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IMPLEMENTATIONOFESSENTIALNEWBORNCARE
EssentialNewbornCare:Implementation
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INTRODUCTONANDOUTLINE 4
STEP1:SETUPATEAM 7
LEADERSHIPFORTHEPROCESSANDPLANNING 7COREGROUPFORIMPLEMENTATION 8DEVELOPINGAVISIONFORNEWBORNCARE 8ADVOCACYFORACTION 9
STEP2:ASSESSTHESITUATION 10
ADAPTINGNORMSANDSTANDARDS 10DEVELOPTOOLSANDAPROGRAMMETOASSESSTHESITUATION 11COMPILETHEDATAANDUNDERTAKEADVOCACY 14
STEP3:DEVELOPANACTIONPLAN 15
DETERMINEYOUROVERALLAIM 15SETPRIORITIESANDDEVELOPAPHASEDACTIONPLAN 15
STEP4IMPLEMENTACTIONPLAN 18
1.SYSTEMSTRENGTHENING 19COMMUNITYADVOCACY 19WARDSETUPANDPROCESSES 19STAFFAVAILABILITY/ROTATION 20EQUIPMENT 20TRANSFERANDREFERRAL 21SUPPORTSERVICES 212.STRENGTHENSKILLSTOIMPLEMENTSTANDARDGUIDELINESANDPROTOCOLS 212.1REVIEWEXISTINGGUIDELINESANDSTANDINGORDERSWITHKEYUSERS 212.2.ASSESSKEYBARRIERSTOIMPLEMENTATIONOFSTANDARDCARE 212.3ASSESSTRAININGNEEDS 222.4IMPLEMENTTRAINING 25HELPINGBABIESBREATH(HBB) 26LINCTRAINING 27PERINATALEDUCATIONPROGRAMME(PEP) 29NEONATALEXPERIENTIALLEARNING 30NEWBORNICUTRAINING 30IMPLEMENTPRE-SERVICETRAINING 30CLINICALMENTORING 303.MONITORINGANDAUDIT 30SUPPORTIVESUPERVISION 31CLINICALAUDITANDQUALITYOFPATIENTCARE 31PERINATALANDNEONATALMORTALITYANDPERINATALREVIEWMEETINGS 32ABOUTPPIPFROM(WWW.PPIP.CO.ZA) 32NEONATALMORBIDITYANDSERVICES 33
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STEP5TRACKPROGRESSANDUNDERTAKEACCREDITATIONASSESSMENTS 34
PROCESSINDICATORS 36OUTPUTINDICATORS 36OUTCOMEINDICATORS 36IMPACTINDICATORS 37ACCREDITATION 38
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INTRODUCTONANDOUTLINE
Improvingnewborncareinyourfacility,districtandprovince,requireschangeagentsandleaderswhohavethevision,dedicationanddeterminationtonurturetheimplementationofessentialnewborncare.Thecommitmentofmanagementisakeyfactorformobilisingthenecessaryresources.
Theintendedpurposeofintroducingessentialnewborncareistoensurethattherearecompetentmaternalandneonatalhealthcareproviderswhoareabletoprovideappropriatenewborncareservicesinawell-functioninghealthsystem.
Onceavisionofthedesiredservicehasbeendevelopedthesituationassessmentwillhelptoidentifywhatneedstobedone.IdentifysmallbutsignificantactivitiesyoucandoNOWwhilstplanningandmobilisingresourcesformediumandlongterminterventions.
FivestepstoachievingessentialnewborncareareoutlinedbelowtogetherwithsuggestionsfromtheexperienceoftheLINCteamandotherswhohavebeenworkingtoimprovenewborncare.Weencourageyoutoadaptthetoolsandideasprovidedordevelopyourownandstartimprovingnewborncare.Wetrustourexperiencewillbeusefultoyou.
Thestepsforimprovementaresummarisedintable1
Step1:Setupateam
Step2:Assessthesituation
Step3:Developanactionplan
Step4:Implementtheactionplanthrough
Strengtheningthehealthcareenvironment
Strengtheninghealthworkercompetencies
Step5:Trackprogressandundertakeaccreditationassessments
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LEVELOFIMPLEMENTATION
Singlefacility Districtlevel Provinciallevelandabove
Step1:SetupateamLeadershipforprocessandplanning
Focalperson,toworkwithamedicalornursingmanagementtoleadtheprocessandplanning
District/regionalpaediatricianinplacetoprovideleadership
Provincetoappointaleadpaediatricianandneonatalnursetoleadtheprocess
Coregroupforimplementation
Involvecoreroleplayerstoimplement,nursingandclinicalmanager,responsiblematernityandpaediatricdoctorsandnurses
Regionalpaediatricianandneonatalnursetoworkwithdistrictmanagerstofromcoregroup
Developacoregroupofprovincialpaediatricians,neonatalnurses,managersandexternalexpertstoleadtheprocess.Appointateamofassessorsandaccreditors
Developingavisionfornewborncare
Developavisionforhownewborncareshouldbebysharingideas,visitingothersites
Districttodevelopasharedvision,byworkshops,visits,benchmarking
Developasharedvisionbylisteningtoall,visiting,benchmarking
Advocacyforaction
Sharethevisiontocreateawarenessofneedforchange
Advocatetoallrelevantroleplayersforchange
Advocatetoheadofhealth,hospitalmanagers,etcAdvocateforfinancialandhumanresources
Step2:AssessthesituationAdaptingnormsandstandards
Reviewavailablenationalandprovincialnormsandstandardsandrevisethembasedonvisionfornewborncare
Developtoolsandprocesstoassessthesituation
Toolforself-assessmentandarrangeforexternalassessment
Basedonnormsandstandardsdeveloptoolsandarrangetoassesnewborncareinstages,adaptLINC,
WHOorSNLtools
Currentstatusofbirths,admissionsanddeaths
Birthsinclinics,hospitalandathome,LBWrates,admission,deathsandcauseofdeath
Fordistrictandprovincereviewbirths,LBWrate,admissions,deaths,causeofdeathtohavebaseline
ofsituationandpriorityareasforintervention
Assesstheservicesandfacilities
ServicesandfacilitiesforResuscitation,Routinecareandcareofsickandsmallnewborns
Assessallservicesandfacilitiesandequipmentateachdistrictandprovincialfacility.Reviewcurrentprovincialplansforfacilityimprovementandup-
grading
Assessthestaffingandstaffdevelopment
Assessstaffing,rotationandcompetencies
Assessandcomparestaffingatfacilities.Determineno.ofNeonaalnursesandpaediatriciansrequired.Assesspre-serviceneonataltrainingandadvanced
neonataltrainingAssessthequalityofcareprovided
Doacareauditbasedonstandardguidelines
Arrangearecordrevieworcareassessmentonkeyconditionsonasampleofrecords
Compilethedataandundertakeadvocacy
Compilethedataateachstepandundertakeadvocacyforchange
Compileanddeterminedataandundertakeadvocacyforchange
Steps3:DevelopanactionplanSetprioritiesanddevelopaphasedactionplan
Developanactionplan;prioritiseactivitiestoimmediateactions,mediumandlongtermaction.
Setuppriorities,andputinplaceimmediateactions,andthenaplanformediumandlongtermwork
Determineprioritiesandensuresupportforshorttermplanswhilstworkingonlongtermplanse.gupgradingfacilities
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Steps4:Implementtheactionplan1.Strengtheningthehealthcareenvironment
Wardsetupandprocesses
Re-arrangewardsandfacilitiestocreatesuitableNNU
Mobiliseresourcesforrefurbishmentandestablishmentofregionalhospitalneonatalunits
DrawupplansfortheservicesInpatientnewborn
careunitSetupNNU,withguidelinesandjobaids
Developprovincialrecords,setupprovincialstandardsforNNU
KMCunit Re-arrangeandorganiseKMC
ProvincialstandardforKMC
Attimeofbirth Organiseservice Ensurefacilitiesandequipmentforneonatalresuscitation
Routinecare Putpoliciesinplace Policiesinplaceforroominginandcaringforwellbabies
Staffing,equipment Shiftandretainstaffanddon’trotatestaff
Determinenormsforstaffingandequipmentandmobiliseresourcestoachievenorms.
Referralandtransport
Strengthenneonataltransport
Provincialneonatalambulanceservice
2.Strengthenhealthworkercompetencies
Reviewguidelines Reviewguidelinesandstandingorders
Reviewprovincialguidelinesforroutinecareandcareoftheandsickbabycare
Assesskeybarrierstoimplementation
Assesskeybarrierstoimplementation
Assessbarrierstoimplementation
Teamsfacilitatesremovalofbarriers
Assesstrainingneeds Assessneeds
Assessprovincialtrainingneeds,andidentifyresourcesfortraining
Implementtrainingifneeded
StartwithHBBandin-servicetraining
Developprovincialanddistricttrainingcapacityofin-serviceandpre-servicetraining
Clinicalsupervisionandaudit
Commencesupervision Developsupervisionandaudittools
Onsitefacilitation,mentoring
Workwithonesitefacilitatorsandmentors
RegionalPaediatriciantovisitdistrictfacilities
Putinplacedistrictteams
Step5:Trackprogressandundertakeaccreditationassessments
Inputs Humanandfinancialresources
Districtteaminplace Numberofdistrictteams,regionalandtertiaryhumanresources
Process AdvocacyActionplans
ActionPlansTeamsinplaceVisitstofacilitiesEquipmentandfacilityneedsidentified
EquipmentneedsTransportneedsTrainingneeds
Outputs NormsandstandardsGuidelinesToolsusedNumberofhealthworkerstrained
NormsandstandardsTrainingsconductedReferralandtransportpoliciesNeonatalambulanceinplace
Provincialjobaids
Outcome FacilitiesaccreditedfornewborncareWellequippedandstaffedfacilitiesDateproperlycollected
QualityoftrainingNooffacilitiesaccreditedReferralpatternsAmbulanceresponsetimes
Accreditation
Impact NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates
NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates
NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates
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STEP1:SETUPATEAM
Setupateamintheprovince,ineachdistrictandeachfacilitywithresponsibilityfortheimplementationofessentialnewborncare.
