Download - Dr. Nigel Livesley, USAID ASSIST Project
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Making changes in the health facility: skills for improving the care of mothers and
babies
Nigel Livesley, MD, MPH
India Project Director USAID ASSIST Project
South Asia Regional Director University Research Co.
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USAID Applying Science to Strengthen and Improve Systems
Three useful ideas
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USAID Applying Science to Strengthen and Improve Systems
Degrees of implementation (Fixsen DL et al 2005)
Paper implementation The new idea remains in paper form
Process implementation The superficial processes associated with a new idea are
put in place
Performance implementation The new idea actually leads to improved benefit
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USAID Applying Science to Strengthen and Improve Systems
Degrees of implementation (Fixsen DL et al 2005)
Paper implementation The new idea remains in paper form
Guidelines and standards
Process implementation The superficial processes associated with a new idea are
put in place People are trained Monitoring of quality of care
Performance implementation The new idea actually leads to improved benefit
Decreased mortality and morbidity
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USAID Applying Science to Strengthen and Improve Systems
Degrees of implementation (Fixsen DL et al 2005)
Paper implementation (90% of efforts) The new idea remains in paper form
Process implementation The superficial processes associated with a new idea are
put in place
Performance implementation The new idea actually leads to improved benefit
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USAID Applying Science to Strengthen and Improve Systems
Improving health service delivery organisational performance in health systems. Pallas et al. International Health 4 (2012) 2029
Leadership and management (supervision)
Organisational structure Standards and guidelines
(accreditation) Knowledge and skills enhancement Incentives Process re-engineering Organisational culture
PresenterPresentation NotesTo highlight that there are many ways to improve quality of care. Talk about how we focus a lot on the first column, not so much on the 2nd but that the 2nd is also important.
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USAID Applying Science to Strengthen and Improve Systems
People mean different things when they say quality improvement
1. Management approach for front line workers to improve processes (Juran)
2. Organizational development approach based on systems and complexity theory (Deming)
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USAID Applying Science to Strengthen and Improve Systems
People mean different things when they say quality improvement
1. Management approach for front line workers to improve processes (Juran)
2. Organizational development approach based on systems and complexity theory (Deming)
3. Specific interventions that come out of definition 1
4. Quality assurance=quality improvement 5. Anything that can improve quality of care
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USAID Applying Science to Strengthen and Improve Systems
Implementation at a single facility Focusing on what didnt work Lessons for implementation
Implementation at large scale ASSIST overview Selected results
Integrating into existing government systems Chamba district, India General approach
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USAID Applying Science to Strengthen and Improve Systems
Maternal mortality in a Delhi hospital in 2013 5854 deliveries
Pt. Age of the patient
Time of death after delivery
Cause
1. 22 96 hrs PPH
2. 20 20 hrs PPH
3. 21 6 hrs PPH
4. 22 4 hrs PIH
5. 21 24 hrs PPH
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USAID Applying Science to Strengthen and Improve Systems
Women assessed only twice in six hours after delivery
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Average number of times vitals recorded within first 6 hrs of birth
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USAID Applying Science to Strengthen and Improve Systems
What changes could the team make?
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USAID Applying Science to Strengthen and Improve Systems
How can higher levels support change?
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USAID Applying Science to Strengthen and Improve Systems
First idea: management directive
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Average number of times vitals recorded within first 6 hrs of birth
Change idea: Letter from medical superintendent instructing labour and delivery room staff to assess women 6 times in the first 6 hours. Week 4, January 2014
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USAID Applying Science to Strengthen and Improve Systems
Success!
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Average number of times vitals recorded within first 6 hrs of birth
Letter from superintendent Week 4, January 2014
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USAID Applying Science to Strengthen and Improve Systems
Success! Or is it?
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Average number of times vitals recorded within first 6 hrs of birth
Massive overcrowding in labour room
Tools: Leadership Standards Incentives
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USAID Applying Science to Strengthen and Improve Systems
What feedback should you give to the team?
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USAID Applying Science to Strengthen and Improve Systems
Success! Or is it?
