hill: crossing the implementation divide - improving quality of newborn services
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Crossing the Implementation Divide:
Improving Quality of Newborn Services
Kathleen Hill, M.D., M.P.H.
Deputy Director USAID ASSIST Project
USAID Health Care Improvement Project
University Research Co. LLC
Global Newborn Health Conference
April, 20131
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What is the Problem?
The reality is straightforward. The power of
existing interventions is not matched by the
power of health systems to deliver them to
those in greatest need, in a comprehensive
way, and at an adequate scale.
Margaret Chan
Director General
World Health Organization
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Scaling up effective coverage
Building health systems capable
of continuously improving and
sustaining quality care is essential forachieving and sustaining effective
coverage of high impact interventions
for every mother and child
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Every system is
perfectly
designed to achieve
exactly the results it
achieves
(Batalden & Stolz1993)
The Issue of Quality in Health Care
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Commercial aviation vs health care:Comparative Risks Adverse event
1:300 1:10,000,000
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How skilled are SBAs?
Harvey et al. Bulletin of the WHO, 2007
0%
25%
50%
75%
100%
Knowledge Neonatal resuscitation Manual removal of
placenta
Bimanual uterine
compression
Benin Ecuador Jamaica Kenya Nicaragua Rwanda
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A framework for continuouslyimproving quality of care
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Achieving effective coverage of impact newborn
interventions: What does it take?
INPUTS PROCESSES RESULTS
Reliable delivery of
effective
interventions
Effective organization
of care processes
Safe (not harmful)
Respectful
Mortality & morbidity
Incidence ofcomplications
Case fatality
Negative patient
experience of care
Low utilization of care
Supportive policy
Available, motivated,competent staff
Essential
commodities available
Standards & robustmeasures
HMIS
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Crossing the Implementation Divide
Improvement Principles: Understanding health care in terms ofprocesses and
systems
Team-work (all relevant actors, all system levels)
Regularmeasurement of quality measures (adherencewith standards) for action
Focus on patient needs
(client-centered)
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Regularly measuring quality ..Despite challenges it is possible
Improvement teams (e.g. DHMT, service delivery) set
improvement objectives based on high impact interventions
(content) and regularly measure prioritized content
indicators to determine whether (or not) they are meetingtheir objectives
Teams adapt medical records and registers as necessary
to measure and regularly track prioritized content indicators
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Adapting local medical records to capturequality of post-partum care: ENC & AMTSL
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Delivering integrated RMNCH packages at criticalleverage points along the RMNCH continuum(Bernadette Daelmans, WHO)
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Improving Care Where Patients Receive Care
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Improving a post-partum package of care formothers and newborns: Niger 28 maternitiesAverage 2,100 births per month
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Indicator Dec 2005(baseline)
2006 2007 JulySept
2008
% births AMTSL applied 0% 34% 98% 99.5%
% births BF within one hour 23% 44% 98% 99%
% compliance ENC standards
(composite)
17% 35% 96% 99%
% compliance AMTSL
standards (composite)
27% 51% 98% 100%
Postpartum hemorrhage
(PPH) rate (#PPH cases/#
births)
2.1% 0.6% 0.4% 0.2%
Total # births 28,937 40,510 12,284
Number of maternity facilities 28 33 39
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Accelerating effective coverage of high impactintervention packages
Multiple teams from different sites & system
levels work together intensively to test, share and
implement changes to reliably deliver high qualitycare for every patient in a common clinical or
public health area
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Shared learning accelerates implementation
QI team site
Which changesreally yield
improvements?
What changes are
robust and effective
across teams?
Collaborative coach
or manager
Site-level summaryQI team
Learning
Session
representative
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Examples of local changes in processes of careto improve integrated post-partum care formothers and newborns
Stocked bedside cooler
with pre-filled oxytocin
Regular breast feeding
support
Equipped ready
Newborn Corner
every delivery room
Regular post-partum monitoring of
mother & newborn first 24 hours
Pre-discharge physical mother &
newborn
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Synthesizing Learning: National Workshop Niger
E t di l i f Ni M li
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Training in
AMTSL and QI
LS1 + Key Niger
successful changes sharing
Coaching visitsBaselineassessment
Baseline results restitution
+ Niger EONC Collaborative
Experience sharing
Learning Session 2
Extending learning from Niger Mali:Improving ENC , 41 health centersKayes & Diema Districts, Oct 2010-Sep 2012
Percent of compliance to ENC norms in EONC collaborative target sites, Kayes
regional hospital, Kayes and Djema districts, October 2010 September 2012
O N D J F M A M J J A S O N DJ12
F M A M J J A S
# of complied criteria to norms 491 502 502 574 597 917 121 124 135 133 138 135 136 133 132 134 139 129 138 137 140 132 129 118
# of cri teria 126 126 128 131 127 136 139 142 142 141 142 137 137 133 132 135 139 129 138 137 141 132 129 124
% of compliance to ENC norms 39 40 39 44 47 67 87 88 95 94 97 99 99 100 100 99 100 100 100 100 100 100 100 96
# Sites 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 40 40 40
0
1020
30
40
50
60
70
80
90
100
% compliance toENC norms
Months21
I i dh ith PNC b t ti
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Improving adherence with PNC best practices:Herat Province Afghanistan; 9 Health Centers
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Uganda: Monthly Coaching /refresher training sessions
Masaka & Luwero Districts Uganda
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Uganda: Improving ENC & PNC, 34 MaternitiesLuwero & Masaka Districts, Nov 2010 Aug 2012
Nov10: Training MNCHdistrict coaches on ENC
Dec 10: Introduction of ENCregisters
Jun 11: TEO stock outs
Jan 12: 2nd Learningsession
Jul12: 3rd Learningsession
Feb 11: Training healthworkers in ENC
Mar 11:Training healthworkers in QI 1st Learning
session
0
20
40
60
80
100
Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12
Perc
entage
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11 Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12 Jul-12
Aug-12
% of newborns who received3 components of ENC
3 24 26 49 51 71 78 74 70 68 60 72 60 65 66 74 80 66 64 60 78 86
# of Sites Reporting 9 20 22 24 28 32 34 34 34 34 34 34 34 34 34 34 34 34 34 34 34 34
% of newborns put to thebreast within 1 hour of birth
1 18 21 34 40 47 55 59 66 59 64 73 68 73 73 79 91 75 67 63 84 88
# of Sites Reporting 8 18 21 24 28 32 34 34 34 34 34 34 34 34 34 34 34 34 34 34 34 34
% of newborns examined by skilledprovider at 4 to 7 days after birth
0 9 8 17 17 13 18 19 22 22 20 21 16 21 24 22 18 19 16 28 30 25
# of Sites Reporting 8 18 21 24 28 32 34 34 34 34 34 34 34 34 34 34 34 34 34 34 34 34
% Newborns who received 3 components of ENC, initiated early BF, and examined by a skilled provider
4-7 days after birth in 34 sites in Luwero and Masaka districts, Uganda, November, 2010 August, 2012
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Uganda: Improvement Team Meeting
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L L d E bli i t f
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Lessons Learned: Enabling environment forcontinuous Improvement
Leadership and engagement key stakeholdersessential(national, regional, district, facility, community)
High impact content is at the heart of rapidly improving
effectiveness of care
Building provider competence must be integrated as a
central component of improvement work
Initially improvement teams need support; then they become
the improvement experts
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A hi i & t i i ff ti
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Achieving & sustaining effective coverageof Best Buys..
Comprehensive improvementapproaches target all levels of a health
system to deliver and scale-up best buys
(vertical) and help strengthen health
systems (horizontal)
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Thn Thank You
Thank you