LEVELOFIMPLEMENTATION
Singlefacility Districtlevel Provinciallevelandabove
Step1:SetupateamLeadershipfortheprocessandplanning
Focalpersontoworkwithmedicalandnursingmanagementandtoleadtheprocessandplanning
District/regionalpaediatricianinplacetoprovideleadership
Provincetoappointaleadpaediatricianandneonatalnursetoleadtheprocess
Coregroupforimplementation
Engagewithhospitalstaffwhoarekeytoimplementation.Nursingmanagerandclinicalmanager,responsiblematernityandpaediatricdoctorsandnurses
Regionalpaediatricianandneonatalnursetoworkwithdistrictmanagerstoformacoregroupatdistrictlevel
Developacoregroupofprovincialpaediatricians,neonatalnurses,managersandexternalexpertstoleadtheprocess.Appointateamofassessorsandaccreditors
Developingavisionfornewborncare
Developavisionforhownewborncareshouldbeprovidedbysharingideas,visitingothersites
Districttodevelopasharedvision,byworkshops,visits,benchmarking
Developasharedvisionbylisteningtoall,visiting,benchmarking
Advocacyforaction
Sharethevisionwithabroadergroupinthefacilitytocreateawarenessofneedforchange
Advocatetheneedforchangetoallrelevantroleplayers
Advocatetoheadofhealth,hospitalmanagers,etcAdvocateforfinancialandhumanresources
LEADERSHIPFORTHEPROCESSANDPLANNING
Healthsystemsarecomplexandthereareinstitutionalcultures*aswellasindividualculturesandbarrierstonavigateuntiltheinstitutionadoptsacultureofchange.Acultureofchangeexistswhenthekeyplayersintheenvironmentareopentonewpossibilitiestoimprovepatientcare.Peoplebegintothinkmorecreativelyaboutapparentinsurmountablebarriers.(*Acultureistheattitudeandbehaviourthatarecharacteristicofaparticulargroupororganisation.)
Onsitefacilitationbyvisitinghealthworkerscanprovidethenecessaryleadershipandtechnicalexpertisetodistricthospitalsthatdonotusuallyhavespecialistsorspecialistnursesontheirstaffestablishment.Thesefacilitatorsshouldideallybemembersofadistrictspecialistteam,whoarechosentobethedriversofchange.Inadditiontotechnicalexpertiseinneonatalclinicalcareandhealthsystemdevelopmenttheymustshowleadershipskills.Thefacilitatormustinvigoratemomentumandhelptheteamtoattempttomeetthetimelines.Whenprogressisslowandfrustrationordespondencythreatentosetinthefacilitatormustmaintainthemoraleoftheteam.Ideallythefacilitatorshouldidentifyanindividualinmanagement(theCEOorclinicalmanager,ornursingmanager)inmaternityandintheneonatalunitincludingadoctorwhowillsharethisresponsibilityforsustainingenthusiasm.Theseindividualsmaybetermedsiteleaders.
Facilitatorsshouldalsobementors.Training,policies,guidelinesandactionplansalonedon’taddressthemanychallengesthatareassociatedwithimprovementandchangeinservice-delivery.Implementing
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EssentialNewbornCarerequiresalong-termcommitmentandongoingsupportthroughadvice,sharedresponsibility,collectiveaccountabilityandadvocacywithandforthoseintroducingandprovidingit.
Leadershipmaybeprovidedbyanindividualorasmallteam.Theleadershipmusthavecredibilityintermsoftechnicalexpertiseintheareaofessentialneonatalcare.Forthisreasontheleadershipwillusuallybeorincludeaclinicianwithexperienceandinterestinthisfield.
Aprovincialpaediatricianoranyhealthworkerwithtechnicalexpertiseinnewborncareandhealthsystemsimprovementiswellplacedtoleadtheimprovementprocess.Itisveryimportantthattheyreceivesupportandbackingfromtheprovinceorregion.
Adistrictspecialistteam,includingthepaediatricianandpaediatricandneonatalnursecanprovideleadershipinthedistrict.Theywillworkwitheachhospitaltoimprovecareatfacilitylevel.
COREGROUPFORIMPLEMENTATION
Oneofthefirsttaskoftheleaderistoidentifyacoregroupatprovince,districtandfacilityleveltoimplementessentialnewborncare.
IntheprovincethecoregroupmayincludethedirectororManagerofMaternalandChildHealth,apaediatricianorneonatologistfromtheprovince,tertiaryandregionalhospitalsandneonatalnurses.Ifyoudonothavetherequiredexpertise,lookoutsideyourprovinceordistrictforpaediatriciansandneonatalnursestoassistonaparttimebasis.Theimplementationrequiresassessment,ongoingsupport,trainingandaccreditation.Areferencegroupthatincludesextermalmemberswhocandotheassessmentandaccreditationareuseful.
TheLINCteamconsistedoftechnicalexpertswhovisitedadistrictforoneweekamonth,todoassessments,providedtraining,andconductsupportvisits.Theywerekeytotheimprovementofneonatalservicesinfacilities.Theyassitedwithnorms and standards, policies and guidelines.While fulltime staff are ideal, ifyoudon’thavethemmakeaplantogetexternalassistance.
Acoregroupatadistrictincludesthedistrictmaternalandchildhealthteam,MCWH,andpaediatricianandneonatalnursesfromthedistrict.
Athospitalsthecoregroupmayincludetheclinicalandnursingmanagers,adoctorandprofessionalnurseresponsiblefornewborncare.
DEVELOPINGAVISIONFORNEWBORNCARE
Todevelopavisionistoanticipatehowsomethingwillbe,andtosharethatvisionistopaintapictureinpeoplesmindsofwhatyouwanttoachieve.Theprovincialpaediatricianorexpertteammayhelpdevelopthevision.Takeprovincial,districtandfacilitymanagerstovisitotherneonatalunits,andexplorewhattheywouldliketheirservicestolooklike.Theremaybedifferentperceptionsofwhatnewborncareisandshouldbeinaparticulararea.InruralhospitalsstaffinthefacilitiesanddistrictmaynothaveseenaNeonatalICUoraKangaroomothercareunit.
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ADVOCACYFORACTION
Shareyourvisionfornewborncareservices,withseniormanagementinordertomobiliseresoucesforthenextimplementationsteps.
TheLINCteamheldaseriesofdistrictworkshopsforkeyroleplayerswherewediscussedtheimportanceofnewborncare,theelementsofnewborncare,andpaintedapictureoftheservicerequired.E.g.WhatisKMCwhyisitsoimportantandeffective.Hospitalswentbackandadvocatedforfurtherservices.Someofthemmobilisedtheircoregrouptogoandbenchmarkatanotherhospitalnearby.Othersrecruitedaneonatalnurseordoctortohelpthemdeveloptheirservice.Advocacyshouldcontinuesuntilallhealthworkersinmaternityknowwhyitisimportanttoimprovenewborncareandwanttogetinvolvedinitthemselves,andmanagementmobiisesresourcesforyoutoact.Resourcesusefulforadvocacyinclude:
1. ImprovingnewborncareinSouthAfrica:lessonslearnedfromtheLINC.ThisUnicefbookletoutlineswhatLINCinLimpopoProvincedidtoimprovenewborncare.Itisespeciallyusefulformanagersatdistrict,provinceandthefacilitiestoseewhatcanbedoneinaruralprovinceandtolearnfromtheexperience.Somofthevignettesfromordinaryhealthworkerswillhelptoinspireotherhealthworkerstoimprovecare.
2. WorkshopsbytheLINCteaminthedistrict.LINCranaseriesof3workshopsineachdistrict.TheprogrammeisintheCDROM.
3. Advocacypresentationsthatcanhelpyouintroducenewborncaretomanagersandhealth
professsionals.
4. HelpingBabiesBreatheisanimportantbasicnewborncareresuscitationprogramme,anadvocacyleafletisattached.
5. KMCadvocacymaterial
6. Breastfeedingadvocacymaterial
TheseresourcesarelocatedintheAppendixandCDROMunder“RESOURCESFORADVOCACY”
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STEP2:ASSESSTHESITUATION
Step2:Assessthesituation
Adaptingnormsandstandards
Reviewavailablenationalandprovincialnormsandstandardsandrevisethembasedonvisionfornewborncare
Developtoolsandaprogrammetoassessthesituation
Toolforself-assessmentandarrangeforexternalassessment
Basedonnormsandstandardsdeveloptoolsandarrangetoassessnewborncareinstages,adapt
LINC,WHOorSNLtools
Currentstatusofbirths,lbw,admissionsanddeaths
Birthsinclinics,hospitalandathome,LBWrates,admission,deathsandcauseofdeath
Fordistrictandprovincereviewbirths,LBWrate,admissions,deathsandcauseofdeathtohavebaselineofsituationandpriorityareasfor
intervention
Assesstheservicesandfacilities
Assessservicesandfacilitiesforresuscitation,routinecareandcareofsickandsmallnewborns
Assessallservicesandfacilitiesandequipmentateachdistrictandprovincialfacility.Reviewcurrentprovincialplansforfacilityimprovementandup-
grading
Assessthestaffingandstaffdevelopmentprogramme
Assessstaffing,rotationandcompetencies
Assessandcomparestaffingatfacilities.Determinethenumberofneonataltrainednursesand
paediatricianstosupportneonatalimprovementandtraining.Assesspre-serviceneonataltrainingand
advancedneonataltraining
Assessthequalityofcareprovided
Doacareauditbasedonstandardguidelines
Arrangearecordrevieworcareassessmentofthemanagementofkeyconditionsforasampleof
records
Compilethedataandundertakeadvocacy
Compilethedataateachstepandundertakeadvocacyforchange
Compileanddeterminedataandundertakeadvocacyforchange
Abaselineassessmentofselectedindicatorsofnewborncareintheprovince,ineachdistrictandfacilitycanbecomparedwiththeagreedvisionforfuturenewborncare.Thiswillformthebasisonwhichanimplementationstrategywillbeplanned.
