aarogyasri health care trustsafecaresavinglives.org/resources/files/change package.pdf · 11. dr....

Change PaCkage for Quality imProvement in newborn Care

Safe Care, Saving Lives

AAROGYASRIHealth Care Trust

3

aCknowledgments

A special mention and thanks to the following reviewers of the Change Package

1. Robert Lloyd, PhD, Vice President, Institute for Healthcare Improvement (IHI)

2. Ms. Jane A. Taylor - Improvement Advisor, IHI

3. Dr. Abha Mendiratta - Director, IHI

4. Dr. Vikram Datta - Director Professor, Department of Neonatology, Lady Hardinge Medical College

5. Dr. Ashok Deorari - Professor and Head, Department of Pediatrics, All India Institute of Medical Sciences

6. Dr. Ajay Gambhir - President, National Neonatology Forum

7. Dr. Gagan Gupta - Health Specialist, UNICEF

8. Dr. Sanjeev Upadhyaya - Health Specialist, The United Nations Children’s Fund (UNICEF)

9. Dr. Meena Som - Health Officer, UNICEF

10. Dr. Srinivas Murki - D.M. Neonatology, Fernandez Hospital

11. Dr. Durga Bhavani Kalavalapalli, Consultant Pediatrician and Neonatologist and Senior Quality Advisor, Safe Care, Saving Lives

We express our gratitude to the Aarogyasri Health Care Trust and Commissionerate of Health and Family Welfare, Government of Telangana and NTR Vaidya Seva Trust, Government of Andhra Pradesh for believing in the Safe Care, Saving Lives program and inviting us to work with select public and private hospitals of the two states. The program would not have been successful without the continuous support we received from the several government officials of the insurance trusts and health departments.

We appreciate the technical support from the Institute for Healthcare Improvement, which guided the implementation of the Model for Improvement in the program hospitals. We thank the Children’s Investment Fund Foundation for not only for funding the Safe Care, Saving Lives program but actively supporting and guiding the program along the way.

Our special thanks to the leadership and quality improvement teams of program hospitals for buying into quality improvement, testing change ideas and sharing what worked. We acknowledge the contribution of current and previous Safe Care, Saving Lives team members for cataloguing the highest leverage change ideas.

Change PaCkage for Quality imProvement in newborn Care 5

“ “

introduCtion

Quality imProvement

Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care processes and outcomes1. The Safe Care, Saving Lives program lies on a central thought; using Quality Improvement (QI) and Continuous Quality Improvement (CQI) as methodologies to improve processes in the newborn area. The benefit of Quality Improvement is that it takes Quality Assurance a step further. If Quality Assurance gives us a set of goals to work towards, Quality Improvement will tell us how to go about meeting those goals, despite the roadblocks. It lists the process, teaches us to think through and test our ideas, helps initiate behavior change, and shows us how to monitor our own progress through appropriate data tools.

The Safe Care, Saving Lives program is a variant of the Breakthrough Series Learning Collaborative approach pioneered by the Institute for Healthcare Improvement. This Institute’s Model for Improvement is used as the framework for quality improvement. The key elements of this model include:

1. Identification of the aim

2. Development of measures and metrics for improvement

3. Identification of changes or change ideas

4. A process for ongoing improvements using the Plan-Do-Study-Act (PDSA) cycle

Change PaCkage

A change package is an evidence based set of changes that are critical to the improvement of the identified care process. This Change Package provides ideas to improve the quality of care in hospital labor rooms and newborn care units. The Change Package was developed based on evidence, learnings and experiences in hospitals across the two states of the Safe Care, Saving Lives program. Safe Care, Saving Lives is a quality improvement initiative by the government to improve newborn survival in Andhra Pradesh and Telangana. The program worked with fifty two public and private hospitals empanelled with the public insurance trusts of the two states. The government, with support from ACCESS Health, technical and financial partners, supports the staff in the labor rooms and special newborn care units of the program facilities to improve the processes with the help of a proven methodology in quality improvement. The package consists of tested ideas successfully driving change in hospitals under the program.

develoPing Change ideas

A “change idea” is a change brought about in existing processes with the goal of improvement. Not all changes bring about improvement. Yet, all improvement requires change. In fact, any medical facility thinking about quality improvement reflects a shift in routine thought processes and is therefore a change idea in itself. Quality may improve once the emerging idea is tested and implemented. Measurement is critical for testing and implementing these changes as it helps to understand which changes are effectively leading to improvement.

What are we trying to accomplish?

How will we know that a change is an improvement

What change can we make that will result in improvement

The InsTITuTe for heAlThCAre ImProvemenT’s model of ImProvemenT

Cycle for Improvement and learning

AIM

MeAsureMent

chAnge

PlAnACT

dosTudy

figure 1 The Institute for Healthcare Improvement’s Model of Improvement1 https://www.hrsa.gov/sites/default/files/quality/

toolbox/508pdfs/qualityimprovement.pdf

All improvement needs change but all change need not result in improvement


introduCtion

No orientation regarding antibiotics stewardship

Asepsis was not provided

adequately

PeoPle environment

methods measurement

Directly attendant enter into NICU with

soiled linen

No data collection

No monthly review of data

No feedback mechanism from

primary team

No Training

Doctors are not confident of treating sick babies without

antibiotics anticipating sepsisTo decrease the antibiotics usage from 80% to less than 20% within one year

No fixed protocols for 1st line, 2nd line and 3rd line

of antibiotics

No preauthorization or restriction of AB usages

by Primary team

No mechanism of reviewing dosages and

duration of drugs

figure 2 Fishbone diagram showing the causes for higher use of antibiotics in the newborn care unit

Change ideas come from the existing processes. The important step in developing a change idea is mapping of the existing process. Hospital teams can use the following approaches to develop change ideas.

1. Process mapping – The team can sit together and write down all the steps that are involved in a particular activity. For example, mapping of the process of insertion of an intravenous (IV) cannula involves noting down all steps from taking the decision to do an insertion to the last steps of waste disposal and maintenance of the cannula. All these steps put together in an orderly fashion becomes process mapping for the chosen activity.

2. Critical thinking of the process – The team can brainstorm together to identify parts of the system, which are not working well or which are needlessly complex.

3. Bench marking – The team can compare the process to an existing standard or best practice. This helps to identify gaps in your own process and find some ideas for improvement.

4. Creative thinking – Thinking out of the box can help to generate change ideas. For example, being in the shoes of a patient and thinking from the perspective of a patient can be used to find ways to improve patient experience or satisfaction.

