC case attended to within 10 minutes / 3

C.18 Every EmONC case assessed by dr within 20 min. / 3

C.19 Vital signs regularly recorded on monitoring sheet / 3

C.20 Correct drug prescribed in correct dose / 3

C.21 Antibiotic prophylaxis given with caesarean section / 3

C.22 Clear treatment instructions on in-patient records / 3

C.23 Fluid balance recorded / 3

C.24 Findings & treatment explained to patient & relatives

/ 3

Total score for this section: / 24

EmONC: Outcome

Delivery outcome (check maternity register) Month 1 Month 2 Month 3 Total

C.25 No of obstetric complications treated in previous 3 months

C.26 Case fatality rate of direct obstetric complications

C.27 No of obstetric complications referred out

C.28 No of stillbirths & stillbirth rate over past 3 months

38

D NEWBORN CARE

Newborn care: Structure Yes/No Score

D.1 Baby weighing scale available in labour ward

D.2 Baby cot available in labour ward

D.3 Resuscitation table available

D.4 Newborn ambu bag & mask available and functional

D.5 Cord clamps available

D.6 Vitamin K available

D.7 Dry cloth available to wrap baby

D.8 Standard clinical protocols available for care of sick newborn

D.9 No of health workers trained in newborn care

D.10 No of health workers trained in Kangaroo Mother Care (KMC)

D.11 No of health workers trained in newborn resuscitation (e.g. LSS-EmONC)

Total score for this section: / 11

Newborn care: Process (check records and

conduct 3 exit interviews with mothers) Yes/No Yes/No Yes/No Total

Score

D.12 Apgar score recorded after delivery / 3

D.13 Baby’s weight measured and recorded after birth / 3

D.14 Baby put on the breast within ½ hour after birth / 3

D.15 Baby wiped dry immediately after birth / 3

D.16 Baby put on mother’s abdomen shortly after birth / 3

D.17 Mother counselled on exclusive breastfeeding / 3

D.18 Mother counselled on childhood immunization / 3

D.19 Antibiotic eye ointment applied to eyes after birth / 3

D.20 Polio 0 vaccination given before discharge / 3

D.21 KMC practiced at health facility and register available

Total score for this section: / 28

Newborn care: Outcome

Client satisfaction (conduct 2 exit interviews) Score 1 Score 2 Total Score

D.22 Mother satisfied with newborn care (score 1-5) / 10

D.23 Mother satisfied with breastfeeding counselling & support (score 1-5)

/ 10

D.24 Mother satisfied with information provided on newborn care at home (score 1-5)

/ 10

Total score for client satisfaction: / 30

Newborn: Outcome (check maternity register) Month 1 Month 2 Month 3 Total

D.25 No of neonatal deaths in last 3 months

D.26 No of babies with LBW (< 2500 gr) in last 3 months

D.27 No of LBW babies treated with KMC in last 3 months

39

E POST NATAL CARE (PNC)

PNC: Structure Yes/No Score

E.1 No of days per week PNC is available / 5

E.2 PNC routinely provided to mother & baby day after birth before discharge

E.3 PNC provided 48 hours and 7 days after birth

E.4 Job aids for FP counselling available / 5

E.5 PNC register available (score: 0=no; 1= improvised; 2= official MOH HMIS)

/ 2

Total score for this section: / 30

PNC: Process (conduct 3 exit interviews) Yes/No Yes/No Yes/No Total

Score

E.6 Mother counselled on birth spacing at each PNC

E.7 Mother counselled on exclusive breast feeding x 6/12

E.8 Mother counselled on danger signs of the newborn

E.9 Baby vaccinated with BCG and Polio 0

E.10 HIV status checked and PMTC given if required

Total score for this section: / 5

PNC: Outcome

Client satisfaction (conduct three exit interviews)

Score 1 Score 2 Score 3 Total Score

E.11 Satisfied with overall PNC (score 1-5) / 15

E.12 Satisfied with skills of health worker (score 1-5) / 15

E.13 Satisfied with privacy (score 1-5) / 15

E.14 Satisfied with health worker’s behaviour (score 1-5) / 15

E.15 Satisfied with information provided (score 1-5) / 15

Total score for client satisfaction: / 75

PNC utilization (check PNC register) Month 1 Month 2 Month 3 Total

E.16 No of deliveries in previous 3 months

E.17 No of PNC visits 48 hours after birth in previous 3 months

E.18 No of PNC visits 7 days after birth in previous 3 months

40

F FAMILY PLANNING (FP) SERVICES

FP services: Structure Yes/No Score

F.1 No of days per week FP services are available / 5

F.2 Consultation room available which provides privacy

F.3 Examination couch available in FP clinic

F.4 Vaginal specula available at FP clinic

F.5 Oral contraceptives available

F.6 Injectable contraceptives available

F.7 Condoms available

F.8 IUCDs available

F.9 Implants available

F.10 No of health workers trained in provision of LARC

F.11 Job aids for FP counselling available at FP clinic

F.12 FP register available (score: 0=no; 1= improvised; 2= official MOH HMIS) / 2

F.13 Routine FP counselling provided as part of PAC, ANC, PNC and HIV counselling of HIV positive mothers

Total score for this section:

