2 Session 1b May 22 2011 FINAL

8/6/2019 2 Session 1b May 22 2011 FINAL

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Session 1b.

The DOH-ARMM IMPROVEMENTCOLLABORATIVE:A quality improvement approach

for the care of mothers andnewborns

IC Orientation and Planning Workshop for QITsMay 23 25, 2011


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Historical Background

Developed in 1998 by the Institute forHealthcare Improvement (IHI) of Bostonand called the Breakthrough Series

IHI saw it as an approach to more rapidlyspread best practices to a largenumber of sites or throughout anorganization

The approach has been widely used in theUSA, the UK, Australia, Canada andEurope

URC (QA and HCI Projects) has led the use

of the approach in developing countries(36 collaboratives in 13 countries since


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How can quality be improved?


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Cas e Fatality f or Infants w ith Res piratory Dis orders in the F

9.1

100.83.

42.

33.

40.

28.33.

50.

66.

50.

75.

25.33.16.

66.

27.16.18.

23.

5.

25.13.

25.12.

3.8.10.

15.4.7

13.16.16.12.7.13.75.5.3.44

1

0.0

20.0

40.0

60.0

80.0100.0

120.0

Jan-0

0

Mar-0

0

May-0

0

Jul-00

Sep-0

0

Nov-0

0

Jan-0

1

Mar-0

1

May-0

1

Jul-01

Sep-0

1

Nov-0

1

Jan-02

Mar-02

May-02

Jul-02

Sep-02

Nov-02

Jan-03

Mar-03

May-03

%

Tver, Russia Case Fatality Outcomesduring the Collaborative


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Best Practices inARMM

DOH-

ARMM

Improvement

Collabora

tive

,MTSL ENC and LAPM services-rovided by DOH ARMM healthorkers are BEST practiceseed to ensure quality ofhese services and to makehese available andccessible to a greaterumber of the ARMM populace

MPROVEMENTCOLLABORATIVE


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Definition of an ImprovementCollaborative

- an r g a n i z e d n e t w o r k o f aa r g e n u m b e r o f s i t e s( ,districts)facilities or communities that o r k

o g e t h e r for a limited period of,time usually t o 2 4 m o n t h s , toa p i d l y a c h i e v e s i g n i f i c a n tm p r o v e m e n t s in a o c u s e d t o p i cr e a through h a r e d l e a r n i n g a n dn t e n t i o n a l s p r e a d m e t h o d s .- , ,the system processes quality and

efficiency of care are to be

.improved

-OH ARMMImprovemen

Collaborative


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Essential Features of anImprovement Collaborative

1. Improvement objectives

2. Organizational structures

3. Initial Implementation Package

4. Spread strategy

5. Qualified and functional quality improvementteams

6. Monitoring system for quality of process andresults

7. Regular support to quality improvementteams (coaching)

8. Opportunities to share experiences andresults (learning sessions, etc.)

-O HA R M MIm p ro v e m

n tC o lla b o ra tiv e


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Two Types ofCollaboratives

Demonstration collaborative:15-60 sites who work intensivelyfor 9 to 24 months to adapt totheir local situation a best modelof care.

Spread collaborative: 40 to 150

sites who work for 12 to 24months to spread to their sitesthe best practices and solutionsdeveloped in the demonstration

collaborative

-OH ARMMImprovemen

Collaborative


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11

Learning Sessions (LS)

Two representatives from eachsite, who later brief their otherteam members, gather at LS

location QI, e.g., review of improvement

model, data collection methods,teamwork, etc.

Technical updates

Each site presents the changesthey made and the results

achieved

-OH ARMMImprovemen

Collaborative


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12

Action Periods

Regular meetings of site teams(usually weekly)

Identify and test changes in site

care system or processes thatmay lead to improvements

Site teams self assess and monitorresults e.g., through chart audits

(all or samples), register tallies,observation, interviews.