5. using change concepts – Associates in Process Improvement (API) define a change concept as “a general notion or approach to change that has been

found to be useful in developing specific ideas for changes that lead to improvement.” The Associates in Process Improvement have broadly grouped the change concepts into nine groups:

a. Eliminate waste

b. Improve workflow

c. Optimize inventory

d. Enhance the producer-customer relationship

e. Change the work environment

f. Manage time

g. Manage variation

h. Design systems to prevent errors

i. Focus on the design of products and services

6. using cause and effect diagrams – Cause and effect diagram is also known as the Ishikawa or fishbone diagram

a. Materials (supply, design, availability, and maintenance)

b. Methods (steps in care process and steps in supply chain)

c. Environment (staffing levels and skills, workload and shift patterns, administrative and managerial support, and physical plant, policies, and regulations)

d. Equipment (any equipment/tools needed to get the job done)

e. People (staff knowledge and skills/training, competence, patient behavior, and supervision)


7. root cause analysis

a. To solve a problem, Root Cause analysis involves asking the question ‘Why’ at every stage until the root of the problem is reached. Root cause analysis is also called the 5 Why’s.

b. For example, in one of the newborn care units, after a steady improvement, the compliance with hand hygiene suddenly dropped. Root cause analysis can be used to assess the situation.

c. In this example, the root cause of the challenge lies outside the purview of the newborn care unit. Unless the problem is probed at every level with ‘Why’, we will not be able to identify the cause and address the problem.

Why is testing of change idea required?

Testing is needed to understand whether the implementation of a change idea has led to improvement. A great and reproducible way of testing change idea is the Plan-Do-Study-Act (PDSA) cycle.

should we test a change idea that has been already tested and resulted in improvement?

Yes. Even if a change idea was tested previously and led to improvement elsewhere, it should be again be tested in your own setting. The effectiveness of ideas depends on the context of the place and an idea that worked in one unit may not work in another. Testing also helps

• To increase your belief that the change will result in improvement in your setting

• To learn how to adapt the change to the particular conditions in your setting

• To evaluate the costs and side effects of changes

• To minimize resistance when implementing the change in the organization

genesis of SAFE CARE, SAVING LIVES

One of the first programs in India for quality improvement was launched in 2012. Six hospitals with active newborn care departments from different parts of India participated in the program to reduce newborn mortality through quality improvement. ACCESS Health facilitated this program. Since 2007, the Aarogyasri Health Care

introduCtion

Why was there a decrease in compliance? Hand rub was not available at each bed

Why was the hand rub is not available?The newborn care unit does not have supply of hand rubs

Why does the unit not have hand rub?The indent was raised to pharmacy but the pharmacy did not supply.

Why was the hand rub not supplied on time?There is no stock and the supplier was not providing further supplies to the pharmacy.

Why is the pharmacy not getting supplies?The hospital has not made pending payments to the supplier

Trust of Andhra Pradesh had emerged as a major purchaser of care with a vision to improve access to high quality care. It was one of few platforms working directly with public and private hospitals. ACCESS Health invited team members from the Trust as observers to a learning session of the six hospitals. Inspired by the commitment of the hospitals to improve quality, Aarogyasri performed a medical audit to examine the level of quality of care among the newborn care units of public and private hospitals contracted by the Trust. There were major variations in the levels of quality of care and health outcomes. The then Chief Executive Officer (CEO) was interested to explore how the insurance program could work with hospitals to improve the quality of care and health outcomes.

Around the same time, the Department of Health and Family Welfare, Government of Andhra Pradesh, commissioned an assessment of fourteen public newborn care units. The aim of the facility-based study was to understand ways to reduce newborn mortality. One of the recommendations from the assessment was to invest in quality improvement. Given that newborn care was a priority of the government, and a collaborative for quality improvement in newborn care had demonstrated results in India, the CEO of Aarogyasri launched the quality improvement program Safe Care, Saving Lives. The program aimed to reduce newborn mortality rate in select hospitals by fifteen percent between 2014-2018. ACCESS Health was invited to be the implementation partner to the government in supporting the hospitals understand and implement quality improvement methods.

The program included selected public and private hospitals empanelled with the public health insurance trusts in the states of Andhra Pradesh and Telangana. The key objectives of the program were to

• Identify the leading causes of morbidity and mortality in labor rooms and newborn care units

• Establish quality care collaborative involving participant hospitals.

• Establish structures within the Aarogyasri Health Care Trust to oversee quality of care, develop and implement strategies to improve quality of care among hospitals working with the insurance program

• Build the evidence base for further scale up of the program and to positively influence local, national, and global policies to improve quality of care.

Program methodology

All the participant hospitals form quality improvement team(s) in their labor room and/or newborn care unit. The team includes doctors, staff nurses, data entry operator and administrative leaders who are involved in improving a particular process. A team of advisors from ACCESS Health, who are trained in quality improvement, supports each facility’s quality improvement team.

The ACCESS Health team typically consists of one quality lead and one to two quality associates. Each such team supports three to five hospitals to implement quality improvement methodology.


One quality lead

One quality associateQuality Improvement Team

The hospital quality improvement teams implement a set of clinical practices called the Potentially Better Practices (PBPs). These evidence based practices have the potential to improve neonatal outcomes. These practices were compiled from the work of Neonatal Intensive Care Units and Maternal and Neonatal Health Safety Collaboratives around the world, and from recommendations of quality improvement and clinical experts. The PBPs address the key drivers of the three leading causes of neonatal mortality namely 1) sepsis, 2) birth asphyxia, and 3) complications due to premature birth. Key drivers include the systems, processes, structures, and norms that need to change in order to reduce neonatal mortality.

Using the model for improvement, the advisors support staff to identify Change Ideas to improve the processes and implement the PBPs. For instance, compliance to optimal hand hygiene practices is a PBP to prevent and manage newborn sepsis. Better signage, availability and use of alcohol based hand rub dispensers, are examples of change ideas to implement, and measure if the compliance to hand hygiene is improving.

The change ideas are identified based on the local circumstances, environmental situations and the belief that the idea works in the current system. The staff can also refer to existing change ideas that worked in other units, but are encouraged to test these ideas in their local system. Depending on degree of belief and the outcome of testing the ideas, the change ideas are adopted directly, adapted according to local circumstances, or even abandoned. The ideas are tested and are evolved through the Model for Improvement (Figure 1).

The Change Package gives examples of Change Ideas that led to process improvement in various facilities. This document is not designed to be comprehensive or exhaustive. Rather, it contains the highest leverage changes to achieve results. As the success of a Change Idea may vary by facility due to differences in circumstances, facilities can use this document as an initial guide to start work on quality improvement in newborn care.