FP services: Process (observe 2 interactions with clients) Yes/No Yes/No Total

Score

F.14 Client counselled on advantages, disadvantages and failure rates of different FP methods

F.15 Client counselled on possible side effects

F.16 Client given opportunity to ask questions

F.17 Blood pressure and weight measured

F.18 Client given opportunity for informed choice

Total score for this section: / 10

FP services: Outcome

Client satisfaction (conduct 2 exit interviews) Score 1 Score 2 Total Score

F.19 Satisfied with overall FP services (score 1-5) / 10

F.20 Satisfied with waiting time at FP clinic (score 1-5) / 10

F.21 Satisfied with skills of health worker (score 1-5) / 10

F.22 Satisfied with privacy (score 1-5) / 10

F.23 Satisfied with health worker’s attitude (score 1-5) / 10

F.24 Satisfied with information provided (score 1-5) / 10

Total score for client satisfaction: / 60

FP utilization (check FP register) Month 1 Month 2 Month 3 Total

F.25 No of new acceptors of FP in previous 3 months

F.26 No of FP re-visits in previous 3 months

41

G ROUTINE IMMUNZATION (RI) AND GROWTH MONITORING SERVICES

RI and growth monitoring services: Structure Yes/No Score

G.1 No of days per week RI services are available (at least once a week) / 5

G.2 Sheltered waiting area with adequate sitting arrangements

G.3 Immunization wall charts available

G.4 Pentavalent vaccine available (no stock-out in last 3 months)

G.5 Oral polio vaccine available (no stock-out in last 3 months)

G.6 Measles vaccine available (no stock-out in last 3 months)

G.7 Tetanus toxoid available (no stock-out in last 3 months)

G.8 BCG vaccine available (no stock-out in last 3 months)

G.9 Vitamin A available (no stock-out in last 3 months)

G.10 No of health workers trained in RI

G.11 Refrigerator available with temperature monitoring chart

G.12 Vaccines stored properly

G.13 Safety boxes available

G.14 Immunization register available (score: 0=no; 1= improvised; 2= official) / 2

G.15 Child weighing scale available

G.16 Height measuring board available

G.17 Under five charts available

Total score for this section:

RI services: Process (observe 2 interactions with clients) Yes/No Yes/No Total

Score

G.18 Child’s weight or MUAC correctly measured and recorded

G.19 Child’s immunization status checked and properly vaccinated

G.20 Safety box properly used for disposal of needles & syringes

G.21 Health education given on either exclusive breastfeeding or weaning food

RI services: Process (cold chain) Yes/No

Total score

G.22 Vaccine refrigerator temperature recorded 12 hourly on monitoring chart

G.23 Vaccines properly stored

G.24 Total score for this section: / 10

RI and growth monitoring services: Outcome

Under 1 children vaccinated in previous 3 months (check RI register)

Month 1 Month 2 Month 3 Total

G.25 Children below 1 year vaccinated with Penta 1

G.26 Children below 1 year vaccinated with Penta 3

G.27 Children below 1 year vaccinated with Polio 3

G.28 Children fully vaccinated before 1 year of age

42

H INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

IMCI: Structure Yes/No Score

H.1 IMCI services provided at health facility

H.2 IMCI assessment card available at point of service

H.3 IMCH classification chart available at point of service (e.g. wall chart)

H.4 No of health workers trained in IMCI

H.5 Amoxycillin syrup available (no stock-outs last 3 months)

H.6 ACT syrup or children’s tablets available (no stock-out in last 3 months)

H.7 Zinc tablets available forRx of diarrhoea (no stock-out in last 3 months)

H.8 Vitamin A capsules available (no stock-out in last 3 months)

H.9 Anticonvulsants for children available (e.g. Paraldehyde inj.)

H.10 MUAC tape available

H.11 Children weighing scale available

H.12 RUTF available (no stock-outs in last 3 months)

Total score for this section:

IMCI: Process (observe 2 patient interactions) Yes/No Yes/No Total

Score

H.13 Care taker checked and recorded child’s weight

H.14 Care taker checked the child for general danger signs

H.15 Care taker asked for presence of fever, diarrhoea or cough

H.16 Care taker checked the child’s immunization status

H.17 Care taker checked nutritional status of child: MUAC or weight and looking for oedema of feet.

H.18 Care taker explained diagnosis and treatment to mother

H.19 Care take prescribed the correct treatment

Total score for this section: / 14

IMCI services: Outcome

Client satisfaction (conduct 2 exit interviews with mothers with a sick under-five child)

Score 1 Score 2 Total Score

H.20 Satisfied with overall services (score 1-5) / 10

H.21 Satisfied with waiting time at clinic (score 1-5) / 10

H.22 Satisfied with skills of health worker (score 1-5) / 10

H.23 Satisfied with health worker’s attitude (score 1-5) / 10

H.24 Satisfied with information provided (score 1-5) / 10

Total score for client satisfaction: / 50

SUMMARY OF FINDINGS (SCORES)

MNCH service component

Total score previous assessment Date:

Today’s total score Date:

FANC

Intra-partum care

EmONC

Newborn care

PNC

FP services

RI & growth monitoring

IMCI

43

MAY 2014