ADAPTINGNORMSANDSTANDARDS
RecommendedstandardsareoutlinedinChapter2.Thesemaybeadaptedtoalignwiththevisionfortheprovince,districtandfacilities.Thenormsandstandardsthathavebeenadoptedwillbeusedtomeasurethecurrentserviceandplanthefutureservice.Thenormsandstandardsshouldbereviewedandadaptedasthenewborncareservicedevelops.
WhenLimpopostartedplanningservicesthenumberoftertiaryandsecondarybeds required seemed unbelievably high, but as the district hospitals havedeveloped their services andbeds there has been an increasing recognitionofbabies inneedof level II and III care to thepoint that level II and III resourceshavebeenoverwhelmed.
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DEVELOPTOOLSANDAPROGRAMMETOASSESSTHESITUATION
TheLINCteamfounditusefultoprovidefacilitieswithabasicself-assessmenttooltoconducttheirownassessment.Thisassessmenttoolwasusedbyfacilitiestoidentifyproblemsanddrawupanactionplan.TheLINCteamthenconductedamoredetailedassessment.Thisprovidedamorespecificsecondassessmentthatcouldbeusedtocomparenewbornservicesatdifferentfacilities.
Acomprehensiveassessmenttoolsisattachedforadaptationanduse.(Appendix1)
Thereareanumerouselementstoadetailedassessment.Anassessmentmaytakemorethanadaytocompleteanditmaybenecessarytovisitafacilityrepeatedlytocompleteanassessment.
Anassessmenttoolfordistrictsandprovincesummarisesinformationfromeachfacilitytoaiddistrictandprovincialplanning.(Appendix2)
CURRENTSTATUSOFBIRTHS,LBW,ADMISSIONSANDDEATHS
Thefollowinginformationshouldbecollectedandcomparedwiththeadaptednormsandstandards:
• Thenumberofdeliveriesinthehospital/s,clinicsinthecatchmentarea.Thenumberofbornbeforearrivalsdeliveriesandotherhomebirthsthathavebeenrecordedatthesefacilities.
• Thenumberoflowbirthweightbabiesandtheirdistributionbyweightbands(eg.1000-1499grams).
• Thenumberofbabiesadmittedtotheneonatalunit.
• Thereasonsforadmissiontotheneonatalunit.Aretheseappropriateindications?Aresomeavoidable?
• Thenumberofstillbirthsandthenumberofearlyandlateneonataldeaths.
• Thecausesofthestillbirthsandneonataldeaths.
• Thebirthweightofthebabiesthatdied.
• Theplaceofdeath.
Thefollowingsourcesmaybeconsultedforinformation:
• PPIPdata
• DHISdata
• CheckthatthedataonPIPandDHIShavebeenaccuratelyrecordedandarecongruous
• Maternityrecordsmaybeusedtocrosscheckthisdata
• Theneonataladmissionbook
• Thepaediatricadmissionbook.Wereanyneonates(<28days)admittedtothepaediatricward?Ifsowhatwasthereasonfortheadmissionandtheoutcomeoftheadmission?
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ASSESSTHESERVICESANDFACILITIES
Theservicesandinfrastructureavailablefornewbornsintheprovinceandateachfacilityshouldbeassessed.
Atfacilitylevel
Assesstheroutinecare.
• Readinessoflabourwardandtheatreforbasicandadvancedneonatalresuscitation
• Babiesarekeptskintoskinwiththeirmotherandbreastfeedinginitiatedwithin30minutes.
• Wellbabiesroominwiththeirmothersandreceiveandsupportisprovidedforbreastfeeding
• Routinepreventivecareisprovidedanddocumentedinthematernitycarechartandroadtohealthbooklet
• PMTCTisprovidedtothemotherandbaby.
• Whenmedicallyindicatedformulaissafelypreparedanddiscretelyadministered.
Theneonatalunitserviceandthefacilitiesandequipmentshouldbeassessed.
• Thenormsareprovided.Assesswhethertheservicesandinfrastructureareappropriateforthelevelofcarethatisrequired.
• Isthereoxygenandmedicalairintheneonatalunit?ForunitsthatprovideorwillprovideCPAPtheoxygenandmedicalairsourcesmustbeabletoprovidetherequiredpressurefortheCPAPdevice.
• Assessthecareprovidedintheneonatalunit.Aclinicalauditformandrecordreviewarepartoftheassessmenttool.
Thecomprehensivefacilitysituationassessmenttoolwillguidethisprocess.
Atprovinciallevel
• Collatetheinformationfromfacilities
• Assesswhatthedistrictandprovincialplansareforinfrastructuredevelopmentandhospitalrevitalisation.
Aretherefacilitiesthatrequireimprovementorarescheduledforimprovements?Havetherequirementsoftheneonatalservicesbeenadequatelyaddressedintheplans?Dotheymeettheagreednormsandstandards?
• Assessthetertiaryandregionalneonatalservices.Arethereenoughbedsandgoodcare.
• Assesstheneonataltransferandtransportintheprovince.
Theprovincialnewbornassessmenttoolcanbeadaptedforthispurpose.
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ASSESSTHESTAFFINGANDSTAFFDEVELOPMENTPROGRAMME
Atfacilitylevelassessthestaffnumbersandbackgroundtrainingandexperienceinnewborncare.
• Dostaffrotateregularlyoraretheyallocatedonlyintheneonatalunit?
• Whatplanisinplaceforstaffdevelopmentateachfacility?
• Dostaffmembershavethecoreneonatalcompetencies?
Atprovinciallevelassesstheprovincialstaffingfornewborncareatthetertiaryservice,theregionalservices,thehospitalandmaternityservices.
Intheprovincialoffice:
• Whoisresponsiblefornewborncare?
• Doesthispersonhaveauthoritytoact?
• Whoprovidestechnicalassistance?
TertiaryandRegionalcare
• Howmanyneonatologistsarethere?
• Howmanypaediatricians?
• Howmanyneonatalnurses?
• Whatistheplantoattractandretainpaediatriciansandneonatologists?
• Whatistheplantotrainneonatalnurses?
• Whattrainingtakesplaceintheprovince?
• Isthissufficientfortheneedsoftheprovince?
ASSESSTHEQUALITYOFCAREPROVIDED
Assesswhatguidelinesandpoliciesareinplacetomanagenewbornsatfacilitiesandintheprovince.
Intheprovince:
• Whatguidelinesareinplacefortheprovince?
• HastherebeenaprocessofdevelopingprovincialguidelinesbasedontheNationalstandardtreatmentguidelines?
• Arepoliciesinplacefor
o BabyFriendlyHospitalInitiative(BFHI)
o Roominginofbabieswithmothers
o Lodgermotherfacilities
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o Referral
o Transportofnewborns
Atfacilities
• Aretheneonatalguidelinesinplace?
• Aretheyuptodateandused?
Conductaclinicalauditoftheimplementationoftheguidelines.Theclinicalaudittoolispartoftheassessment.Thismaybeusedtodetermineifguidelinesarebeingfollowed.Apersonconversantwiththestandardclinicalguidelinesshouldconducttheaudit.
TheLINCteamhasdevelopedarecordaudittoassessthequalityofclinicalcare.Foreachmajorclinicalconditionthereisanassessmentwhichgivesascoreforthecareprovidedagainstthestandardcarerequiredforthatcondition.Ascoreof>80%isregardedasgoodcare,60–80%acceptablecare,and<60%unacceptablecare.Thepersonconductingtheassessmentshouldbeconversantwiththestandardcareandwouldusuallybeapaediatricianorexperienceddoctororneonatalnurse.Thesetoolsareattached.Teamsareencouragedtolearnfromsiteswithexperienceoftheassessmentprocess.
COMPILETHEDATAANDUNDERTAKEADVOCACY
Compilethecollecteddataandwriteareport.Ensurethatmanagersandhealthworkersreceivethereport.Focusfirstonthestrengthsandthenoutlinewhatneedstobedone.
Conductadvocacyaroundtheissuesthatneedtobedealtwith,forexample:
• Visitafacilitywhereacertainaspectofcareisgood,e.gtheKMC.
• Haveadiscussionaboutacontentiousnewborncaretopic
• Inviteanoutsidespeakertotalkaboutanaspectofnewborncare
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STEP3:DEVELOPANACTIONPLAN
Steps3:DevelopanactionplanDetermineyourgoalforimprovementinneonatalmortality
Determineagoalfortheperinatalandneonataloutcomesinyourfacility
Determineagoalforneonataloutcomesinhospitalsineachdistrict
Setprioritiesanddevelopaphasedactionplan
Developanactionplan;prioritiseactivitiesforimmediateaction,mediumandlongtermaction.
Setuppriorities,andputinplaceimmediateinterventions,thenplanformediumandlong-termactivities.
Determineprioritiesandensuresupportforshortermplanswhilstworkingonlongtermplanse.gupgradingfacilities.
DETERMINEYOUROVERALLAIM
Basedontheperinatalandneonataldatayoucollecteddetermineagoalfortheimprovementofperinatalandneonataloutcomes.Theseshouldbeshorttermsgoals(1year)andlongtermgoalsnext3–10years.
e.g
Currentlevel
Targetfornextyear
Targetfor3years
Targetfor10years
NNMR 18 12 10 NNMR>1000g 14 10 8 ENMR 15 12 10 LNMR 3 2 2 NNMR(BW>2500g) 6 5 4 NNMR(BW2000g–2499g) 40 25 20 NNMR(BW1500g–1999g) 200 120 50 NNMR(BW1000g–1499g) 500 300 150 NNMR(BW<1000g) 800 600 400 %admissionstoneonatalunit 10% 15% 15% Forregionalhospital%admissionsfromDH
2% 5%
Fordistricthospitals%transferouts
5%
SETPRIORITIESANDDEVELOPAPHASEDACTIONPLAN
Identifytheissuesthatrequireaction.Prioritisethembyimportance.Categoriseplannedresponsestoeachissueintoimmediate,mediumandlong-terminterventions.Issuesthatmayneedinterventionsinclude:
• Advocacy
• Protocolsandpolicies
• Labourwardresuscitation
• Postnatalwardcare
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• MedicalStaffing
• NursingStaffing
• Staffdevelopment
• Neonatalunitfacility
• Equipmentandsupplies
• Infectioncontrol
• Qualityofneonatalcare
• Neonatalreferralandtransport
Planimmediate,mediumandlong-terminterventionsforeachproblem.Considerusingthefollowingformat:
• Problem
• Intervention/srequired
• Stepstobetaken
• Personresponsible
• Timeframe
• Resourcesrequired
• Personresponsibleformonitoringintervention
Atfacilitylevelbeginwithchangesthatcanbemadeimmediatelyanddonotrequiresignificantadditionalresources.Forexampleunderfacility,theproblemmaybeinadequatespace.Rearrangingthenurserylayoutandremovingunnecessaryfurnitureandequipmentmayhelp.Whilewaitingforprovincialprotocolsotherguidelinesmaybetemporarilyadapted.