This Change Package is organized into three sections. Each section provides change ideas pertaining to select potentially better practices (PBPs) pertaining to each of the key drivers – birth asphyxia, newborn sepsis, and complications of prematurity.

We suggest using the Change Package along with the Quality Improvement toolkit. The Quality Improvement Toolkit is a guide, which suggests practices, process and outcome measures, and tools to implement the quality improvement methodology in labor rooms and special newborn care units.

review / audit of data

The ‘magnifying glass’ icon indicates auditing, assessment, review or random checking of data

training of staff

This icon indicates training, sensitizing, reorientation or instructions passed on to staff.

how to read the iCons in this doCument

use of human resourCes

The ‘people’ icon indicates use of human resources to delegate, assign, swap or post staff in the unit.

reCording of data

The ‘pen’ icon indicates recording or capturing data in either a register, a new format, a chart or case sheet or board.

Change in infrastruCture

These icons indicate change required at the infrastructure or system level

use of external doCuments

These icons indicate the use of external documents (checklists, posters, stickers) to remind or help perform a task


aim

key drivers

Potentially better PraCtiCes

high risk categorization of women in labor

Partogram for all women in labor

oxytocin infusion protocol

Trained personnel attend to high risk deliveries

Pre-delivery checklist for high risk deliveries

Intra-partum

Intra-partum

Intra-partum

Newborn

Newborn

Newborn

Positive pressure ventilation for all babies with perinatal depression within the golden minute

BIrTh AsPhyXIA

sePsIsDecrease neontal mortality rate in Safe Care Saving Lives hospitals by 15%

PremATurITy ComPlICATIons

Antibiotics to women with risk factors for sepsis

hand hygiene, gloves for Per vaginal examination

Who’s 6 Cleans for all deliveries

hand hygiene practices

Aseptic non Touch Technique during peripheral Iv line insertion

Antibiotics stewardship

Antenatal corticosteroids to women with risk of spontaneous preterm delivery

early breast feeding

CPAP for newborns with respiratory distress (snCu / delivery room)

first temperature within 15 minutes of birth

exclusive breast feeding (expressed/direct)

Kangaroo mother Care*

figure 3 Driver diagram showing the relationship between PBPs, key drivers and goal of Safe Care, Saving Lives

*Kangaroo mother care & Early breastfeeding also PBP for prevention of newborn sepsis

Reliable care to prevent and manage


management of

birth asPhyxia

Follow categorization of high risk women in labor

Ensure compliance to plotting Partograph

Ensure a person trained in resuscitation attends all high-risk deliveries

Prepare a pre delivery checklist to be used for all high risk deliveries


birth asphyxia

what is the Change idea?

why to imPlement it?

how to imPlement it?

se

tuP

Adopt or customize standard checklist for categorizing high risk cases. (E.g. National guidelines on Maternal and Newborn Health, Dakshata guidelines)

Neonatal outcomes in high risk mothers are poor and to improve neonatal outcomes it is important that no high risk case is missed

Develop the checklist of high risk conditions and attach to the case sheets

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vie

w

Track the outcome of pregnant women until delivery, to track the type of delivery (normal or Caesarean section), and the condition of the baby

To know the outcomes of the high-risk delivery, and track success of the intervention

Add a column in high risk register to track the case until delivery

tra

in

Sensitize nurses of the labor room to appropriate categorization of high risk mothers

To enhance the knowledge of nurses and ensure uniformity in identification of high risk mothers

Conduct periodic training sessions for the staff nurses and doctors of obstetrics department about maternal risk factors and importance of categorizing high risk cases

aC

t

Use a “flower” sign / High-risk stamp / “High risk” label with red pen to mark all the high risk women case sheets

To demarcate the high risk cases from normal cases and give special attention to the high risk cases

Sensitize the staff to the appropriate way of marking the high-risk cases using the stamp or other selected means. Segregate from other sheets to give special attention

Follow categorization of high risk women in labor




re

Co

rd

Display the names of high risk women in the obstetrics and gynaecology department

To monitor high risk cases regularly and to ensure that a staff trained in Newborn Resuscitation Protocol (NSSK, NRP) is present during high risk deliveries

Display the names of high risk cases on a black board or suitable display mechanism shift wise in the obstetrics and gynaecology department. Assign the responsibility to staff shift wise

Maintain a register for high risk cases

To track the condition and outcome of the baby born to high risk mothers

Keep separate register for high risk cases in an easily accessible place. Sensitize the staff on the use of the register and the different columns that need to be filled up

Put up a chart with data on high risk cases being updated daily

To capture data on high-risk cases daily and follow up whether a paediatrician is available during high risk deliveries

Create a chart to record the number of high risk deliveries, number of cases for which paediatrician was called and attended. Plot the number of birth asphyxia cases so that if the cases increase the staff can review these cases immediately

re

min

d Display a poster with all the high risk conditions in the labor room

To avoid missing high risk cases by helping nurses remember all the high-risk conditions

Display the poster in a place where it is easily visible and from where it serves as a visual reminder to the staff


birth asphyxia




se

tuP Ensure availability of

Partograph sheets in the Labor Room

Ensure Partograph sheets are always available in the unit to avoid shortage during critical times

If government supplies are not available, ensure access to photocopier until the supplies are resumed. Designate a person for regular supply such as the administrative staff or data entry operator

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in

Conduct a training session for postgraduate trainees

Training sensitizes the postgraduates on the importance of monitoring the progress of labor using a Partograph

Conduct a training session for post graduate trainees on filling/documenting Partograph

Delegate responsibility of training other staff to Skilled Birth Attendants

As the incharge nurse or Head of Department may not be available for training at all times, the responsibility can be delegated to other trained staff such as Skilled Birth Attendants

Designate responsibility of training to Skilled Birth Attendants. Conduct brief sessions daily

Periodic retraining schedule which includes training on Partograph on a monthly basis

To ensure that newly appointed staff or those posted to the labor room get trained and keep up with compliance

Head of Department to create a periodic retraining schedule for the staff of the Labor Room. Make the training a monthly activity to avoid missing out





aC

t

Fill at least the essential components of partograph

To make sure that all the essential data is captured and at the same time the staff do not feel like it is an extra work to fill in all the components.