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Average number of times vitals recorded within first 6 hrs of birth
Massive overcrowding No action to address crowding for 1 week
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USAID Applying Science to Strengthen and Improve Systems
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Average number of times vitals recorded within first 6 hrs of birth
A Letter from the Boss doesnt affect systemic issues
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USAID Applying Science to Strengthen and Improve Systems
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Average number of times vitals recorded within first 6 hrs of birth
A Letter from the Boss doesnt affect systemic issues
Not testing the letter led to a week of problems
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USAID Applying Science to Strengthen and Improve Systems
Addressing overcrowding
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Average number of times vitals recorded within first 6 hrs of birth
Clarified that women should be discharged to ward Made some changes in efficiency of assessment
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USAID Applying Science to Strengthen and Improve Systems
Sustained improvement!
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Average number of times vitals recorded within first 6 hrs of birth
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USAID Applying Science to Strengthen and Improve Systems
What feedback should you give to the team?
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USAID Applying Science to Strengthen and Improve Systems
Sustained improvement! Or is it?
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Average number of times vitals recorded within first 6 hrs of birth
What are we trying to accomplish?
Doing assessments or identifying and managing women in danger?
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USAID Applying Science to Strengthen and Improve Systems
0.16% of women identified with complications
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Number of women with danger signs identified in PNC ward
Average number of times vitals recorded within first 6 hrs of birth
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USAID Applying Science to Strengthen and Improve Systems
0.16% of women identified with complications
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Number of women with danger signs identified in PNC ward
Average number of times vitals recorded within first 6 hrs of birth
Lots of change in assessment; not much improvement in care
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USAID Applying Science to Strengthen and Improve Systems
What feedback should you give to the team?
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USAID Applying Science to Strengthen and Improve Systems
What changes could the team make?
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USAID Applying Science to Strengthen and Improve Systems
How can higher levels support change?
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USAID Applying Science to Strengthen and Improve Systems
Improving ability to identify and management women with complications
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Number of women with danger signs identified in PNC ward
Average number of times vitals recorded within first 6 hrs of birth
What the team did differently:
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USAID Applying Science to Strengthen and Improve Systems
Improving ability to identify and management women with complications
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Number of women with danger signs identified in PNC ward
Average number of times vitals recorded within first 6 hrs of birth
What the team did differently: Identified the root cause of
poor assessment
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USAID Applying Science to Strengthen and Improve Systems
Improving ability to identify and management women with complications
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Number of women with danger signs identified in PNC ward
Average number of times vitals recorded within first 6 hrs of birth
What the team did differently: Identified the root cause of
poor assessment Used small scale tests to
learn what works
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USAID Applying Science to Strengthen and Improve Systems
Improving ability to identify and management women with complications
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Number of women with danger signs identified in PNC ward
Average number of times vitals recorded within first 6 hrs of birth
What the team did differently: Identified the root cause of
poor assessment Used small scale tests to
learn what works Focused on the aim
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USAID Applying Science to Strengthen and Improve Systems
Women with complications are now 12 times more likely to be identified early
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Number of women with danger signs identified in PNC ward
Average number of times vitals recorded within first 6 hrs of birth
New system of care Observation room Partnering with patients
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USAID Applying Science to Strengthen and Improve Systems
Sustained improvement and NO MATERNAL DEATHS in post partum ward
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% of women identified withcomplications and managedappropriately
number of times women were assessed in first 6 hours
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USAID Applying Science to Strengthen and Improve Systems
Sustained improvement and NO MATERNAL DEATHS in post partum ward
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% of women identified withcomplications and managedappropriately
number of times women were assessed in first 6 hours
Tools: Leadership Standards Incentives Process redesign Organizational culture
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USAID Applying Science to Strengthen and Improve Systems