Belowisanexampleofaninitialactionplanfromadistricthospital.
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Problem Activityrequired Stepstobefollowed
Person/sresponsible
Timeline Newresourcesrequired
1. Lack of information about neonatal care in community and hospital
Advoacy meeting with maternity staff, doctors and management Advocacy meeting with clinic nurses and IMCI HHCC groups
Plan meetings with management
N.S 1 month Catering for community meeting
2. Inadequate numbers of professional nurses
Need dedicated staff 2AMW + 4 Prof. Nurses
-Discuss rescheduling of allocation -Draw training schedule & present it to supervisor
T. N Matron T M R. M T. N
3 August
3. Lack of policies on referral
Develop referral policy to and from clinics and to regional hospital
-Discuss with unit manager -Meet with regional hospital -Meet with PHC -Draw up policy -Meet with all role players to implement plociy
T. N
3 July
None
3. Protocols Get appropriate written policies. Distribution & implementation of policies
-Discuss with unit Manager -Meeting with all staff nurses & doctors . -Discussion & formulation of protocols -Proper filing of protocols
N. T N. J
LINC charts Standard treatment guidelines PEP manual Notes on newborn care
AnexampleofablankactionplanispartoftheSituationAssessmenttool
Atprovinciallevelsetprioritiesandsettargetsforimmediate,mediumandlong-termactivities;
1. ForProvincialcoordinationandsupport
2. ForProvincialpoliciesandprotocols
3. ForProvincialtoolsandjobaids
4. ForTertiaryservices
5. FordevelopmentofRegionalservices
6. Fortraining
7. Forequipmentandsupplies
8. Foraccreditationandmonitoring
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STEP4IMPLEMENTACTIONPLAN
Steps4:Implementactionplan1.Systemstrengthening
Wardsetupandprocesses
Re-arrangewardsandfacilitiestocreatesuitableNNU
MobiliseresourcesforrefurbishmentandestablishmentofregionalhospitalneonatalunitsDrawupplansfortheservices
Inpatientnewborncareunit
Setupnewborncareunits,withguidelinesandjobaids
Developprovincialrecords,setupprovincialstandardsforNNU
KMCunit Re-arrangeandorganiseKMC
ProvincialstandardforKMC
Attimeofbirth Organiseservice Ensurefacilitiesandequipmentforneonatalresuscitation
Routinecare Putpoliciesinplace Policiesinplaceforroominginandcaringforwellbabies
Staffingandequipment
Determinestandardsandshiftandretainstaff
Determinestandardsforstaffingandequipmentandmobiliseresourcestoachievestandards.
Referralandtransport
Strengthentransportforneonatesfromclinicsandtoreferralhospital
Provincialneonatalambulanceservice
2.Strengthenskillstoimplementstandardguidelinesandprotocols
Reviewguidelines Reviewprovincialguidelinesandstandingordersforfacility.
Reviewprovincialguidelinesforroutinecareandcareoftheandsickbabycare
Assesskeybarrierstoimplementation
Assesskeybarrierstoimplementation
Assessbarrierstoimplementation
Teamfacilitatesremovalofbarriers
Assesstrainingneeds Assessneeds
Assessprovincialtrainingneeds,andidentifyresourcesfortraining
Implementtrainingifneeded
StartwithHBBandin-servicetraining
Developprovincialanddistricttrainingcapacityofin-serviceandpre-servicetraining
Clinicalsupervisionandaudit
Commencesupervision Developsupervisionandaudittools
Onsitefacilitation,mentoring
Workwithonsitefacilitatorsandmentors
Regionalpaediatriciantovisitdistrictfacilities
Putinplacedistrictteams
Implementationmustbeapproachedwiththeunderstandingthatimprovementofaserviceisacontinuousprocessthatmustcontinueforthelifetimeofthatservice.Becauseitrequiresacollectiveandunifiedeffortthedegreetowhicheffectiveimplementationoccurswilldependonskilfulleadershipandthewillingnessofallrole-playerstorespondpositivelytothechallengescreated.Persistence,compromise,adaptationandenthusiasmareamongthecharacteristicsthattheteamwillneedtodisplay.
Havingcompletedtheassessmentandactionplantheprocessofimplementationneedstobesetinmotion.Althoughatimelineformspartoftheactionplanitislikelythatdeadlinesandtargetswillbereviseddependingoncircumstancesattheparticularfacility.
Thefrequencyofon-sitefacilitationwilldependontheneed,theavailabilityoftheteamandtheresources.Ideallymonthlyvisitsallowforon-sitefacilitationaswellasin-servicetrainingandindividualclinicalmentoring.Ifpossible,thefacilitatorshouldattendtheperinatalreviewmeetings,andshouldplantodosobyarrangingvisitsonthedayswhenthemeetingsarebeingheld.Thisformspartoftheclinicalteachingandauditprocess.
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1.SYSTEMSTRENGTHENING
Thesystemistheenvironmentinwhichthehealthcareworkerprovidescareforthenewborn.Theimportanceofanefficientandergonomicsystemisoftenoverlookedtotheseriousdetrimentofstaffproductivityandsatisfaction.Carefulattentionshouldbegiventothefacilityintermsofspace,lighting,workflowandphysiologicalneedsofthestaff.Theequipmentshouldbeproperlymaintainedandadheretotheagreedstandards.Staffingshouldbeadequateandthereshouldbeanappropriateambulanceserviceinsupport.
Inadditionitisimportantthateverynewbornintheserviceareashouldbeabletoaccesstherangeofservicesavailable.Thisentailsplanningforalldeliveriesnotonlythosethatoccuratfacilities.Thereisaneedforcommunityengagement.
Afacilitatorormentorfromadistrictteammayprovidesupportforimplementation,otherwisetheresourcesthatareavailableinthispackageorelsewheremaybeuseful.
COMMUNITYADVOCACY
Communicatewiththecommunityaboutessentialnewborncareservice,whatisimportant,importantmessagestokeepnewbornshealthy,howtousetheservice.Identifyproblemsthecommunityhaswiththeservice,culturalbeliefsandpracticesthataregoodorpossiblyharmful.Communitybuyinisvitaltomaximizingtheimpactofthenewbornservice.Ensureanon-goingcommunicationchannelwiththecommunity.
WARDSETUPANDPROCESSES
Standardsforaneonatalwardhavebeenprovided.Iftheexistingwarddoesnotmeettherecommendedstandardsconsiderinnovationsthatimproveefficiencywhilemotivatingforanewwardoralterations.Cantheincubatorsbere-arranged,orthenursingstationre-positioned?Arethereproblemswithinfectioncontrol?Aretheresmallstructuralchangesthatcanbemadeatminimalcost?Isthereanalternativespacewhereequipmentmaybestoredwhenitisnotinuse?
INPATIENTNEWBORNUNIT
Provinciallevel:Setupprovincialstandardsforinpatientnewborncareunits.Developaplantoensureappropriateneonatalunitsatalllevelsoftheservice.
Identifyjobaidsandtoolsrequiredintheprovince,forexamplenewbornadmissionbook,newbornrecordsandobservationcharts,dischargeandtransferforms,posters.AttachedareexamplesofjobaidsfromLimpopoandotherprovinces.Thesemaybeusedtoassistwiththedevelopmentofprovincialjobaids.
Atfacilityleveladoptstandardsandensurethatthereareappropriatedailyroutinesintheneonatalward.Theprovincialnewbornadmissionbook,newbornpatientrecord,observationchartsandstandardguidelinesforcareshouldbeavailableinthefacility.
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KMCUNIT
EstablishstandardsforKMCunitsandworktowardsimplementingtheseateachhospital.IfnoKMCfacilityexistsidentifyaspace(albeittemporary)forKMC.MostdistricthospitalsinLimpopohaveusedacubicleinthepostnatalward.
SetuptheKMCunitandmakeitashomelyaspossible.Recruithelptomakeduvetcovers.Requestreadingmaterials,motivateforaTV,DVD.MakebabywrapsfortheKMCmothers.Involvethestaffandthecommunity.
SeveraloftheLimpopoKMCunitshavesewingprojects,onemakesdolls,anotherduvetcovers.Thiskeepsthemothersandstaffoccupiedandmotivated.
ATTHETIMEOFBIRTH
Thelabourwardmustbeadequatelypreparedtoreceivethebaby.Thisincludesprovidingforthepossibilityofneonatalresuscitation.Awarmdrysurfaceorresuscitairemustbeavailableinthebirthingareaandanadvancedresuscitationtrolleyshouldbeonsiteornearby.Suction,oxygenandabag,valve,maskdeviceshouldbeon-handandregularlychecked,preferablybeforeeachdelivery.Aclockwithanalarmsetat1minute,5minutes,10and30minutes,ifpossible,willpromoteaccuratemonitoringofthenewbornbaby.
Thereshouldbeappropriatejobaidstosupportcareatbirthsuchasbasicneonatalresuscitationcharts,apgarchart,hand-washingchartsandbreastfeedingcharts.
