Use of Clinical Standards for Improved Quality of Maternal and Newborn Care

7/29/2019 Use of Clinical Standards for Improved Quality of Maternal and Newborn Care

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Use of Clinical Standards for improved

Quality of Maternal and Newborn Care

Dr.Somesh Kumar

Team Leader: Maternal Health/Family Planning

MCHIP/India

GMHC, Arusha

16th January 2013


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Objectives of the presentation

Give an overview of the approach andprocess adopted

Share the results from the program


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Need..

Tremendous increase in institutional deliveries in India-from 700,000 (2005) to 1.1 Million (2012)

Increased load on existing public health facilities Compromise in QoC, observed in multiple studies/

assessments Gap in translation of protocols/guidelines/trainings to

practice

Even the facilities teaching midwifery do not adhere tothe protocols

Need for a practical, cost-effective programmaticapproach to improve adherence to protocols in laborrooms


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The approach: Standards Based Management

and Recognition

Translation of protocols into an easy to use tool,containing standards & their verification criteria

Use of performance assessment tool to measure actuallevel of performance (Baseline assessment)

Compare to desired level of performance Identify gaps/causes

4

Desiredperformance

Actualperformance

GapCause

analysis

Interventionidentification &implementation

Devise site specificcustomized action plan

Implement the action plan Conduct Periodic Internal

assessments ( 3-6 month )


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Guiding Principles

Applied at the level of facility Includes the highest impact interventions for

ante-,intra- and immediate postpartum care

Has components related to Inputs: commodities, equipments and

infrastructure

Evidence based practices Needs an on-site clinical update of the providers for

its implementation

Should be implemented in through a inclusiveprocess


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The Process

6

Share theclinical

standardswith the

stakeholders

Orient theclinical

providers tothe 21

standards

Conductbaseline

assessmentof facilitywith the

providers

ProvideClinicalUpdate

Support theimplementat

ion ofclinical

standards

Periodicassessmentsof facility with

providersusing samestandards


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Clinical standards

21 clinical standards applied at the clinical practice sitesof the health facilities linked to nursing-midwifery

institutions

They can be broadly classified into:Area Numberofstandards

Antenatal Care 4

Labour room: Intra-partum 12

Family planning 1

Equipments at the clinical site 4

Total 21


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Standard 10: AMTSLThe provider

performs activemanagement of

the third stage of

labor.

Observe two women during a delivery and determine whether the provider

(in the labor or delivery rooms):

Palpates the mothers abdomen to rule out the presence of a second baby Tells the woman that she will receive an injection, and administers 10 IU of

oxytocin IM

Clamps the cord near the perineum and Holds the cord and clamp with onehand

Places the other hand just above the womans symphysis pubis (over thesterile towel) and gently exerts pressure upwards

Maintains gentle but firm traction on the cord and waits for the uterus tocontract

Upon contraction, applies gentle but firm and sustained downward tractionon the cord with counter force above the pubis to guard the uterus, until theplacenta is expelled

Once the placenta bulges at the vaginal introitus, assists its expulsion withboth hands, by turning it clockwise over in the hands, without applying

traction, teasing out the membranes to roll them out

Checks whether uterus is contracted Massages the uterus with one hand on a sterile cloth over the abdomen, until

it contracts firmly


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Standard 11: ENBC

The providerproperly conducts

a rapid initial

assessment and

provides immediate

newborn care.

.

In the labor or delivery rooms, observe two women with theirnewborns in the immediate postpartum period and determine whether

the provider :

Receives and dries the baby vigorously with a sterile dry towel fromhead to feet, cleans the babys eyes with sterile gauze, and determines

whether the baby is breathing

Discards the used towel and covers the baby, including the head, with aclean, dry towel

If the baby does not begin breathing or is breathing with difficulty, asksassistance, rapidly cuts and ties the cord, and initiates resuscitation

If the baby is breathing normally, places the baby in skin-to-skin contacton the mothers chest or abdomen and encourages immediate

breastfeeding

Informs the mother of the babys condition Clamps and cuts the cord using sterile instruments as soon as the cord

has stopped pulsating

Places an identification bracelet on the baby


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Improvement in Clinical Standards

14%

5%

33%

52%

14% 15% 15%20%

40% 40%

90%

81% 81%

71%

81%

70%

90%

80%

95%

85%

0%

10%

20%

30%

40%

50%

60%70%

80%

90%

100%

CMC,Ludhiana

GCON,Vadodara

CMC,Vellore

NRSM,Kolkatta

StStephesHospital,

Delhi

DistrictHospital

Chaibasa

DistrictHospital,Giridih

DistrictHospital,Simdega

DistrictHospital,Gadarpur

DistrictHospital,Ranipokri

Baseline Current status (Dec 2012)


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Improvement in Practices

0% 0%

70%

0%

20%

10%

50%

30%

100%

90%

100%

90%

100%

90%

100%

90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Educating

women onwarning signs

during

pregnancy

Birth

preparednessdevelopment of

a birth plan

Includes

member offamily forantenatal

counseling

Use of

partograph

Provider

performs AMTSLproperly

Cord clamping

within 1 to 3minutes

Initiating

Breastfeedingwithin 1st hour of

birth

Prepration of

ChlorineSolution for

decontamination

Baseline Current status (December 2012)


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Improvement in Practices

40% 40%

10%

20%

50%

10%

0%

40%

90%

80%

70%70%

90%

80% 80%

90%

0%

10%

20%

30%

40%

50%

60%70%

80%

90%

100%

Receiving thewoman in

labor in

cordially

Manangementof PPH as per

GoI protocols

Provision ofessential

newborn care

appropriately

Monitoring thenewborn till

discharge

Verification ofresuscitation

equipment for

functionality

Properlyperforms

resuscitation

of the

newborn

Infectionprevention

practices

followed

appropriately

Emergencydrug tray is

available

Baseline Current Status (December 2012)


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The Framework For Improving Quality of

Care Through Checklist Use

Quality of Care

SCC

Adherenceto practices

Supervision

Supplies

Accountability


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Successes

Demystifies the concept of quality for the frontline providers/faculty It is a self assessment approach and hence is self motivating. Enables the providers/faculty to operationalize quality improvement

processes

It is very objective It is a simple and easy to understand tool. It shows what to do and how to do things for quality

improvement.

It is measurable and quantifiable Provides a framework for infrastructural/HR improvements Provides a framework for supportive supervision Recognition is an integral part of the process which motivates for quality

improvement


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Contributions

Dr.Bulbul Sood Dr.Sudarshanam Balasubranyam Ms.Princy Fernando Dr.Rashmi Asif

and the entire MCHIP India team.


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Thanks

Documents

Use of Clinical Standards for Improved Quality of Maternal and Newborn Care