change agent or troublemaker – engaging stakeholders and making change
DESCRIPTION
Change agent or troublemaker – engaging stakeholders and making change. Implementing Change in northern India . Umass -Boston Oct 21, 2014. Robyn Churchill, CNM, MSN. Goals of this presentation: Understand barriers to change Learn one framework for building lasting change - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/1.jpg)
Change agent or troublemaker – engaging stakeholders and making change.
Implementing Change in northern India.Umass-BostonOct 21, 2014
Robyn Churchill, CNM, MSN
![Page 2: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/2.jpg)
![Page 3: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/3.jpg)
Goals of this presentation:
1. Understand barriers to change2. Learn one framework for building lasting
change3. Draw lessons learned from India and apply to
case study
Plan for today:
Using 5 element framework for implementing systems change:
1. Review experience of BetterBirth project in northern India
2. Use lessons learned to address implementation plan for case study
![Page 4: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/4.jpg)
What is needed for change?
Supportive Environment
Knowledge
Skills
Resources
Motivation
![Page 5: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/5.jpg)
Barriers-Resistance
Initial Response to Resistance
![Page 6: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/6.jpg)
Barriers
Expect Resistance
![Page 7: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/7.jpg)
Barriers
Understand Resistance by Listening
![Page 8: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/8.jpg)
Barriers-Resistance
Outsmart Resistance
Increase Drivers
Decrease Resistance
![Page 9: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/9.jpg)
Framework for Implementing Change
Engage Stakeholders
Make local modifications
Identify team and champions
Collect and USE data to learn and iterate
Build capacity/plan for sustainability
![Page 10: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/10.jpg)
Approach to Implementing Change
Make local modifications
Understand processes (map them)Adapt to local policy and standardsConsider resources and barriers
![Page 11: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/11.jpg)
Approach to Implementing Change
Identify team and champions
Who needs to be involvedIdentify early adoptersConsider role for resistorsRecognize and develop championsBuild coaches/on going mentors
![Page 12: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/12.jpg)
Approach to Implementing ChangeCollect and USE data to learn and
iterate
Identify metrics of importanceinputsprocessoutputsoutcomes
Create meaningful and individual reportsregularcustomizedreal-time
Develop system for regular review with front line staffshow what you know (successes, areas for improvement)learn from front line experience
![Page 13: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/13.jpg)
Approach to Implementing Change
Build capacity/plan for sustainability
Identify existing structure to plug intoIdentify owners of processLocate systems for funding, supervision, monitoringCreate policy-facility, regional, national
![Page 14: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/14.jpg)
BetterBirth Safe Childbirth Checklist Implementation
Uttar Pradesh India
![Page 15: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/15.jpg)
Moments of Greatest Risk
Conception
Antenatal period
Admission to birth facility
Delivery
Discharge from birth facility
28 days
42 days
Mat
erna
l & n
eona
tal m
orta
lity
risk
Time
![Page 16: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/16.jpg)
Moments of Greatest Risk
Conception
Antenatal period
Admission to birth facility
Delivery
Discharge from birth facility
28 days
42 days
Mat
erna
l & n
eona
tal m
orta
lity
risk
Time
Check point #1 On admission
Check point #2Just before pushing(or before Cesarean)
Check point #3 Soon after birth (within 1 hour)
Check point #4 Before Discharge
![Page 17: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/17.jpg)
Safe Childbirth Checklist Program
![Page 18: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/18.jpg)
Safe Childbirth Checklist Program
![Page 19: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/19.jpg)
Objective: Measure health worker performanceAdherence to 29 essential processes linked with improved maternal, fetal, and neonatal health outcomes
Intervention: Introduction of checklist supported by coaching
Methods: Prospective, pre-post-intervention study over 6 months in single sub-district level hospital in south India using observations by independent data collectors
Gokak Pilot Study
![Page 20: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/20.jpg)
![Page 21: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/21.jpg)
After
Before
0 5 10 15 20 25 30
9.8 (9.4, 10.1)
Essential childbirth practices delivered (n=29)
25 (24.6, 25.3)
Gokak Pilot Study
![Page 22: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/22.jpg)
Safe Childbirth ChecklistSingle center pilot, Karnataka, India
Indicator (selection) Baseline Post-Intervention
Hand washing and gloving 1.3% 97.8%
Breastfeeding initiation within one hour of birth 50.4% 90.6%
Routine administration of Oxytocin within 1 minute after birth
8.4% 68.9%
PLoS One 2012;7(4):e35151
![Page 23: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/23.jpg)
Stakeholders
Government of Uttar PradeshGovernment of India
World Health OrganizationGates Foundation
Ariadne Labs (BWH/HSPH)Population Services International
Community Empowerment Lab, LucknowJNMC Medical College, Belgaum
![Page 24: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/24.jpg)
Stakeholders
District LeadersFacility LeadersMedical Officers
NursesANMs (Auxiliary Nurse Midwives)
![Page 25: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/25.jpg)
Stakeholders
District LeadersFacility LeadersMedical Officers
NursesANMs (Auxiliary Nurse Midwives)
Ward AyasSweepers
ASHAsWomen
Mothers in law
![Page 26: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/26.jpg)
Stakeholders
![Page 27: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/27.jpg)
Local Modifications
What factors would you consider in making local modifications? Whose input counts?