Lessons learned
1. Standards and instructions from management dont fix all problems
2. Small scale testing is necessary for solving some problems
3. Focus on the right aim 1. so what?
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USAID Applying Science to Strengthen and Improve Systems
General principles for problem solving
Subject knowledge
Context knowledge
Change method
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USAID Applying Science to Strengthen and Improve Systems
ASSIST overview
USAID Applying Science to Strengthen and Improve Systems (ASSIST) is a five-year project of the Office of Health Systems of the USAID Global Health Bureau designed to: Improve health and social services at scale Strengthen host country capacity to improve care Learn and share knowledge about improvement
globally
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USAID Applying Science to Strengthen and Improve Systems
ASSIST has worked in 24 countries
PresenterPresentation NotesRashad
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USAID Applying Science to Strengthen and Improve Systems
Scale of USAID ASSIST Activities, FY13-FY14
4,339 facility based improvement teams
994 community based improvement teams
222 government and implementing partners
124 million catchment population
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USAID Applying Science to Strengthen and Improve Systems
ASSIST India
349 improvement teams
12-17,000 deliveries per month 30% of deliveries in 27 High Priority Districts
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USAID Applying Science to Strengthen and Improve Systems
If ASSIST-supported sites in India were their own country, they would rank 88th out of 180 countries in the world in total deliveries, just behind Azerbaijan and the Netherlands
109 110 110 113 116 117 118
123 126
131 137 138 140
144 145
154 156 156 157 158
179 180 181 184
193 194
Turkmenistan
Cuba
Serbia
Sweden
Czech Republic
Greece
Mauritania
Belgium
El Salvador
Kyrgyzstan
State of Palestine
Nicaragua
Lao People's Democratic Republic
Libya
Congo
Jordan
Central African Republic
Israel
Liberia
Paraguay
Tunisia
ASSIST India supported sites
Netherlands
Azerbaijan
Eritrea
Tajikistan
Births per country in 2010 (1000s of births)
ASSIST India supported sites
PresenterPresentation NotesNigel
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USAID Applying Science to Strengthen and Improve Systems
What we do
Support team-based problem solving at facility and community level
Support peer-to-peer learning between networks of teams
Support government to incorporate these approaches into their systems
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USAID Applying Science to Strengthen and Improve Systems
Seven steps to support team-based problem solving
Decide what problem you want to fix Get a team together to fix it Identify the causes of the problem Develop a simple measurement system Come up with some possible solutions Test the solutions on a small scale Implement the effective solutions
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USAID Applying Science to Strengthen and Improve Systems
Support networks between teams based on peer-to-peer learning
QI team
site
Site-level summary QI team
LearningSession
representative
Site-level testing of changes and analysis of results
QI team
site
QI team
site
QI team
site
QI team
site
QI team
siteQI team
site
QI team
site
Collaborative-level sharing and synthesis of best practices
QI team
site
QI team
site
Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care
PresenterPresentation NotesA variation of modern QI is what we call collaborative improvementthat builds on the efforts of individual QI teams but links them in important ways that heighten the impact of their efforts. This approach was originally developed by the Institute for Healthcare Improvement about 15 years ago and has been used extensively in the US and other developed countries. How does it work? Just like the Uganda team example, it starts with individual teams testing changes and analyzing their results (using time series charts to assess whether their changes led to improvement). But now other teams are also working on the same issues at the same timeThese teams get together periodically to share their changes and results so they can learn from each other. This periodic sharing, known as learning sessions, also has the effect of inducing teams to compete against each other in a friendly way to get the best resultsFor the collaborative as a whole, the results are validated, consolidated and synthesized. This facilitates rapid gains across all teams because the consolidation of best practices out of the work of all teams helps all teams to move forward, faster.So, collaborative improvement is simply multiple teams simultaneously testing changes, using common indicators and peer learning about what are the most effective changes to improve the same area of care.