Retrain Labor Room Staff on filling the essential components of Partograph

Attach the Partograph sheet within the case sheet

To ensure availability of the partograph sheets and to help staff fill the details during the course of labor

Paste or staple the Partograph sheet within the case sheet before delivery. The revised Labor room case sheet designed by Ministry of Health has the partograph included

Post staff nurses trained on use of partograph across different shifts, especially when there is a high patient load

To ensure availability of trained staff comply with filling of partograph even during higher patient load. They could also support and hand hold the junior staff

Identify the trained staff who are filling with partographs appropriately. The nursing superintendent to create the duty roster of nurses ensuring at least one trained nurse is posted per shift. Post more trained staff nurses for the shifts with high patient load. For e.g. Post two Dakshata trained staff nurses in the morning and afternoon shifts

Create a WhatsApp group with the staff including the head of the unit

Having the head of the unit on the WhatsApp group could ensure that trainees and other staff plot and share the partographs real time. The staff can also use this group to clarify any doubts in filling the partographs.

Collect contact numbers of all concerned staff. Create a WhatsApp group with the head of the unit, or use an existing group of the unit. Suggest staff to share pictures of the Partograph plotted. Encourage the team to use the platform to learn and share suggestions


birth asphyxia




re

Co

rd

Include the Partograph data in the daily duty statistics of Labor Room Medical Officer register

To monitor compliance in a sustainable way

Suggest the post graduates to start mentioning the Partograph data plotted in daily duty Labor Room Medical Officer register along with other statistics

ev

alu

ate

Identify the eligible cases for plotting Partograph (excluding ones where it is not required)

Including the non-eligible cases for Partograph lowers compliance

Classify the active phase of labor cases and Intra Uterine Deaths to be reported separately. Exclude all the active phase labor and the Intra-Uterine death cases

Evaluate the Partograph sheets filled by duty doctors

To identify knowledge and skill gaps in filling Partograph

Carry out a random check of the registers for filled Partograph sheets. Conduct review sessions to discuss and address gaps in filling the sheet

Monthly review by Head of the unit

To involve leadership so that the work continues smoothly and the system is self-sustainable

Encourage heads of the units to review the data sent by their postgraduates in the WhatsApp group. Sensitize and follow up with the postgraduates during their weekly meetings or daily rounds. Heads can audit case sheets to understand the compliance with appropriate filling in of partographs




se

tuP

Set up a mode of communication between the labor room and newborn care unit such as a bell, bulb, or telephone

For every high risk case there are good chances that the baby may need resuscitation. So a person trained in resuscitation is called from newborn care unit to labor room for every high-risk delivery

Set up a mode of communication such as an alarm bell, or a light bulb or telephone between the two units of the hospital. Stick the contact details of the Duty Medical Officer in labor room and Neonatal Intensive Care Unit. Orient all the staff that ringing of the bell indicated an emergency in the Labor room and trained staff from newborn care unit must immediately attend to the case in labor room

tra

in

Train all the newborn care unit staff in Newborn Resuscitation Protocol. Also train the Labor Room staff in NRP

To fill any knowledge gaps for efficient management of birth asphyxia cases. Due to shortage of staff in Newborn Care Unit, it is essential to also train the Labor Room staff in basic Newborn Resuscitation Protocol

Sensitize and train the newborn care unit staff on Newborn Resuscitation Protocol. Train the Labor Room staff by the in house Newborn Resuscitation Protocol (NRP) trainer. Indian Academy of Paediatrics or National Neonatology Forum can support the training.Swap one NRP trained staff nurse between the Labor room and the newborn care unit for a limited period of time. This can help on job training of Labor Room staff




birth asphyxia




se

tuP Prepare a pre

delivery checklist for high risk deliveries

The pre delivery checklist helps to find the supplies easily, reduce human errors and use the golden minute effectively

Nodal officer (head) of the newborn care unit to prepare the checklist based on NRP guidelines and practical requirements for attending to high risk deliveries. Discuss among the resuscitation team, conduct demo resuscitation sessions in the labor room to modify and finalize the checklist. Designate an area to place the checklist

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Educate the staff of the labor room about the uses of the checklist

For reliable usage of the checklist and ready availability of all requirements for high risk deliveries

Coordinate monthly meetings to discuss about implementation of the pre- delivery checklist

Train the resuscitation team on filling in the details

To make better utilization of the checklist for easy audits and data capture

The team should be educated that filling the list is not time taking and that all the necessary columns in the sheet are filled appropriately. The personnel from both departments understand the list and make requirements available

Prepare a pre delivery checklist to be used for all high risk deliveries




aC

t

Display the roster of the NRP trained staff in the labor room

To ensure that the appropriate person can be easily contacted during an emergency

Fix Labor Room postings of Newborn Resuscitation Protocol trained staff. Make the roster of the NRP trained personnel well in advance (for example for the whole month) and display in the labor room

Post a staff from newborn care unit in the obstetrics department during busy shifts

All staff in the newborn care unit are Skilled Birth Attendants who can handle high-risk cases. As posting newborn care staff to labor room full time is difficult, they can be posted during high load times such as 9 am to 2 pm

Post Newborn Care Unit staff in labor wards on a rotation basis during busy shifts, for example, 9 am to 2 pm

re

Co

rd

In the high risk register, note the time taken for arrival of the staff from newborn care unit from the time of the call. Make sure this information is used only for the purpose of improvement.

As the audit sheet may get misplaced, use a register to record the time taken to attend to high risk delivery. It also helps to have the month’s data ready for review during monthly meetings

Suggest the labor room incharge nurse to include two additional columns case in the high risk register. One column for recording time of call and another for noting the time of arrival of NRP trained staff from newborn care unit

Compare the data on number of high risk deliveries attended by trained staff between labor room and newborn care unit

Verifying the data from both the labor room and special newborn care units helps to correctly track the number of high risk deliveries attended by trained staff

Keep a separate book in the newborn care unit in which high risk deliveries attended by their staff are noted. Compare the data in this book with the labor room high risk register data on a monthly basis



management of

sePsis Antibiotic Stewardship

Ensure Per Vaginal examination is conducted under aseptic conditions in the labor room

Ensure that the World Health Organization’s six cleans are followed during every delivery in the labor room

Ensure compliance with optimal hand hygiene practices among all staff in the newborn care units

Ensure compliance to Aseptic Non Touch Technique (ANTT) during Peripheral Intravenous line insertion

Intravenous fluid preparation aseptically

key outComes

0 0

86%

87%

95%92%

86%

79%

88%

79% 78%

66%71%

90%

96% 94%92%

0

0.2

0.4

0.6

0.8

1

1.2

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Apr-

16

May

-16

Jun-

16

Jul-1

6

Aug-

16

Sep-

16

Oct

-16

Nov

-16

Dec-

16

Jan-

17

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Percent of high-risk deliveries attended by labor room staff trained in neonatal resuscitation

