Improving Quality of Child Health Services

Using the Standards Based Management and

Recognition (SBM-R) Approach in Guinea and

Zimbabwe

Dyness Kasungami, Child Health Team Leader, JSI

Serge Raharison, Child Health Technical Officer, JSI

Presentation outline

• Introduction

• Basic principles of SBM-R

• Implementation of SBM-R

and results in Guinea &

Zimbabwe

• Discussion of findings,

recommendations and

way forward Photo source Kate Holt/MCSP and Jhpiego

Background

• Quality improvement (for child health services)

• Purpose of the review

• Inform the discussion on quality improvement of child health services

that is responsive to the unique needs of this technical area

• Identify lessons learned from applying SBM-R to child health to inform

its adaptation in countries where it is the preferred approach

• Limitations of the review

• Retrospective review

• Limited involvement of reviewers in implementation

What is SBM-R?

Child Health SBM-R in Guinea and Zimbabwe

1. Developing and validating the performance standards based on the IMNCI

algorithm

2. Training of supervisor and primary providers in case management of childhood

illness

3. Identifying performance gaps against the performance standards and

developing a plan of action to address the gaps

4. Implementing action plans and self assessments

5. Supervision and coaching of the health care workers who manage sick

children on the use of IMNCI/SBM-R standards

6. Evaluating the performance of the providers against the set IMNCI/SBM-R

standards before training (baseline assessment), and thereafter periodically

7. Recognition event

Implementation Guinea Zimbabwe

• Adopted SBM-R for MNH in 2009

and applied in 60 HFs

• CH tested in 3 urban HCs in 3

districts, over 6 months

• All had full cycle of SBM-R for MNH

• 134 standards

• Developed and implemented facility-

level action plans

• Coaching weekly over 4 weeks

• One “external” assessment

• Adopted SBM-R for MNH in 2010

and applied in 17 high-volume HFs

• CH tested in 17 + 4 rural HFs in 2

districts (Manicaland) over 3 years

• 17 HFs had full cycle of SBM-R for

MNH

• 39 (11 + 28) standards

• Developed and implemented facility-

level action plans

• A baseline & 2 “external”

assessments

Implementation Guinea Zimbabwe

• 6 standards covered (1) patient flow,

(2) equipment, (3) drugs, (4) supplies,

(5) data quality and use, and (6)

implication in community health

activities.

• The primary output measure is

“individual provider’s adherence to

the IMNCI algorithm.”

• Immediate results indicate a

remarkable improvement in

adherence to performance standards

under observation.

• No standards to improve and

monitor health systems support.

• The primary output measure is

“number of health facilities meeting

at least 60% of the performance

standards.”

• 79% of the 21 HFs met the target

over the two periodic assessments,

compared to baseline.

Results Guinea Zimbabwe

• No outcome measures

• Implementation costs for introducing

MNH standards est. at $4,200 per HF

• Adding child health performance

standards to this existing SBM-R

platform costs on average $2,400 per

HF

• MoH used IMCI as a quality

improvement approach for child

health; need to be convinced about

SBM-R

• No outcome measures

• No information on cost

• MoH adopted SBM-R

What is common about the findings?

• Weak link between strength and

duration of implementation (fidelity)

and results, esp. the lack lack of “self-

assessment results”

• Recorded improvement in “correct case

management”

• No “immediate explanation” for

improvement based on dose-response

and lack of comparison with non-SBM-

R implementing HFs

Photo source Karen Kasmauski/MCSP

Key Messages

• The implementation of the SBM-R approach in Guinea and Zimbabwe, as

documented, lacks fidelity as described in the Jhpiego SBM-R manual.

• The approach improved clinical skills of HWs and adherence to IMNCI

performance standards under observation.

• There is no information on what motivated the staff to apply the

performance standards.

• Understanding the motivating factors will help in scaling up SBM-R and

potentially other QI/PI approaches.

• The case studies do not demonstrate that this process was led by HF staff

as opposed to outsiders, i.e. supervisors.

• Lack of results on health system support implies “quality” is about HWs.

Key Messages, Continued

• Implementation of SBM-R for child health did not include outcome

measures, which is a major limitation on commenting on the success and

impact of the approach on child health indicators.

• Both case studies are based on health facilities with more than one staff

member. Adaptations also need to include applications of the approach to

low-volume/single-staff health facilities.

• The process presents the challenge of negotiating leadership for cross-

cutting areas among project partners. Implementing SBM-R depended on

specialists with their own mandates and time constraints, which left child

health officers in a weak position to lead the process, resulting in delays in

implementation.

Recommendations for QI/PI Approaches

• Any QI/PI approach should build on existing approaches to increase the

likelihood of acceptance by health workers and to leverage resources.

• Implementing partners must recognize differences in how services are

delivered for different technical areas and adapt each approach to ensure

that necessary changes are proposed to the flow of services.

• Any QI/PI approach should focus on influencing health outcomes

ultimately at minimum additional cost.

Adapting SBM-R for child health

• Standards: Focus on high-impact activities, use a manageable number of

performance standards, and apply weighting of verification criteria in an

effort to recognize gradual improvements

• Results: Define and measure improvements that focus on both processes

and health outcomes

• Implementation: Include monitoring and reporting results from self and

peer assessments as part of routine health management information

systems

Adapting SBM-R for child health

• Quality of care: include standards that reflect client perspectives on

quality

• Documentation: participatory design, structured implementation, and

process documentation in an effort to learn and decide what approaches

work in what context and why and sustainability beyond project support

• Cost/cost benefit: collecting data on both the cost of implementation

and possible cost savings resulting from increased adherence to

performance standards in pilot projects and studies

Recommendations for MCSP

• MCSP should define roles and

responsibilities for technical areas versus

leadership for cross-cutting areas (like

quality). This will clarify accountability for

quality of work and products of and

timeliness of implementation.

• MCSP should ensure that country teams

develop a single plan for implementing

activities for cross-cutting areas that

clarifies responsibilities and provides both

technical and financial capacity for

implementation.

Photo source Kate Holt/MCSP

Way Forward

• Guinea: provided feedback to influence scale-up, especially reducing number

of standards.

• Zimbabwe: under the MCHIP Associate Award, baseline assessment

should include health system support and outcomes, and better process

documentation.

Under MCSP, we are:

• Conducting a limited review of QI approaches applied to child health.

• Launched a community of practice; engage more with people in the field.

• Developing a tool with “key principles” for QI that will be adapted in each

country to build on what is in place.

Questions for discussion?

• What model of quality

improvement works best for

weak health systems?

• How can we create a balance

between project investment to

achieve short term results versus

long term sustainability?

Photo source Karen Kasmauski/MCSP

Thank you!

For more information, please visit

www.mcsprogram.org

This presentation was made possible by the generous support of the American people through the

United States Agency for International Development (USAID), under the terms of the Cooperative

Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not

necessarily reflect the views of USAID or the United States Government.

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