ROUTINECAREINPOSTNATALWARDORWELLBABYCARE
Mostbabiesroominwiththeirmothersinthepostnatalward.Theyrequiremonitoringandcareasdoesthemother.Ifneededmakechangestothepostnatalwardtoaccommodatethebabywiththemother.Reviewthepolicy,practicesandprocedures.Communalbathingandpracticesthatkeepbabiesseparatefromtheirmothersshouldbestopped.Besidesthebenefitstothemotherandbaby,thiswillfreeupmorespace.Thebabyshouldbeattendedtotogetherwiththemother.Helpthemothertoestablishbreastfeeding,torecognisethatthebabyiswellandtoidentifyearlysignsofpossibleillness.
STAFFAVAILABILITY/ROTATION
Exploreproblemsrelatedtofrequentstaffrotation.Isittheresultofamanagementdecision,pressurefromtheunionordomidwivesnotwanttostayintheneonatalunitormaternity?Identifytherootcauseandworkonfindingandretainingstaffthatwanttoprovidenewborncare.
Isthestaffestablishmentinsufficientandaretherevacantposts?Addresstheseproblemswithmanagement.
EQUIPMENT
Equipmentnormsandstandards,andspecificationsareattached.Ensurethatthereisanequipmentbookintheneonatalunittokeeptrackofallequipmentpurchasedandhowitisfunctioning.Buyingrobustequipmentandteachinghealthworkershowtocorrectlyusetheequipmentwillextenditslife.Someequipmentrequiresdedicatedconsumablesandthesupplyandaffordabilityoftheseshouldbeassessedbeforemakinganequipmentpurchase.
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TRANSFERANDREFERRAL
Agreeonreferralpoliciesfortheclinicsandbetweenhospitalsintheprovince.Theseshouldbecommunicatedtoalltogetherwithasystemforreportingandmonitoringdisagreementsorconfusion.Setupandprioritiseneonataltransportintheprovincesothatbabiescanbecompetentlytransportedtotheappropriatelevelofcare.
SUPPORTSERVICES
Workwiththelaboratory,radiology,dieticians,audiologists,physiotherapistandothersupportservicesonaspectsofcarethatneedimprovement.
2.STRENGTHENSKILLSTOIMPLEMENTSTANDARDGUIDELINESANDPROTOCOLS
Thecarenewbornsreceiveisdependentontheexperience,knowledgeandskillsofthehealthworkers.Inthisregardthehealthworkersactasateamandthereshouldbeabalancedspreadofabilitiesacrossthewholestaffcomplement.
2.1REVIEWEXISTINGGUIDELINESANDSTANDINGORDERSWITHKEYUSERS
Reviewtheguidelinesandprotocolsthatareinuseatfacilitiesinthedistrictandprovince.
SomeguidelinesthatmaybeadaptedforusearelistedbelowandmaybefoundontheattachedCDROM.Facilityprotocolsarenotessentialifanacceptablestandardnationalguidelinehasbeenadopted.Theguidelineshouldbeacceptabletoallthekeyroleplayersatfacilitiesandintheprovincesothatmutualunderstandingandconsensusisachieved.
• PaediatricEssentialDrugListandStandardTreatmentGuidelines(SouthAfrica)
• LINCNewbornCareCharts:RoutineCare
• LINCNewbornCareCharts:CareoftheSickandSmallNewborn
• LINCNewbornCareGuidelines
• Mosttertiaryhospitalshavetheirownguidelinesforexample
o NotesonNewbornCareUCT
o Stellenboschguidelines
2.2.ASSESSKEYBARRIERSTOIMPLEMENTATIONOFSTANDARDCARE
Thekeybarrierstotheimplementationofguidelinesshouldbeassessedbeforeinitiatingatrainingprogramme.Theadvocacyworkshopsandsituationassessmentwillhaveidentifiedanumberofkeybarrierstoimplementation.ASWOT(strength,weaknesses,opportunities,threats)analysiswillhelptodeterminethebarriersandopportunitiesforimplementation.
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Helpfultoachievingobjective
Harmfultoachievingobjective
Attrib
utes
oft
he
orga
nisa
tion Strengths Weaknesses
Attrib
utes
oft
he
enviro
nmen
t Opportunities Threats
SomeofthebarriersidentifiedbytheLINCteamwere:
v Rotationofstaffinmaternity,andintheneonatalunit.Somehospitalsrotatestafffrequentlymakingitdifficultforstafftobemotivated,tolearnguidelinesandpolicies.Maternalandnewborncarebenefitswhenstaffarepermanentlyplacedinthematernityorneonatalunit.Studentsandnewstaffmayrotatethroughtheunit.Thisisanopportunitytoinstitutionalisegoodpractice.
v Lackofavailabilityofguidelines.Guidelinesnotdisplayedoravailableincasualty,maternityandneonatalunit.
v Lackofbuyintotheprotocols.Evenwhenusingprovincialornationalprotocolstheseshouldbediscussedwithallthestaff.Explaintherationalefortheguidelinesandwherenecessarydrawupanadaptedlocalprotocolthatwillassistwithimplementationoftheguidelines
v Guidelinesmaynotbecommunicatedtoalldoctors,includingsessionalandnewdoctors.Somedoctorsonlylookafternewbornswhentheyareoncall,andarenotawareoftheguidelines.Insmallhospitals,standingordersforcareofnewbornsbythenurses,withclearinstructionsforthedoctorscanfacilitateimplementationoftheguidelines.
v Theremaybeinadequatestaff,equipmentandfacilitiesbutthisshouldnotbecomeanabsolutebarriertoimplementation.
v Thelackofcontinuouson-sitesupporttopromotetheimplementationofanewguidelinecanallowareversiontooldpractises.Thisisparticularlythecasewhentheoldpractiseisentrenchedintheinstitutionalculture.
2.3ASSESSTRAININGNEEDS
Ensuringthatdoctorsandnurseshavethecompetenciestoprovideessentialnewborncarecanbeaddressedthroughthetrainingofmotivatedpermanentstaff.Newborncarecompetencyrequirements
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shouldfirstbeevaluated.Acompetencyisablendofskills,abilities,andknowledgeneededtoperformaspecifictask.
Identifythecompetenciesrequiredbydifferenthealthworkers,andplantrainingandlearningtoensurethattheyaremet.Acquiringandmaintainingthecompetencyrequirestheuseofdifferentteachingstylesandreinforcementthroughpracticeandfollowup.Aprogrammeofmentoringandsupportshouldparallelanytrainingprogramme.
Basicneonatalresuscitationisacorecompetencyforallhealthworkersinmaternityandneonatal.HelpingBabiesBreathe©isrecommendedasacourseforallhealthworkers.Wherepossibledoctors,advancedmidwivesandneonatalnursesshouldattendanadvancedneonatalresuscitationcourse.
TheLINCchartsandvariousLINCtrainingpackagesweredevelopedtoaddressthecompetenciesrequiredtoprovideessentialnewborncare.Thesearebasiccompetenciesfornewborncarethatallstaffworkinginmaternityandtheneonatalunitneedtohave.ThereareadditionalcompetenciesthatmaybeneededandothertrainingpackagessuchasthePerinatalEducationProgrammearealternativesthatcanbuildonthebasiccompetencies.
AtregionalandlargedistricthospitalsthatprovideCPAPandhighcare,someofthenursesshouldhavetraininginneonatalintensivecare.Sometertiarycentresofferthisasa1-yeartrainingtrainingcourseatintervals.
DoctorsinpaediatricwardsareencouragedtoobtainaDiplomainChildHealth.Thiswillprovidevocationalgrowthandimprovethelocalskillsandknowledgeinpaediatricandnewborncare.
Someimportanttrainingandupdatesmaybeavailableasshortcoursesorintegratedintoothercourses.Forexample:
v PMTCTv Breastfeedingv EPIv Genetics
ThelistbelowidentifiesthecompetenciesaddressedbytheLINCtrainingpackage.Italsoliststhecompetenciesrequiredfordifferentcategoriesofstaff.Ablankchartisincludedintheappendixandeachfacilityisencouragedtodrawupasimilarlist.