20%

47%58%

85%

40%

93% 94%100%

0%

20%

40%

60%

80%

100%

120%

Jan-

15Fe

b-15

Mar

-15

Apr-

15M

ay-1

5Ju

n-15

Jul-1

5Au

g-15

Sep-

15O

ct-1

5N

ov-1

5De

c-15

Jan-

16Fe

b-16

Mar

-16

Apr-

16M

ay-1

6Ju

n-16

Jul-1

6Au

g-16

Sep-

16O

ct-1

6N

ov-1

6De

c-16

Jan-

17Fe

b-17

Mar

-17

Apr-

17M

ay-1

7Ju

n-17

Jul-1

7

Introduced High Risk stamps and stickers

80+20+N

40+60+N

80%

40%

The percentage of high risk deliveries attended by personnel trained in neonatal resuscitation increased from 0 to 80% after the labor room staff received training in neonatal resuscitation.

district hospital, nalgonda

The percentage of high risk mothers appropriately categorized as ‘High Risk’ increased from 40 to 80% by introducing high risk stickers and stamps


Percentage of high risk deliveries attended by nrP trained personnel in dh, nalgonda

Percent of high-risk mothers appropriately categorized as high-risk in dh, nalgonda

alternate and additional tools for birth asPhyxia

Maternal health guidelines - http://nhm.gov.in/nrhm-components/rmnch-a/maternal-health/guidelines.html WHO Safe Childbirth Checklist - http://www.who.int/patientsafety/implementation/checklists/childbirth/en/


SEPSIS




se

tuP

Make a unit specific antibiotic policy

To ensure that there is standardized prescription of antibiotics

Make a unit specific antibiotic policy depending on the previous three months culture data. Make sure that the policy is displayed in the unit

Adopt the All India Institute of Medical Sciences sepsis management algorithm for appropriate antibiotic administration

All India Institute of Medical Sciences sepsis management algorithm can be used as a base guideline which can then later be modified according to the unit cultures

Sensitize the Head of Department and request adherence to the policy. Suggest doctors to follow the policy

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in

Antibiotics of second line and above should be prescribed only after discussion with a senior doctor

To ensure that the antibiotics are used judiciously

Clearly instruct the junior doctors that they can prescribe only the first line antibiotics and if the antibiotics need to be upgraded, they have to take consent from senior doctor. Monitor the practice from time to time so that this is adhered to.

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Quarterly review of the antibiotic policy and antibiotic rotation depending on the cultures

Bacteria develop resistance to the antibiotics quickly and rotating the antibiotics reduces the incidence of resistance

Review of the antibiotic policy can be done by reviewing the culture and sensitivity pattern of the positive blood cultures every quarter. As a team, decide about the antibiotics of choice for the next quarter

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ate

Assess the adherence to appropriate antibiotic administration

To evaluate the usage of antibiotics. To know the unit’s performance in relation to the antibiotic policy

Use PPS (point prevalence survey) method to collect the data for antibiotic usage and compare it to the antibiotic policy. Designate staff trained in quality improvement methodology to implement and review the antibiotic practice

Antibiotic Stewardship




ste

uP Ensure continuous

availability of running water and gloves of all sizes

To help staff follow hygiene during Per Vaginal examination

Perform consumption analysis to procure sufficient number of gloves. Arrange for continuous running water in the facility

tra

in Train all the Labor room staff on sterile Per Vaginal examination

To sensitize staff about the importance of sterile Per Vaginal examination

Conduct a training session on the importance of sterile Per Vaginal examination

aC

t

Assign responsibility of performing Per Vaginal examination to specific nurses

To track adherence to this activity more efficiently;tracking is easier when its known as to who is doing the procedure

Designate a nurse from each shift to do the Per Vaginal examination. Assess reasons for non-compliance and fill the gaps

Limit the number of Per Vaginal examinations to three for women in labor

To reduce the early onset of sepsis cases

Instruct all staff in the unit to limit the number of Per Vaginal examinations to three per woman in labor

re

min

d Display ‘Steps of sterile Per Vaginal examination’ poster in the labor Room

To ensure the staff do not miss any steps in the procedure

Display ‘Steps of sterile Per Vaginal examination’ poster in the labor Room

Ensure Per Vaginal examination is conducted under aseptic conditions in the labor room


SEPSIS




se

tuP Ensure availability of

mackintosh and clean delivery kit

To ensure sterile surface for delivery

Perform gap analysis and consumption analysis to estimate the correct quantities of supplies required for deliveries. Bridge the gaps in availability of equipment and supplies conducting delivery

tra

in

Train the staff frequently on the compliance with WHO six cleans

To fill knowledge gapConduct training session and demo sessions to sensitize the staff on WHO six cleans

Regularly sensitize the housekeeping staff about maintenance of cleanliness in the labor room

To maintain the labor room infection-free

Prepare a protocol and a checklist for the cleaning process. Paste the checklist in an appropriate place. Ensure housekeeping staff fill out the checklist daily

aC

t Counsel mothers during the antenatal period to take a bath before delivery

To ensure clean perineum and sterile conditions

Assign a person to counsel mothers about cleanliness before delivery during each shift

re

min

d

Display WHO’s six cleans poster in the labor room

It acts as a reminder of sterile conditions in all the stages of labor

Posters are to be displayed on walls facing the labor room staff

Ensure that the World Health Organization’s six cleans are followed during every delivery in the labor room




ste

uP

Install elbow operated taps in the newborn care unit

Elbow operated taps prevent contamination of the hands again after washing as elbows are used to open and close the taps

Identify the place to setup the hand washing area. Install elbow operated taps in the identified hand washing area

Ensuring availability of liquid soap solution

Usage of solid soaps is not recommended, as they can carry infections

Ensure continuous supply of liquid soap solution at hand washing area

tra

in

Reorient and train the staff on correct steps for hand washing

Assessment of knowledge of the staff from time to time and hands on training is important to maintain the standards of care

Conduct training sessions on hand hygiene through presentations and videos. This includes demo sessions to orient about steps of hand wash and moments for hand hygiene

aC

t

Ensuring that the personnel dry their hands after washing

It is important to thoroughly dry the hands after washing as moisture causes disease causing germs to thrive