![Page 28: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/28.jpg)
Team and Champions
Team Leader Coach
• Building relationships is key to getting buy-in and making changes• Leader to Leader • Coach to Health Care Worker
• Many staff contribute to checklist adoption• Ayas, ASHAs• Sweepers
![Page 29: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/29.jpg)
Study Measures • Outcome measures (7 days postpartum)
• Call center• Home visits
• Practice behaviors• Observers
Monitoring and Evaluation• Implementation team
• Implementation processes• Facility adoption
• Process observation
• Facility champion-Childbirth Quality Leader
Data
![Page 30: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/30.jpg)
Sustainability
What is needed to build sustainability?
![Page 31: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/31.jpg)
![Page 32: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/32.jpg)
![Page 33: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/33.jpg)
![Page 34: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/34.jpg)
![Page 35: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/35.jpg)
Measurement
Study Measures • Outcome measures (7 days postpartum)
• Call center• Home visits
• Practice behaviors• Observers
Monitoring and Evaluation• Implementation team • Facility champion-Childbirth Quality Leader
![Page 36: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/36.jpg)
Digital Data Collection (Apps)
![Page 37: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/37.jpg)
M and EData*
Improvement in implementation
The Goal: for learning and improvementProgram management
Implementation of intervention and of research activities
*M and E data include inputs, activities, outputs and selected short term outcomes from routine program data
![Page 38: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/38.jpg)
Our intervention team’s two key tasks
• Discovering why she hadn’t followed a given practice (e.g., skin-to-skin).– Had the knowledge. – Effect seems invisible. No
thermometer.– Requires skill in persuading
mothers.
• Using consistent methods to persuade her and others to change.– Required multiple visits.– But after a relationship with
the coach was created, she changed.
![Page 39: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/39.jpg)
![Page 40: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/40.jpg)
Sustainability
Make it work there: Local adaptation and modification• GoI Checklist• Identify local owners• Identify birth team (official and unofficial)
![Page 41: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/41.jpg)
Sustainability
Don’t reinvent the wheel: Integration into existing systems
• Build on Quality Improvement systems
• Build and support local ownership
![Page 42: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/42.jpg)
Coordinating with GoI QA: Childbirth Quality Improvement Structure
NRHM – GoI
NRHM – GoUP (State QA Comm)
CMO/DHO (forms District QA Comm)Nodal officer/nurse mentor
MOIC (forms internal QA Comm)LMO, Childbirth Quality Nurse = Sr. Nurse
Nurse/ANM/Other staff
BetterBirth Team (PSI/HSPH) supplies quality/progress data
BB (COP/DCOP/HSPH) supplies data/support for problem-
solving in study sites Q3mo.
BB (DCOP/TLs/DQA/HSPH M&E) supplies data/support for problem-solving Q1mo.
BB (TLs/Nurse Coaches) supplies data/support for problem
solving Q weekly
![Page 43: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/43.jpg)
![Page 44: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/44.jpg)
The MOH of Odyssia has invited you in to direct implementation of an immunization program in an urban slum• Population unknown but estimated at
~1m souls.• Overall vaccination coverage is
estimated at ~50%. • Literacy rates: ~80% men and ~60%
women. • Local health facility has 50 beds in 4
rooms—5 nurses, 1 radiologist, 1 anesthetist, 1 traditional healer/doctor
Questions:1. What other information would be useful?2. Who do you talk with first?3. Identify the first 3 steps you would take
![Page 45: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/45.jpg)
![Page 46: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/46.jpg)
What do you do?
![Page 47: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/47.jpg)
a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers
Task ShiftingOr
Task Sharing
![Page 48: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/48.jpg)
Framework for Implementing Change
Engage Stakeholders
Make local modifications
Identify team and champions
Collect and USE data to learn and iterate
Build capacity/plan for sustainability
![Page 49: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/49.jpg)
Stakeholders
![Page 50: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/50.jpg)
Local Modifications
What factors would you consider in making local modifications? Whose input counts?
![Page 51: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/51.jpg)
Team and Champions
How do you select your team (trainers, first trainees, supervisors?)
![Page 52: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/52.jpg)
Data
How do you use it?
Why is it important?
What data do you collect?
![Page 53: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/53.jpg)
Sustainability
What is needed to build sustainability?
![Page 54: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/54.jpg)
![Page 55: Change agent or troublemaker – engaging stakeholders and making change](https://reader035.vdocuments.mx/reader035/viewer/2022081603/568134c2550346895d9be6f7/html5/thumbnails/55.jpg)