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USAID Applying Science to Strengthen and Improve Systems
Continuum of care
District Hospital
Community Health Centre
Primary Health Centre
Sub-centre
Community
- Active management of 3rd stage of labor - Essential newborn care - Improving ANC - Improving PNC
- Improving ANC (BP, Hb, weight, counseling) - Early registration - Identification of danger signs - Identification of severe anemia - Promotion of institutional delivery
- Management of anemia - Neonatal resuscitation - PPH management - Management of pre/ -- eclampsia - Prevention and control of infection - Other
Routine care Complication care
Aims
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USAID Applying Science to Strengthen and Improve Systems
Improving routine care for over 15 000 pregnancies and deliveries per month
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Oxytocin
Vitamin K
Hb checked
Newborns breastfed in first hour
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USAID Applying Science to Strengthen and Improve Systems
Improving routine care for over 15 000 pregnancies and deliveries per month
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Oxytocin
Vitamin K
Hb checked
Newborns breastfed in first hour
Tools used: - Standards - Process re-engineering - Culture change
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USAID Applying Science to Strengthen and Improve Systems
Improvement in recording and drug management
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Refrigerator Room temp Oxytocine
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USAID Applying Science to Strengthen and Improve Systems
Improved organization and cleanliness
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After building improvement skills on routine care, teams
move on to complications care
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USAID Applying Science to Strengthen and Improve Systems
Delivering baby on mothers abdomen
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Immediate drying11,11
Delayed cord clamping0,9
Sterile cord clamping11,11
Avoid prelacteals11,11
Breast feeding within 1 hourof birth
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Inj. Vit K to all newborns10,10
Kangaroo Mother Care0,0
No. of Facilities practising before training
Practice of ENC in 11 facilities in Delhi
PresenterPresentation NotesBefore= Yellow/ black+orange glow, with leader linesAfter = White box+red font, without leader linesSame for before and after yellow box with red font with glow
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USAID Applying Science to Strengthen and Improve Systems
Delivering baby on mothers abdomen
1,9
Immediate drying11,11
Delayed cord clamping0,9
Sterile cord clamping11,11
Avoid prelacteals11,11
Breast feeding within 1 hourof birth
9,11
Inj. Vit K to all newborns10,10
Kangaroo Mother Care0,0
No. of Facilities practising before training
No. of facilities practising after 1 month
Improvement after mentorship/process improvement support
PresenterPresentation NotesBefore= Yellow/ black+orange glow, with leader linesAfter = White box+red font, without leader linesSame for before and after yellow box with red font with glow
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USAID Applying Science to Strengthen and Improve Systems
Delivering baby on mothers abdomen
1,9
Immediate drying11,11
Delayed cord clamping0,9
Sterile cord clamping11,11
Avoid prelacteals11,11
Breast feeding within 1 hourof birth
9,11
Inj. Vit K to all newborns10,10
Kangaroo Mother Care0,0
No. of Facilities practising before training
No. of facilities practising after 1 month
Tools used: - Skills building - Process re-
engineering - Culture change
Tools for improvement
PresenterPresentation NotesBefore= Yellow/ black+orange glow, with leader linesAfter = White box+red font, without leader linesSame for before and after yellow box with red font with glow
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USAID Applying Science to Strengthen and Improve Systems
Availability of mucous suckers6.9
Availability of masks & bag11,11
Ready to use masks & bag5,9
Tubing for Oxygen10,11
Oxygen source8,11
Functional NB care unit11,11
Use of NB care unit10,9
Practice of checking beforeevery delivery
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Practice of cleaning/disinfectingafter every use
1,9
No. of facilities having before training
NR equipment readiness
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USAID Applying Science to Strengthen and Improve Systems
Availability of mucous suckers6.9
Availability of masks & bag11,11
Ready to use masks & bag5,9
Tubing for Oxygen10,11
Oxygen source8,11
Functional NB care unit11,11
Use of NB care unit10,9
Practice of checking beforeevery delivery
0,4
Practice of cleaning/disinfectingafter every use
1,9
No. of facilities having before training No. of facilities having 1 month after training
Tools used: - Skills building - Process re-
engineering - Culture change
Improvement after mentorship/process improvement support
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USAID Applying Science to Strengthen and Improve Systems
Perinatal mortality all ASSIST supported sites 10 000 15 000 deliveries per month
Baseline mortality 2.35% Current mortality 2.07%
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Transfer of improvement skills into government
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USAID Applying Science to Strengthen and Improve Systems
India: Timeline of activities in Chamba District
In December 2013, ASSIST supported 5 facilities in Chamba to set up QI teams
In May 2014, the District Chief Medical Officer requested ASSIST support the rest of the district
They began to achieve some impressive results
Impressive!
Nov 2013
Dec 2013
Jan 2014
Feb 2014
Mar 2014
Apr 2014
May 2014
PresenterPresentation NotesTESSIE
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USAID Applying Science to Strengthen and Improve Systems
Timeline of activities in Chamba District
May 2014 Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014
In September 2014, ASSIST trained 38 new facilities and 10 government coaches
Going forward
Coaches will provide on-site coaching support to facilities
2 Block Medical Officers will oversee the work
Improvement reports will be included in monthly district meetings
District will organize quarterly peer-to-peer learning sessions
These 43 facilities cover 35% of the births in this district of 540,000 people
In July and August 2014, ASSIST worked with the district to plan scale up of activities.