Install hand dryers at washbasins. Else, provide paper napkins to wipe wet hands each time after hand wash

aC

t

Use autoclaved newspaper/paper napkins to wipe wet hands

All the bugs stick to wet hands and therefore drying of hands is a very important step in prevention of sepsis. Autoclaved newspapers are a safe alternative to tissues or dryers if there are cost concerns

Ensure availability of autoclaved newspapers/paper napkins at point of use (wash basins)



SEPSIS




aC

t

Introduce alcohol based hand rub at every bed of the newborn care unit

Availability of alcohol based hand rub at every cot increases the compliance of hand hygiene as it serves as a visual reminder as well as it decreases the time and energy to get to the hand rub after every patient contact

Ensure availability of separate hand rubs with a stand to hold it at each warmer

re

Co

rd

Maintain a register to record handwashing practice, at the entry of newborn care unit

To track hand washing of healthcare providers and attendants before they enter the unit

Keep a register at the newborn care unit entrance to track hand washing of entrants

re

min

d

Display steps of hand wash and 5 Moments for hand hygiene posters at wash basins. Stick posters/stickers on warmers that serve as reminders for hand wash

To remind staff about steps of hand wash

Stick poster for steps of hand wash and 5 Moments for hand hygiene in sink/hand washing area. Posters should also be in local language and the messages should be given in a thought provoking manner. Stick poster/sticker on warmers to remind staff to wash their hands with liquid soap or alcohol handrub before touching the babies

Floor taping in red colour at the entrance of newborn area

To remind all health care workers and attendants to wash hands, wear cap, mask, and clean footwear before entering newborn area

Mark a red line or put a red sticker line at the entrance of newborn area along with a reminder note





ev

alu

ate

Conduct regular handwashing audits

To provide a system to monitor staff compliance to hand washing practices

Designate one person to do the monthly (or more frequently depending on the need) data audit. Develop and use audit forms for conducting audits

Display monthly data compliance of hand wash in the form of graphs for the team to assess themselves

Displaying data in the unit motivates the team for improvement in compliance and gives a sense of ownership of the practice

Encourage the team to update the data compliance periodically. Decide a place where the graph will be displayed. Designate the responsibility of making and displaying the graphs to the staff turn wise. Conduct a session for mentoring the team about data interpretation. Acknowledge improvements in compliance in unit meetings


SEPSIS




aC

t Start the practice of Aseptic Non Touch Technique in elective insertions first

Following all steps of Aseptic Non Touch Technique during emergency insertions may be difficult for staff initially

Encourage staff to follow steps of the Aseptic Non Touch Technique in elective insertions at least to start with. Ensure this is taken forward to emergency insertions once the staff are familiar with the technique

ev

alu

ate

Audit compliance with Aseptic Non Touch Technique separately for elective and emergency cases

Staff may not be able to follow all steps perfectly during an emergency. Auditing separately gives an idea of the actual knowledge and skill gaps

Classify insertions into elective and emergency insertions. Audit the cannulation procedure separately for elective and emergency cases




se

tuP

Delegate two nurses to perform the intravenous cannulation procedure

A second nurse is necessary to help the nurse who is doing the procedure in opening all the required items in an aseptic manner and place them on a clean trolley. The second nurse also helps to hold the baby so that the procedure can be done smoothly

Assign two nurses to do the Aseptic Non Touch Technique procedure (instructed by senior staff nurses). Provide extra staff in the morning shift when patient load is higher

Assign a dedicated trolley with the sets of supplies required for intravenous cannulation

Intravenous cannulation requires a number of sterile medical equipment. Assembling sets of all the requirements, specifying trolleys with sets saves time and effort of gathering them during the procedure. Maintaining sterile sets also helps to maintain asepsis

Designate one trolley in which an autoclaved tray with the sets of supplies required for intravenous Cannulation are available. Analyze requirement and ensure availability of kits based on consumption

tra

in

Sensitize the staff on steps of Aseptic Non Touch Technique for intravenous cannulation procedure

To educate the staff on sterile steps of peripheral IV cannulation so that the cannulation is done aseptically

Conduct orientation session on the steps of Aseptic Non Touch technique for intravenous cannulation procedure. Display the steps for cannulation procedure as a checklist

Train the nurses to perform Aseptic Non Touch Technique for doing cannulation both in elective and emergency cases

To help staff feel confident about performing Aseptic Non Touch Technique as per the recommended sterile guidelines

Conduct demo sessions and training program for performing cannulation both in elective and emergency cases. Conduct pre-test and post test to assess the effectiveness of training

Ensure compliance to Aseptic Non Touch Technique (ANTT) during Peripheral Intravenous line insertion


SEPSIS




aC

t Prepare intravenous fluids at the same time everyday

Reorganising the work of the staff and having a specific time for making the fluids will create more time for the staff nurses to concentrate on important clinical aspects

All the staff nurses along with the in charge could sit together and decide what time best suits the intravenous fluid preparation. Follow the decided time to prepare the intravenous fluids everyday

ev

alu

ate Record video of the IV fluid

preparation in real time and give feedback to the staff on the procedure

This actually would reveal the mistakes done by the nurses and also the practical issues that the nurses face while doing the procedure. This gives opportunity for correction or teaching them alternative methods of doing preparation

The medical personnel or the other nurses could video record a procedure (without recording the face of the person who is doing it – only the procedure to be recorded) that is done and then this could be discussed in a non threatening way by asking the nurses themselves to comment on the procedure




se

tuP

Have a designated corner or a room for intravenous fluid preparation

Having a designated area ensures that the IV fluids are prepared aseptically

Designate a suitable place in the newborn care unit where the intravenous fluids are prepared. Place a trolley covered with autoclaved sheet, and place all the things needed for making the fluids near the trolley, Sensitize all the staff to be sensitised about these specifications

Designate nurses in every shift for preparing fluids and medications for all the babies in the unit

Having designated IV fluid nurses who are trained in Aseptic Non Touch Technique standardises the process and ensures that the fluids are prepared uniformly with maintenance of asepsis. All nurses preparing fluids for their own babies increases chance of contamination

Train some of the nurses on the unit in Aseptic Non Touch Technique thoroughly. Make sure at least one of the trained nurses is present in each shift. These nurses in turn can train others so that ultimately all of them can be IV fluid nurses

tra

in Hands on training sessions on preparation of intravenous fluids

To fill knowledge and skill gaps

Training sessions could be organised once in a quarter or more frequently on a need basis. Hands on training and training with the help of role play of the nurses gives them a better idea of how to handle things in an actual scenario