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COMPETENCIESREQUIREDINNEWBORNCARECompetency Subcompetency
MO
Paed
iatricM
O
Adv
ance
midwife
Neo
natalP
N
Mid-w
ife
Neo
natalE
N/ENA
MSS
Nm
odulean
dlesson
nu
mbe
r
Othermaterial
Resuscitatethenewbornatbirth
Basicresuscitation ü ü ü ü ü ü HelpingBabiesBreathe
ProvideAdvancedresuscitation
ü ü ü ü NRPAPLSPALSSAMA/FM
Provideroutinecaretonewbornsatbirth
Provideroutinecareandtriageinlabourward
ü ü ü ü M0
Assessthenewbornafterbirth
ü ü ü ü ü M0 PEP
Provideroutinecareinpostnatalward
ü ü ü ü ü M0 PEP
Dischargeandmakeafollowupplan
ü ü ü ü ü ü M0
Assessandsupportbreastfeeding
ü ü ü ü ü ü M0 IMCI,Lactationmanagement
Assessandclassifythesickandsmallnewborn
AssessandClassifyneedforemergencycare
ü ü ü ü ü M1,L2
AssessandClassifyprioritysignsinnewborns
ü ü ü ü ü M1,L2
Assessabnormalities ü ü ü ü M1,L3
PEP
Assesslocalinfections ü ü ü ü M1,L3
PEP
Assessriskfactors ü ü ü ü ü ü M1,L4
PEP
Providesupportivecaretonewborntomaintainhomeostasis
Monitor,prevent,andmanagehypothermia
ü ü ü ü ü ü M2,L5
PEP
Monitor,prevent,andmanagehypoglycaemia
ü ü ü ü ü ü M2,L7
PEP
ProvidesafeKangarooMotherCare
ü ü ü ü ü ü M2,L5
Providesafeoxygentherapy
ü ü ü ü ü ü M2,L6
PEP
Providesafefeedsandfluidstobabies
ü ü ü ü ü ü M2,L8
PEP
Safelytransferbabies ü ü ü ü ü ü M2,L10
Diagnoseandmanagecommonspecificnewbornproblem
Managebabieswithrespiratorydistress
ü ü ü ü M2,L11
PEP
ManagebabiesonCPAP ü ü ü ü AdditionalLessons
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Managelowbirthweightbabies
ü ü ü ü ü M2,L12
PEP
Managebabieswithinfections
ü ü ü ü M2,L13
PEP
Preventandmanageneonatalencephalopathy
ü ü ü ü M2,L15
PEP
Preventandmanageneonataljaundice
ü ü ü ü ü ü M2,L16
PEP
Managecongenitalabnormalities
ü ü ü ü M2,L17
PEP,
ManageexposuretoHIV,Tbandsyphilis
ü ü ü ü ü ü M2,L18
PMTCT
Counselmothertocareforhernewborn
Assessfeedingandgrowthandcounselonfeeding
ü ü ü ü ü ü M3,L19L20,L21
IMCILactationmanagement
Counselmotheroncare,whentoreturn
ü ü ü ü ü ü M3,L22
Ensureaclean,safeandfriendlynewbornenvironment
ü ü ü ü ü ü M2,L9
Abbreviations PEP: Perinatal education Programme IMCI: Integrated Management of Childhood Illness PMTCT: NRP: Neonatal Resuscitation Programme HBB: Helping Babies Breathe MSSN: Management of Sick and Small Newborns
2.4IMPLEMENTTRAINING SuggestedtrainingandlearningfordifferentcategoriesofhealthworkersDoctors:
• DiplomaChildHealth• 2dayLINCtrainingcourse• MotherandInfantHIVcourse• PMTCTtrainingandupdates• SelfstudywithNeonatalPEP
ProfessionalNurses
• DiplomainAdvancedMidwifery• DiplomainNeonatalNursing• LINCtrainingforProfessionalnurses• PMTCTtrainingandupdates• MotherandInfantHIVcourse• Lactationmanagement/BFHIcourse• NeonatalPEPcourse
Enrollednurses
• LINCtrainingcourse• Lactationmanagement/BFHIcourse
Belowaresomerecommendedtrainingcoursesorprogrammes:
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RESUSCITATION
HELPINGBABIESBREATH(HBB)
HBBisabasicneonatalresuscitationtrainingprogramme.Itishighlyrecommendedforallhealthworkersinmaternityandneonatalcare.Theskillslearnedshouldbereinforcedthroughregularupdatessessionsordrillsateachfacility.
“HelpingBabiesBreathe®(HBB)aimstohelpmeetMillenniumDevelopmentGoal4targetsforreductionofchildmortalitybyaddressingoneofthemostimportantcausesofneonataldeath:intrapartum-relatedevents(birthasphyxia).HBBisanevidence-basededucationalprogrammethatteachesaneffectivestepwiseapproachforsuccessfulresuscitationofthemajorityofinfantsnotbreathingatbirth.
HelpingBabiesBreatheisdesignedtobecoordinatedwithotherinterventionsinapackageselectedtoimproveneonatalandmaternalhealth.HBBcanbeusedastheresuscitationcomponentincoursesteachingEssentialNewbornCareandcoursesinmidwiferyskills.HBBcanbeusedatalllevelsinthehealthsystem.Itenablestheextensionofresuscitationtrainingtofirst-levelhealthfacilitiesandhealthworkersinresource-limitedsettings,wheretheseskillsaremostlacking.Italsocanbeusedinhigher-levelhealthfacilities,includingtertiaryfacilities,whereitcomplements,butdoesnotreplace,comprehensiveresuscitationprogramssuchastheNeonatalResuscitationProgram(NRP).BothHBBandNRPteachthesamefirststepsinresuscitation,butNRPalsoincludestheuseofsupplementaloxygen,chestcompressions,intubation,andmedications.
HBBusesalearner-centerededucationalmethodologywithemphasisonmasteryofkeyskills.Pictorial,color-codedprintmaterialsandalow-cost,high-fidelityneonatalsimulatorengagelearnersandempowerthemtocontinuelearningintheworkplace.HBBencouragesfrequentpractice,usingjobaids,simulators,andmannequinsavailableintheworkplacetomaintainskills.
Asanintegralelementofmaternalandneonatalcare,HBBcanactasacatalystforbroaderimprovementsintheseservices,particularlyattheperipheryofthehealthsystem.
FurtheradvocacyandinformationaboutHBB,thetrainingmethods,andanimplementationpackageareintheResourcesectionandCDROM.
Itisrecommendedthatthereshouldbe2HelpingBabiesBreathefacilitatorsateachdistricthospital.Thesefacilitatorscanrunregularcoursesformaternityandprimaryhealthcarestaff.4–6participantscanbetrainedinonedaybyafacilitator.
ADVANCEDNEONATALRESUSCITATION
Ensurethatalladvancedmidwives,andseniordoctorsaretrainedinadvancedneonatalresuscitation,andmaintaintheirskillandaccreditationforresuscitation.SeveralaccreditedcoursesareofferedthroughoutthecountryandincludetheAmericanAcademyofPaediatricscoursestheNeonatalResuscitationProgram(NRP),andtheBritishPaediatricAssociationCourse,AdvancedPaediatricLifeSupport(APLS)coursethatincludesneonatalresuscitation.ESMOEEincludesamoduleonneonatalresuscitation.
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ROUTINECARE
Allmaternitystaffprovideroutinecaretonewborns.Thisincludesidentifyingriskfactorsandillness,supportingbreastfeedingandprovidingroutinepreventivecare.Thecaregivenisdocumentedandinformationisprovidedtothemother.RoutinecareincludeslactationmanagementandPMTCT.
Trainingcanbeprovidedaspartofin-servicetrainingoronanintegrated1–3daytrainingcoursethatincorporatesalltheaspectsofcareincludingHBB.
AseparatePMTCTandlactationmanagementcoursemaybeofferedinthedistrictorprovince.
LINCprovideschartsonroutinecareofnewbornswithalearnermoduleandtrainingthatcanaccompanythecharts.Trainingmaybeprovidedaspartofacourseorasanin-servicetrainingmoduleorasself–learning.
ThePerinatalEducationProgrammehasamoduleonPrimaryNewbornCarethatcoversroutinecareofthenewborn.
LINCTRAINING
TheLINCtrainingisbasedontheprinciplethattherearedifferentstylesanddomainsoflearninganddifferentmethodsengagedifferentlearners.
Adultlearnersbringpriorknowledgeandexperiencetothelearningsituationandnewknowledgeshouldbepresentedinafashionthatfacilitatesassimilationandintegration.Differentlearnerslearnindifferentwaysandtrainingprogrammesneedtoincludevisual,auditoryandinteractivemethods.
Adultlearnersaremotivatedbytasksperceivedasmeaningful.Theyaredecisionmakersandself–directedlearners.Presentedwithnewinformationtheybenefitfromopportunitiestoputitintopracticethroughcarryingoutnewtasksandcompetencies.Thiscanbethroughsimulationsorappropriateworkplaceexposurewiththeoversightofamentorifnecessary.
LINCtrainingincorporates:
• Aneedsassessment
• Pre-readingandadditionalreading
• Presentations
• Smallgrouplearningtoallowforsharingofideas,discussionandrefocusingthelearningonexpressedlearnerneeds.
• Visualdemonstrationsandpracticalsessionsfortherehearsalofnewskills.
TheLINCNewbornCareChartsaredesignedaspersonalaidstoguidethehealthworkerinmaternityandtheneonatalunitinprovidingcarefornewborns.Thetrainingmaterialsrefertothecharts,andlearners
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areencouragedtohavethemopenatalltimesduringthecourse.Thisdevelopsfamiliaritywiththechartsandprovidesacontextfortheguidelines.
Readinglearnermanual
Thelearnermanualexplainsthechartsandprovidesbackgroundinformation.Themanualisreadbeforethecourse,andsummarizedinclassbythegroup.Itcanalsobeusedforself-study.Sectionscanbereadbeforecomingtoclass,orindividuallyfordistance-basedlearning.
IntroductiontoToolsfornewborncare
Themanualintroducesanumberoftoolsthatareusedtofacilitatethecarethatisprovidedtonewborns.Theseinclude:
• Newbornrecordaspartofthematernitychart• Observationchartfornewbornaspartofmaternitychart• NewbornAdmissionRecordforsickandsmallnewborns• Initialassessmentformforsicknewborns• Admission/Dischargesummary• Weight,feedingandtreatmentsummary• Ballardscore• Fetal-infantgrowthchartforpreterminfants• Bilirubincharts• KMCscorechart• HIEscorechart• Healthworkernotes• NewbornObservationChart
LINCtrainingusesthechartsdevelopedforuseinLimpopo.Ifdifferentsuitablechartsareinusethesemaybeusedinstead.TheLimpopochartsareprovidedforadaptation.
Writtencasebasedexercises
Writtenexercisesareinterspersedinthemanual.Thewrittenexercisesusuallyrefertoaclinicalcaseandareusedtoreinforcethelearninginthemodulesbytheoreticalapplicationoftheinformationtotheassessmentandcareofanewborn.Aseparateexercisebookisgiventoeachparticipant.Facilitatorshavetheanswerstotheexercisesintheirlessonplans.
Role-plays
Role-playsareusedtoexplorecounselingandinteractionsbetweenhealthworkers.
Visuallearning
Powerpointpresentationsorslideshowsareusedtodemonstrateclinicalsignsandcare.Thisreinforceslearningsuchastherecognitionofclinicalsigns.Anumberofvideosareindevelopmentasanalternativetothepowerpointpresentation.Thiswillenableeasierself-learningandaidfacilitiesthatdonohaveexperiencedfacilitators.
ClinicalSession
Theclinicalsessionsareconductedintheclinicalarea(NeonatalUnitandPostnatalWard)andensurethattheparticipantsseeandpracticeclinicalandproceduralskills.