ASSIST MOHFW
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USAID Applying Science to Strengthen and Improve Systems
37 of 38 facilities supported by government coaches collecting and reporting data and showing initial signs of improvement
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Iron supplementation
Oxytocin at delivery
>2gm inc in Hb
ANC Hx and Px
PresenterPresentation NotesTESSIE
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USAID Applying Science to Strengthen and Improve Systems
General principles of setting up a system for quality improvement
Facility and community-based improvement teams
Team support system Leadership component
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USAID Applying Science to Strengthen and Improve Systems
General principles of setting up a system for quality improvement
Facility and community-based improvement teams Team-based QI ID problems that need to be solved at other levels
Team support system Leadership component
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USAID Applying Science to Strengthen and Improve Systems
General principles of setting up a system for quality improvement
Facility and community-based improvement teams Team-based QI ID problems that need to be solved at other levels
Team support system Support QI skills development Spread good ideas between teams Support multi-level problem solving
Leadership component
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USAID Applying Science to Strengthen and Improve Systems
General principles of setting up a system for quality improvement
Facility and community-based improvement teams Team-based QI ID problems that need to be solved at other levels
Team support system Support QI skills development Spread good ideas between teams Support multi-level problem solving
Leadership component Set goals Encourage problem identification and solving Fix problems at their level Encourage learning
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USAID Applying Science to Strengthen and Improve Systems
For more information and resources please visit:
www.usaidassist.org
Or contact
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USAID Applying Science to Strengthen and Improve Systems
Baseline perinatal mortality in Jama CHC Dumka District, Jharkhand
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USAID Applying Science to Strengthen and Improve Systems
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Improvement team working on neonatal resuscitation and partograms
Changes in perinatal mortality in Jama CHC, Dumka District, Jharkhand
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USAID Applying Science to Strengthen and Improve Systems
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Improvement team working on neonatal resuscitation and partograms
Changes in perinatal mortality in Jama CHC, Dumka District, Jharkhand
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USAID Applying Science to Strengthen and Improve Systems
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deaths in hosp deaths in ref
Improvement team working on neonatal resuscitation and partograms
Baseline 2.4% babies died in hospital 2.4% babies died after referral
After improvement work 1.7% babies died in hospital 1.0% babies died after referral
Perinatal mortality including when mothers and babies are referred to other facilities
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USAID Applying Science to Strengthen and Improve Systems
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Improvement team working on neonatal resuscitation and partograms
Baseline mortality 4.8% Intervention mortality 2.7%
Improved management and decreased referrals of moribund babies
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USAID Applying Science to Strengthen and Improve Systems
How does performance compare between facilities with improvement aims and those without improvement aims?
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Teams NOT TRYING to improve Hb measurement
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USAID Applying Science to Strengthen and Improve Systems
Women attending clinics which are aiming to improve Hb measurement are now more likely to get their Hb measured
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100%
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14
Teams TRYING to improve Hb measurement
Teams NOT TRYING to improve Hb measurement
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USAID Applying Science to Strengthen and Improve Systems
Antenatal care in Mandi, Himachal Pradesh
020406080
100
W-1
W-2
W-3
W-4
W-1
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W-3
W-4
W-1
W-2
W-3
W-4
W-1
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W-3
W-4
W-5
W-1
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W-4
W-1
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W-3
W-4
W-1
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W-4
W-5
W-1
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W-3
W-1
W-2
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Denominator: Number of ANCs conducted per week in Mandi, Himachel Pradesh (average = 45.6)
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USAID Applying Science to Strengthen and Improve Systems
Antenatal care in Mandi, Himachal Pradesh
020406080
100
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W-4
W-1
W-2
W-3
W-4
W-1
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W-4
W-1
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W-3
W-4
W-5
W-1
W-2
W-3
W-4
W-1
W-2
W-3
W-4
W-1
W-2
W-3
W-4
W-5
W-1
W-2
W-3
W-1
W-2