Intravenous fluid preparation aseptically

Aseptic preparation of intravenous fluids was not one of the potentially better practices of Safe Care, Saving Lives program. Nevertheless, these change ideas were followed and were helpful for the staff in containing sepsis.


management of

Prematurity ComPliCations

Give a single course of antenatal steroids as per the recommended schedule to all pregnant women between twenty four and thirty four weeks of gestation who are at a risk of iatrogenic or spontaneous preterm delivery in the next 7 days

Ensure initiation of early breastfeeding for all the babies who have no contraindication to breastfeed

Take the first temperature of all babies within fifteen minutes of admission into the newborn care unit

Ensure that all mothers are counselled on how to express breast milk at least 48 hours before discharge

Ensure all eligible babies are given Kangaroo Mother Care (KMC) for a minimum of four hours per day

alternate and additional tools for sePsis

Sepsis in the newborn - http://www.newbornwhocc.org/2014_pdf/Neonatal%20sepsis%202014.pdfWHO Safe Childbirth Checklist Implementation Guide - http://apps.who.int/iris/bitstream/10665/199177/1/9789241549455_eng.pdf

key outComes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% SNCU nodal officer approval for using higher antibiotics

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18

60+40+N

50+50+N

60%

50%

Usage of antibiotics in the newborn care unit reduced from 80% to 20% by introducing nodal officer approval for higher order antibiotics. There is no change in the incidences of sepsis or there is a decrease in the sepsis morbidity in the facility after the PBP/change idea is implemented.

district hospital, sangareddy

Increase in the compliance with hand hygiene by SNCU staff from 30% to 80% in five months.

district hospital, hanamkonda

Percentage of babies given antibiotics in dh, sAnGAreddy

Compliance with hand hygiene by snCu staff of dh, hAnAmKondA


Prematurity ComPliCationsGive a single course of antenatal steroids as per the recommended schedule to all pregnant women between twenty four and thirty four weeks of gestation who are at a risk of iatrogenic or spontaneous preterm delivery in the next 7 days




se

tuP Introduce a register or tool

for capturing the details of administration of Ante Natal Corticosteroids

To document the gestational age of pregnancy, and dosage, frequency of administration of corticosteroids and correlating with the health outcome of the baby

Standardize the reporting of Ante Natal Corticosteroids administration in which timings, dosage of corticosteroids as well as health outcome of the baby are documented

aC

t Conduct regular perinatal morbidity and mortality meetings

Regular reviews can help identify areas of progress to continue with and also helps identify the gaps in the processes

Organise monthly perinatal mortality and morbidity meetings between paediatricians and obstetricians

re

min

d Use reminders, such as posters signs, to heighten urgency for administration of corticosteroids

To remind staff to administer antenatal corticosteroids

Use reminders near the antenatal clinics and the labor rooms and ensure availability of antenatal corticosteroids to sustain practice

ev

alu

ate Audit the eligible cases with

the administration of Ante Natal Corticosteroids

To keep a record of the mothers who are not given Ante Natal Corticosteroids and understand the reasons for not giving the antenatal steroids

The neonatologist or paediatrician can audit all the eligible cases and see the compliance of the steroid coverage. He/she can provide feedback to the concerned obstetricians’ perinatal mortality and morbidity meetings




se

tuP Introduce a new format

for recording details of expressed breast milk

To encourage staff to follow the practice of documenting the details of expressed breast milk

Develop a format to capture details regarding expressed breast milk. Train sisters in documenting the feeds given to the baby.Conduct a random check of registers during discharge to check whether baby given expressed breast milk

tra

in

Train staff on the steps of counselling mothers on exclusive breast feeding or expressed breast milk

Appropriate counselling by staff can ensure that the mother understands the importance, positioning and frequency of breast feeding

Train new staff on the importance of expressed breast milk. Conduct periodic reorientation of staff on how to counsel during rounds and on the key points to be discussed at the time of discharge

ev

alu

ate

Assess whether every baby has been on exclusive breast feeding or expressed breast milk forty eight hours prior to discharge

To evaluate whether counselling by staff has been effective

Document the time when breast feeding was initiated/expressed breast milk was first given to the baby. Evaluate whether this happened forty eight hours prior to discharge

Ensure that all mothers are counselled on how to express breast milk at least 48 hours before discharge



Ensure initiation of early breastfeeding for all the babies who have no contraindication to breastfeed




se

tuP

Encourage mothers to wear suitable clothing for feeding the baby after delivery

Clothing should be comfortable for initiating breastfeeding on the labor table in case labor gowns are not available in facilities

Advise mothers to wear clothes that open in the front. These are suitable for mothers to initiate feed and to support breast crawl

tra

in

Allow a birth companion and sensitize her to support the baby during breast crawl

For emotional support to mothers and to assist the baby during breast crawl and feeding

Sensitize birth companions about their role and to maintain hygiene before entering the labor room

Regular sensitization of doctors, staff nurses and support staff on breastfeeding by the Head of the department

To ensure sustainability of practice

Monthly training session or review meetings to re sensitize the staff

re

Co

rd

Document the time of first breast feeding in the parturition register to review the time taken for feeding after delivery

To ensure accountability and measure the improvement

Add a column to the parturition register to document time of breast feeding or use a stamp to document the practice

re

min

d

Display posters in local language about importance of early breast feeding

To educate mothers and remind nurses during delivery

Display the posters in labor room, antenatal ward and postnatal wards at a place from where it is easily visible for the mothers and the staff.

ev

alu

ate Assign the responsibility

of monitoring the practice to one person per shift

To fill the behavioural gaps like neglecting the practice or attitude issues or failing to remember

Designate one person per shift who should monitor the way staff support mothers in breastfeeding. Head nurse can conduct surprise monitoring visits and encourage the staff to take up the practice seriously




se

tuP

Introduce a format for recording the baby’s temperature

To create awareness in staff regarding the importance of recording temperature

Sensitize the team on importance of recording temperature. Introduce a new format for the team to record temperature and other details

Designated triage area to be there outside the newborn care unit for the admission of the newborns. Note the first temperature within fifteen minutes in the designated triage area of Neonatal Intensive Care Unit

A designated area with a digital thermometer and a reminder facilitates the staff to measure the temperature within fifteen minutes.