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LINCCDROM
TheCDROMcontainsthefollowing
• LINCCourseDirectorGuide
• LINCfacilitatorGuideandLessonPlans
• LINCManagementofSickandSmallNewbornLearnerManualandWorkbook
• LINCRoutineCareLearnerManualandWorkbook
• LINCPowerPointPresentationfortraining
• LINCtoolsforuseintraining
• LINCCPAPguidelineandworkshop
• LINCPPIPguidelineandworkshop
PERINATALEDUCATIONPROGRAMME(PEP)
Thisisaself-study,distanceeducationprogramme.Itdoesnotrequiretutors,andtheonlycostisthepurchaseofthemanuals.Therearetworelevantmanualsfornewborncare:PrimaryNewbornCare,andNewbornCare.ThePrimaryNewbornCaremanualissuitableforstaffworkinginClinics,HealthCentresandMidwifeObstetricUnits.TheNewbornCaremanualisforstaffworkinginhospitals.
Thequalityofhealthcareprovidedbynursesanddoctorsdependslargelyontheirabilitytoaccessahighstandardofbothbasicandcontinuingtraining.Thisisparticularlyimportantforhealthcareworkersinunder-resourced,ruralareaswhereeducationalsupportandopportunitiesforin-servicelearningareverylimited.Traditionalmethodsofcentralisedteachingwithformaltutorsandsmallclassesoftencannotbeprovidedtomeettheirneedastheyareexpensive,dependonadequatenumbersofcompetenttrainersandrequireparticipantstoleavetheirplaceofemployment.Allthesefactorsaremajorobstaclestoimprovingthequalityofpatientcareinmanyunder-servedareasofSouthAfrica.
Inordertoaddressthechallengesofbetterprevention,diagnosisandmanagementofcommonandimportantmedicalconditions,apackageofcost-effectiveandpracticaltrainingmethodsisneeded.Thisshouldincludeasystemofself-studyandco-operative,grouplearningtoenablehealthcareworkerstotakepartialresponsibilityfortheirowneducationandprofessionalgrowth.Itisparticularlyimportanttoprovideagoodbackgroundknowledgeandunderstandingoftheessentialstepsusedinaprotocol-drivenapproachtotrainingandhealthcare.Unlessaparticipantknowswhyastepinmanagementisimportant,theyareunlikelytoincorporatewhattheylearnintotheirclinicalpractice.
Awell-balancedprogrammeoffacilitatedtrainingshouldhavecomponentsofbothindividualstudyandgrouplearningaswellastutoredexercisesinclinicalskills.Inthiswayalimitednumberoftrainerscanmanagemanyparticipantsaseachgrouponlyneedslimitedface-to-faceteaching.Withtheemphasisonlearningratherthanteaching,traditionaltrainersbecomefacilitatorswhoencouragethedevelopmentofself-confidenceandcompetence.
ThePerinatalEducationProgrammehaspresentedappropriatelearningmaterialinmaternalandnewborncareforthepast20yearsandhasenabledbothnursesanddoctors,aswellasmedicalandnursingstudents,toplayanactiveroleintheirownlearningprocess.Coursebooksuseaproblem-basedapproachtoaddressawiderangeoftopicsandarehelpfulforbothself-studyandgroupdiscussions.Usinga
30
question-and-answerformat,togetherwithcasestudiesandmanagementprotocols,theyprovidealogicalapproachandclearunderstandingofallstepsinpatientcare.Multiplechoicetestsbeforeandaftereachchapterenablesparticipantstomonitortheirownprogress.Recentlythelearningmaterialhasalsobeenmadeavailableontheinternetforeasyaccess.Anumberofprospectivestudieshavedocumentedthesignificantimprovementinknowledge,clinicalskills,attitudesandpatientcarepracticeswhenmidwivesandneonatalnursesusethisself-helplearningmethodtomanagetheirowntrainingprogrammes.ThecontentofthePerinatalEducationCarebookshasbeenincorporatedintootherpartsoftheNewbornCarepackage.Itisstronglyrecommendedthatthisbecomesanessentialpartofneonataleducation,especiallyinunder-resourcedsettings.
MoreinformationonPEPisincludedintheImplementationToolXonTraininginthenextsection.
NEONATALEXPERIENTIALLEARNING
NeonatalExperientialLearningisansupportivecomprehensivelearningprogrammebasedonclinicalgovernancestructure.NELSutilisestheNewbornCarePEPmanualduringa2weekcontactsession.MoreinformationonNELSisprovidedintheadditionalresourcessectionChapter4.
NEWBORNICUTRAINING
FewuniversitiescurrentlyofferNeonatalICUtrainingastheNursingCouncildoesnotcurrentlyregisterthecourse.Theskillsprovidedinthiscoursewillbenefitnursesatlevel2and3facilitiesanditishopedthatthecouncilwillsoonregisterNICUtraining.
IMPLEMENTPRE-SERVICETRAINING
Newborncareisrequiredtobepartofpre-servicenursingandmedicaltraining.Provinceneedtoensurethatthisishappeningandthattheyareuptodate.
CLINICALMENTORING
Clinicalmentoringasmentionedpreviouslyisanimportantpartoflearningandhelpinghealthworkerswhohavebeentrainedimplementwhattheyhavelearned.
3.MONITORINGANDAUDIT
Asystemofmonitoringandauditshouldbeestablishedateachfacility.Thiswillinclude
1. Supportivesupervision
2. ClinicalAudit
3. PerinatalAudit
4. Monitoringkeynewbornindicators
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SUPPORTIVESUPERVISION
Everybodywhohassomeroleinoverseeinghealthcareisresponsibleforsupervisingatleastsomepartofthesystem.Theclinicalmanagerisresponsibleforclinicalcareinthehospital.He/sheneedstobeclearaboutwhattherequirementsfornewborncareare,toassesstheseandtomakethenecessarychangestoensurethattheunitisabletofunctionoptimally.He/she,particularly,shouldbethechairpersonoftheperinatalreviewmeetings,andtakeresponsibilityforcheckingthattheactionplansarebeingimplemented.
Thenursemanagerensuresthatthereareadequatenursingstaffandthatthestaffhavetheappropriateknowledgeandskillstobeabletoprovideahighqualityofcare.He/sheneedstotakeresponsibility,withthemedicalmanagerandotherstaff,forclinicalauditofrecordsandforassessingqualityofcareintheward.
ThefacilityCEOhasoverallresponsibilityforensuringthatalltherequirementsforprovidingqualitycareareprovided.He/sheneedstobeadvisedbytheclinicalmanagersandcliniciansonwhatisneededandwhattheoutcomeofevaluationsare,sothatappropriateactioncanbetaken.
Thedoctorisresponsibleforthepatientcareonadaytodaybasis.He/sheneedstoevaluatecarefullyclinicaloutcomes–morbidityandmortality,lookingspecificallyforavoidablefactors/substandardcare.He/sheneedstoactinanadvisorycapacityforotherclinicalmanagers,particularlyinmatterswhichaffectthedaytodaypatientcareandtherunningoftheward.
Allhealthworkerswithasupervisoryfunctionshouldstriveto:
• Demonstratetherightwaytoperformtasksratherthanpointingouterrors
• Provideanenablingenvironmentinwhichtheirjuniorcolleaguesfeelfreetousetheirowninitiativeratherthancreatingacontrollingenvironmentthat,throughtheexcessiveuseofdirectives,stiflesinitiative
• Promotetheprofessionaldevelopmentofstaffundertheirsupervision
• Assumeasmuchresponsibilityandaccountabilityasisjustifiable
CLINICALAUDITANDQUALITYOFPATIENTCARE
Clinicalauditreviewshowguidelinesareimplemented.Thereareanumberofwaystoperformclinicalaudits.
1. Apaediatricianconductingwardroundswillreviewallaspectsofthepatient’scareandimmediatelyidentifygoodandbadclinicalpracticesanddiscussthesewiththemedicalandnursingteam.Thisauditrequiresanexperiencedclinicianavailableforwardrounds.
2. Clinicalauditform.Achecklistofgoodpractice,whichcanbeappliedtoanumberofpatientsatintervalstomonitorcompliancewithguidelines.Thismaybeusefulfortheclinicalmanagerwhomaynotbeanexpertinnewborncareasanaidtoidentifyingcompliancewithguidelines.
3. Recordreview.TheLINCsituationassessmentandaccreditationutilisesarecordreviewofpatientswhohavebeencaredforintheneonatalunit.Thecareforeachconditionisscoredagainststandardcareforthatcondition.Thescoresaretotalledandapercentageforstandard
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careforeachconditionisachieved.Therecordreviewmustbeconductedbyskilledcliniciansoftenfromoutsidethefacility.
PERINATALANDNEONATALMORTALITYANDPERINATALREVIEWMEETINGS
ThePerinatalProblemIdentificationProgramme(PPIP)isagoodtoolforperinatalaudit,andoneendorsedforusebytheDepartmentofHealth.Itprovidestoolstoassistincollectingbaselinedataandauditingthecauseofperinataldeaths.
Perinatalreviewmeetingsshouldbeheldeverymonthineachfacility.Thecauseofaperinataldeathmustbeassessedwithin24hoursofthedeath.
ABOUTPPIPFROM(WWW.PPIP.CO.ZA)
PPIPWILLTAKECAREOFTHENUMBERS,WHILEYOUTAKECAREOFMOTHERSANDTHEIRBABIES
ThePerinatalProblemIdentificationProgram(PPIP)isatooltomakeyourperinatalandmaternaldeathauditeasier.Itdoesnotdotheauditforyou,butittakesthetediouspaperworkoutoftheprocess.Themomentyouenterthebasicdata,youcaninstantlydoextensivedataanalysis,andevenpresentyourdataingraphsandprintreports-allwiththepressofabutton.
Lettherebenodoubt:medicalaudit(andcertainlyperinatalandmaternaldeathaudit)isnotaprocessthathappenswithoutdedicatedindividualsspendingtimeandefforttomakeithappen.Furthermore,auditisafutileprocessifitdoesn't'closetheloop'bychangingthepracticeitisauditing.Thepurposeofauditisnottheaudit,orthefigures,orthereportsitgenerates,buttheimprovementofpractice.Ifyoudonotintendtochangethewayyoucareformothersandtheirbabies,PPIPwilldonothingforyou.If,ontheotherhand,youwantthequalityofyourcaretobeweighedandmeasuredbecauseyouwanttodobetter,PPIPwillprovideyouwithaninstrumenttomakesenseofyourdatawithoutspendinghoursgoingthroughdatasheets.