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Denominator: Number of ANCs conducted per week in Mandi, Himachel Pradesh (average = 45.6)
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100%
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Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Percentage of ANCs during which BP and Hb were measured in Mandi, Himachal Pradesh, July 2013-March 2014
% BP measured
% Hb measured
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USAID Applying Science to Strengthen and Improve Systems
Mandi, Himachal Pradesh case study
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12
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100%
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Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Number of high-risk pregnancies identified and percentage of ANCs during which BP and Hb were measured in Mandi, Himachel Pradesh
# high-risk identified % BP measured % Hb measured
18 high-risk pregnancies identified (1.4%)
39 high-risk pregnancies identified (12.3%)
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12
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W-1
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W-1
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Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Number of high-risk pregnancies identified and percentage of ANCs during which BP and Hb were measured in Mandi, Himachel Pradesh
# high-risk identified % BP measured % Hb measured
0
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12
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W-1
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W-4
W-1
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W-3
W-4
W-5
W-1
W-2
W-3
W-1
W-2
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Number of high-risk pregnancies identified and percentage of ANCs during which BP and Hb were measured in Mandi, Himachel Pradesh
# high-risk identified % BP measured % Hb measured
Making changes in the health facility: skills for improving the care of mothers and babiesNigel Livesley, MD, MPHIndia Project DirectorUSAID ASSIST Project South Asia Regional DirectorUniversity Research Co.Slide Number 2Degrees of implementation(Fixsen DL et al 2005)Degrees of implementation(Fixsen DL et al 2005)Degrees of implementation(Fixsen DL et al 2005)Improving health service delivery organisational performance in health systems.Pallas et al. International Health 4 (2012) 2029People mean different things when they say quality improvementPeople mean different things when they say quality improvementSlide Number 9Maternal mortality in a Delhi hospital in 20135854 deliveriesWomen assessed only twice in six hours after deliveryWhat changes could the team make?How can higher levels support change?First idea: management directiveSuccess! Success! Or is it? What feedback should you give to the team?Success! Or is it? Slide Number 19Slide Number 20Addressing overcrowdingSustained improvement! What feedback should you give to the team?Sustained improvement! Or is it? 0.16% of women identified with complications0.16% of women identified with complicationsWhat feedback should you give to the team?What changes could the team make?How can higher levels support change?Improving ability to identify and management women with complicationsImproving ability to identify and management women with complicationsImproving ability to identify and management women with complicationsImproving ability to identify and management women with complicationsWomen with complications are now 12 times more likely to be identified earlySustained improvement and NO MATERNAL DEATHS in post partum wardSustained improvement and NO MATERNAL DEATHS in post partum wardLessons learnedGeneral principles for problem solvingASSIST overviewASSIST has worked in 24 countriesScale of USAID ASSIST Activities, FY13-FY14ASSIST IndiaSlide Number 43What we doSeven steps to support team-based problem solvingSupport networks between teams based on peer-to-peer learningContinuum of care Improving routine care for over 15 000 pregnancies and deliveries per monthImproving routine care for over 15 000 pregnancies and deliveries per monthImprovement in recording and drug management Improved organization and cleanlinessAfter building improvement skills on routine care, teams move on to complications careSlide Number 53Slide Number 54Slide Number 55Slide Number 56Slide Number 57Perinatal mortality all ASSIST supported sites10 000 15 000 deliveries per monthTransfer of improvement skills into government systemsIndia: Timeline of activities in Chamba DistrictTimeline of activities in Chamba District37 of 38 facilities supported by government coaches collecting and reporting data and showing initial signs of improvementGeneral principles of setting up a system for quality improvementGeneral principles of setting up a system for quality improvementGeneral principles of setting up a system for quality improvementGeneral principles of setting up a system for quality improvementSlide Number 67Baseline perinatal mortality in Jama CHCDumka District, JharkhandChanges in perinatal mortality in Jama CHC, Dumka District, JharkhandChanges in perinatal mortality in Jama CHC, Dumka District, JharkhandPerinatal mortality including when mothers and babies are referred to other facilitiesImproved management and decreased referrals of moribund babiesHow does performance compare between facilities with improvement aims and those without improvement aims?Women attending clinics which are aiming to improve Hb measurement are now more likely to get their Hb measuredAntenatal care in Mandi, Himachal PradeshAntenatal care in Mandi, Himachal PradeshMandi, Himachal Pradesh case study