Position the warmer such that it is enclosed from all sides to maintain the temperature

Record temperature of the baby at the first point of contact in the ambulance, in case of referral

To start temperature management of the babies, even prior to their admission to the newborn care unit

Train hospital technicians/paramedics in the ambulance in hypothermia management (All India Institute of Medical Sciences tool can be used). Maintain end-to-end checkpoints in recording temperature for effective management of hypothermia

Record temperature of the newborn in the labor room

To make the baby’s temperature history available to the newborn care unit

Record the baby’s temperature in the labor room. When the baby is shifted, hand over the document with temperature reading to the doctor/ nurse of the newborn care unit

Take the first temperature of all babies within fifteen minutes of admission into the newborn care unit







se

tuP

A separate dedicated space with reclined chairs, clean towels and gowns is to be made available

Privacy and comfortable environment is suitable for a greater duration of mother and baby contact

The team should identify space near the newborn care unit to accommodate chairs.Towels and gowns are to be made available, and cleaned on a daily basis

Provide gowns for use by mothers while providing kangaroo mother care

Gowns tailor made for Kangaroo Mother Care help to hold the baby in place during KMC process. Gowns serve as a visual reminder to provide KMC

Prepare gowns with fastening straps for the use during KMC. Ensure that gowns are cleaned and sterilized after use by every mother and daily, even if it is the same mother using a particular gown

Provide separate gowns to mothers whose babies have sepsis

Separating the KMC gowns for babies with sepsis prevents other babies from contacting infection

Designate and label some gowns for exclusive use by mothers whose babies have sepsis

Provide sling for holding baby during KMC

To ensure that the baby is properly fastened and there is no risk of dropping the baby

Mothers providing KMC can be handed over the slings and asked to continue using at home till the baby gains adequate weight, is able to suck properly from the breast and tries to get out of the sling




aC

t

Counsel mothers to maintain hygiene before skin to skin contact

Mother has to be clean and tidy to prevent cross infection to the baby during Kangaroo Mother Care

Encourage mother to take bath/sponge bath before KMC

Encourage father or grandmother or any other family member to give KMC

To motivate other family members to give KMC when mother is not with the baby or when longer durations of skin to skin contact are required

Motivate other family members by showing videos and sharing success stories of weight gain in babies

aC

t

Have peer groups (organizing small groups with experienced mothers in KMC teaching the new mothers)

Being talked to by a mother who had given KMC before about the advantages of KMC and sharing of the success stories is much more motivating than a counsellor. It also can help in solving a lot of practical issues

When the NICU babies come for review, we can request the mothers of the NICU graduates to talk to the mothers who are present in the SNCU / NICU

Motivate the mother by counselling about exclusive breast feeding

Ensure direct breast feeding for baby forty eight hours prior to discharge

Prepare a chart for type of feeding based on the weight and health status of baby

re

Co

rd Monitor the duration of skin

to skin contact in every shift

A minimum of two hours of skin to skin contact per shift is advised to expect an effective weight gain in the baby

The staff nurse is to audit the number of hours per shift using a tool designed for KMC







re

min

d Show videos to mothers and nurses and displaying educational posters of KMC in the room

To educate mothers about positioning the baby during KMC, and to serve as a reminder to provide KMC

Presence of audio visual educational material in the designated area

ev

alu

ate

KMC sheets to be filled in by parents (or KMC providers themselves)

Recording the duration and frequency of KMC helps to ensure that baby is receiving adequate KMC. The longer the duration, the better the outcomes. Mothers or the care givers feel more responsible towards the baby and are more likely to fill in the KMC sheets accurately

Teach mothers and other KMC givers how to fill in the sheet. Sensitize them to the importance of filling in the sheet

Assign a medical officer to review the baby’s vitals to assess improvement during Kangaroo Mother Care

To take a clinical decision based on monitoring the vitals if necessary

Assign a medical officer to assess the baby’s vitals such as temperature, head circumference, weight gain, and the type of feed regularly

alternate and additional tools for Prematurity ComPliCations

Use of antenatal corticosteroids in preterm labor - http://nhm.gov.in/images/pdf/programmes/child-health/guidelines/Operational_Guidelines-Use_of_Antenatal_Corticosteroids_in_Preterm_Labour.pdfFeeding of low birth weight infants - http://newbornwhocc.org/pdf/Feeding_of_Low_Birth_weight_Infants_050508.pdfKangaroo mother care and optimal feeding of low birth weight infants - http://nhm.gov.in/images/pdf/programmes/child-health/guidelines/Operational_Guidelines-KMC_&_Optimal_feeding_of_Low_Birth_Weight_Infants.pdf

key outComes

30%32%

35%38%

40%42%

44%

50%52%

55%

60%

20%

30%

40%

50%

60%

70%

Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18

0

10

20

30

40

50

60

70

80

90

100

Star mark on the case sheets after administration of ANCs

Use of NHM antenatal corticosteroidsregister

30+70+N

70+30+N

30%

70%

Increase in the percentage of babies given breast feeding within one hour of delivery from 30% to 60% in 10 months by creating awareness among the pregnant mothers during ANC and also to the birth companion by the family planning counsellors.

rIms, AdIlABAd

Increase in the percentage of mothers (gestational age of 24 to 36 weeks) administered antenatal corticosteroids from 30% to 100% in three months.


Percentage of babies breastfed within one hour of delivery in rIms Adilabad

Percentage of mothers administrated antenatal steroids in dh, nalgonda

Change PaCkage for Quality imProvement in newborn Care

for Queries or further information, Please ContaCt

dr Ajitkumar sudke Director, Quality and Process Improvement Mobile: 8811074411 E mail: [email protected]

Cover photo Paul Joseph Brown, www.globalhealthphoto.com

design Team Whitespace35

Nilgiri 1st Floor, Room No. 221 & 222, IIIT-H Campus, Survey No. 25, Gachibowli, Hyderabad, Telangana 500032, India

About ACCess health International

ACCESS Health is an international think tank, advisory group, and implementation partner. We work to improve access to high quality and affordable healthcare. We also work to reduce health disparities by shaping the social and environmental determinants of health. We conduct practical, evidence based research. We cultivate partnerships. We foster health innovation. We establish long term, in residence, country and regional programs. ACCESS Health works in low and middle income countries to improve maternal and child health. Our primary focus is on reducing infant, child, and maternal mortality. We identify successful programs in rural and urban settings and work with care providers to understand and document best practices. We take that knowledge and adapt to fit the work of other public and private providers, helping them improve their programs and quality of care.

We promote collaboration among research institutions, policymakers, healthcare providers, health insurance suppliers, and other payers of care to bring good practices to scale. This approach improves the quality of maternal and child care and creates lasting institutional change within the healthcare system.

Website: www.accessh.org/maternal-child-health/

This document can be accessed at: www.safecaresavinglives.org/resource

Copyright © 2018

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