AUDITSUPPORTPROVIDEDBYPPIP
Medicalauditincludesanumberofactions.PPIPmakessenseofthisprocessbyprovidingyouwiththree'levels'ofdataentry:
DOINGTHENUMBERS
PPIPallowsyoutocollectnumbersofdeliveries,stillbirths,earlyandlateneonataldeathsandmaternaldeaths.Thisallowsthecalculationofdifferentrates(e.g.aperinatalmortalityrate)andisusedasdenominatorinvariouscalculations.Aselectionof'miscellaneous'datafieldsallowsentryandanalysisofspecificdetail,e.g.modeofdelivery.
IDENTIFYINGCAUSES
Eachperinatal,neonatalandmaternaldeathisenteredinmoredetail.PPIPallowsentryofbasicdemographicdata,afterwhichaprimaryobstetriccauseofdeathandafinalcauseofdeathmustbeidentified.Obviouslythesecausescanthenbeanalyzedindetail.
AVOIDABLE?
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Lastly,PPIPallowsfortheidentificationofspecificavoidablefactors.Theseareincidentsrelatedtotheactionsofthemotherorhealthcarepersonnel,orthehealthcaresystem,whichmayhavealteredtheoutcomeofthespecificcasehaditbeenmanageddifferently.Again,theseavoidablefactorscanbeincludedindataanalysis.
FurtherinformationaboutPPIPcanbefoundontheirwebsitewww.ppip.co.za
NEONATALMORBIDITYANDSERVICES
Additionaldataandinformationisrequiredtomonitortheneonatalservice.Thisincludes
• Thenumberandpercentageofadmissionstotheneonatalunitandthereasonsfortheadmission
• Thetrendsinadmissions
• Transfersinandoutoftheneonatalunitandoutcomefromtransfers
• Neonataltransportresponsetimesandoutcomes
• Numberandnatureofbirthabnormalities
• Outcomeofspecificconditions
SeetheattachedtoolsinAppendix3,Neonatalregistersandsummarydata
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STEP5TRACKPROGRESSANDUNDERTAKEACCREDITATIONASSESSMENTS
Step5:TrackprogressandundertakeaccreditationassessmentsInput Humanandfinancial
resourcesDistrictteaminplace Numberofdistrict
teams,regionalandtertiaryhumanresources
Process AdvocacyActionplans
ActionPlansTeamsinplaceVisitstofacilitiesEquipmentandfacilityneedsidentified
EquipmentneedsTransportneedsTrainingneeds
Output NormsandstandardsGuidelinesToolsusedNumberofhealthworkerstrained
NormsandstandardsTrainingsconductedReferralandtransportpoliciesNeonatalambulanceinplace
Provincialjobaids
Outcome FacilitiesaccreditedfornewborncareWellequippedandstaffedfacilitiesDateproperlycollected
QualityoftrainingNooffacilitiesaccreditedReferralpatternsAmbulanceresponsetimes
Accreditation
Impact NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates
NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates
NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates
Progressshouldbemonitoredatfacility,districtandprovinciallevel.Thechoiceofindicatorswillvaryaccordingtothepointofmonitoringanduniquecircumstances.Itisusefultoaggregateindicatorsintothe5categoriesshowninthetableabove.Thiswillprovideforacontinuumofmonitoringduringimplementation.Anexampleofthisprocessisprovidedinthetableandsubsequentdiscussionbelow.
AnAccreditationSystemformspartoftheLINCprogrammeinLimpopo.ItenablestheimplementationoftheNewbornCareInitiativetopbetrackedandprovidesanincentiveforparticipatingfacilities.Thisisdescribedatthecloseofthischapter.
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Input Process Output Outcome Impact
FacilityLevel HumanandFinancialResources
Teaminplaceatfacilitywithchangeagent
Actionplansaredrawnupinfacility
Advocacyworkshops
Community
Healthworkers
Normsandstandardsfornewborncareidentified
Guidelinesinplace
Jobaidsinplaceandbeingused
Numberofhealthworkerstrained
Facilitiesaccreditedforexcellentnewborncare
Wellequippedfacilities
Improvementinnewborncarenotedonrecordreviews
Neonatalmortalityrates
Perinatalmortalityrates
Admissionratesandcasefatalityrates
National,ProvinicalandDistrictlevel
Teaminplaceinxnumberofdistricts
Advocacyprogramme
Actionplansinplace
Numberofteamsinplace
Numberofvisitstofacilities
NormsandstandardsandGuidelinesinplace
Trainingsconducted
Appropriatetransferpolicies
Neonatalambulancesinplace
Nooffunctionalregionalhospitals
Nooffacilitiesaccreditedforexcellentnewborncare
Responsetimes
Qualityoftraining
Improvedreferralpatterns
Neonatalmortalityrates
Perinatalmortalityrates
Admissionratesandcasefatalityrates
Meansofverification
Numberofteamsinplace
Visitreports
Trainingreports
Recordreviews
ClinicalAudit
Accreditationvisits
Equipmentaudits
PPIPdata
DHISData
StatsSAData
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INPUTINDICATORS
MonitorthebudgetandhumanresourcesforEssentialCare.Haveprovincesandfacilitiesallocatedadequateresourcesforessentialnewborncareatprovince,district,regionalanddistricthospitallevel?
• Hasthehospitalrevitalisationprogrammeincludedneonatalunits?
• Hastheprovinceidentifiedstaffforneonatalimprovement?
• Havethefacilitiesidentifiedstafftoprovidenewborncare?
• Hastheprovinceidentifieddistrictsupportteamsorexternalfacilitatorsandmentors?
PROCESSINDICATORS
Thiswilldependontheplanthatwasdrawnupbutmayincludethefollowing:
• Isthesituationassessmentcomplete,andcommunicatedtorelevantstakeholders?
• Hastherebeenadvocacyatcommunity,healthworkerandmanagementlevel?
• Haveactionplansbeendevelopedateachfacilityforimmediateaction,mediumandlongtermactivities?
OUTPUTINDICATORS
Whataretheresultsofactionplansrelatedtofacilities,staffing,training?
• Howmanytrainingcourseswereconductedandpeopletrained?
• Havethenormsandstandardsbeencompletedandadoptedbyfacilities?
• Areprovincialguidelinesinplace?
• Isthereareferralguidelineandtransportpolicy?
• Areotherprovincialjobaidsinplaceforexample,admissionbook,newbornrecord,monitoringcharts?
OUTCOMEINDICATORS
Outcomeindicatorsassesstheoutcomeofactionsintermsofquality.
• Whatisthequalityofthetrainingprovided?
• Whatisthequalityofpatientcare,isstandardclinicalcarebeingprovidedatfacilities?
• Whatistheresponsetimeoftheneonatalambulance?
• Arereferralpatternsappropriate?
Thiscanbeassessedbyclinicalaudit,andcommunitysatisfaction.TheaccreditationsystemdevelopedbyLINCincludesanassessmentofthequalityoftheserviceprovided.
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IMPACTINDICATORS
Theimpactindicatorsmeasurewhethertheservicehashadanimpactandachieveditsobjectives.Iftheobjectivewastodecreaseneonatalmortalitytrendsintheneonatalmortalityratesmustbemeasured.
Impactindicatorswillnotshowthedesiredimprovementifaprojecthasnotbeenimplementedtoscale,orifaspectsoftheimplementationhavebeenincomplete.
Theimpactmeasuresforessentialnewborncareinclude:
• Neonatalmortalityrate
• Intrapartumasphyxiarates(SBrates)
• Causespecificmortalityrates
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ACCREDITATION
TheaccreditationprocessinLimpopowassetuptomotivate,monitorandrewardhospitalsforachievingthesetnormsandstandardsforneonatalservices,andasetclinicalstandardfornewborncare.Theaccreditationsystemincludesanumberofcomponents
Accreditationassessesallaspectsofnewborncare.
InLimpopoHospitalsapplyforaccreditationoncetheyareready.Ateamconsistingofexternalandinternalmembersvisitandassessfacilities,services,staffingandnewborncare.Thelatterisassessedbyrecordreviewandclinicalaudit.
Hospitalsthathaveachievedaccreditationdidsomostlybecauseofgoodclinicalcareprovidedtonewborns.Thosethatdidnotoftenhadfacilitiesandequipmentinplacebutfailedtoprovideanadequatelevelofclinicalcare.
InthefirstroundofaccreditationfacilitiesachievedSilver,GoldandPlatinumrankingsaccordingtothesystemdescribedbelow.Theintentionisthatthesewillbeadjustedforthenextroundofaccreditation.
Accreditationisvalidforaperiodof2–5years.
Theaccreditationutilisesthecomprehensivesituationassessmenttoolstoassessfacilities.
SILVER
EachoftheitemsintheHospitalVisitcheck-listmustbeinplacewithascoreof65%plus
Criteriaareasthatarenon-negotiableare:
• Checklistscored65%plus
• 12stepstoKMCimplemented
• Admissionrecordsused
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• Observationrecordsused
• Oxygenmonitoring
• Statisticsavailableinthe1000–1999gbirthweight
• Evidencethattheneonatalmortalityrateinthisweightgroupisimproving
• LevelIIfacilitiesmusthaveCPAP
• Patientrecords(qualityofcare)scoremorethan60%
GOLD
AllthecriteriaasforSliver
Additionalitemswhichareessential:
• Check-listscores75%plus
• CPAPavailableandbeingusedappropriately
• Multi-parametermonitoring
• Infusionpumps
• Decreasedmortalityratein1500–1999gbirthweightgrouptolessthan50/1000
• Abilitytointerprettheperinatalstatistics
o ● Patientrecords(qualityofcare)scoremorethan70%
PLATINUM
AllofthecriteriaforSilverandGold
Additionalessentialitemsare:
• Check-listscores85%plus
• In-servicetrainingforstaffinthehospital
• Out-reachtotheDistrict–clinics
- hospitals
- training
- perinatalauditmeetings
Patientrecords(qualityofcare)scoremorethan80
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