Collaborative coaches (project staff,district or regional supervisors or

technical experts) visit sites,usually once a month to review

-OH ARMMImprovemen

Collaborative


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Improvement Objectives,Implementation Packageand Measurement

Strategy

-OH ARMMImprovemen

Collaborative


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very system iserfectly designed toachievehe result it gets- ,aul Batalden MD

:Fundamental Concept of Improvement


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Improvement Objectives

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An improvement objective is

one objective (amongseveral) for achievingmeasurable improvements inthe quality of care oroutcomes.

-OH ARMMImprovemen

Collaborative


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Relationship of Objectives, Implementation

Package, and Measurement Strategy

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The implementation packageenables the attainment of the

improvement objectives Indicators measure the

progress toward achieving

improvement objectives Data are collected according to

specified indicators(measurement)

-OH ARMMImprovemen

Collaborative


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ImprovementObjectives

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DOH-ARMM improvethe quality of services

and the scaling up of : Active Management of

the Third Stage of

Labor (AMTSL),

Essential Newborn Care(ENC)

o

o

-OH ARMMImprovemen

Collaborative


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Stretch Targets

Sometimes specific targets are set Should have some evidence that they

are attainable

Example: Reduce post partumhemorrhage (PPH) by 75% by the endof the collaborative

Example: Increase the proportion of

newborns breastfed within the firsthour from 50% to 90%

Example: Increase the % of mothers whodeliver with Active Management of theThird Stage of Labor (AMTSL) from 5%to 100%

-OH ARMMImprovemen

Collaborative


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Implementation Package -Definition

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The technical and operationalinterventions essential forachieving an improvement

objective and desired results

Typically, an implementationpackage consists of standards,

evidence-basedbest practicesand/or operational changesnecessary to implement thesebest practices

-OH ARMMImprovemen

Collaborative


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Measurement of Results

Monitoring is a key function in allcollaboratives and must include:

Identified key, common indicatorsto measure progress toward

meeting improvement objectives

Record of changes made

Strategy for data collection (whocollects data; from what source;with what tools; organization ofcollective collaborative data)

Strategy for data analysis and

-OH ARMMImprovemen

Collaborative


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Status of the ImplementationPackage in DOH-ARMM

>90% of Rural Health Midwivestrained on CMNC

At least 76% of trained RHMspractice AMTSL

At least 84% of trained RHMspractice ENC

Seven out of 18 trained BTLteams proficient on the MLLA

procedure

-OH ARMMImprovemen

Collaborative


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Standards for AMTSL, ENCand BTL (Implementation

Package)

AMTSL- Injection of a uterotonic within

one minute of delivery(Oxytocin 10 IU)

- Controlled cord traction at the

height of a contraction- Uterine massage through the

abdominal wall to keep theuterus well-contracted after

the placenta is extruded

-OH ARMMImprovemen

Collaborative


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Standards for AMTSL, ENCand BTL

ENC

- Immediate drying of the skin

- Immediate skin-to-skin contact(maintain temperature)

- Timely cutting of the umbilical

cord (after cord pulsations havestopped)

- Early initiation of breastfeeding

(within 90 minutes after delivery)

-OH ARMMImprovemen

Collaborative


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Standards for AMTSL,ENC and BTL

BTL- Counseling to ensure informed

choice and voluntarism

- Referral of clients to BTLservice point following

standard flow- Use of Minilap under Local

Anesthesia (MLLA) to achieveBTL

-OH ARMMImprovemen

Collaborative


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. Study, :ollect data answer the questions- id the change lead to improvement?- s it significant improvement?

. Planlan thechanges

. Actext steps onhe basis ofhe analysis. Doest the changes

Scientific Method

How do we change the system?

-OH ARMMImprovemen

Collaborative


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Scientific Method

When you have tried outa change

Answer the questions

s thehangesignificant?

id thehangesead toimprovement?Yes

Yeso

Noryanotherchange

dapt thehange& ry againeep thechanges


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Preparatory phase 1

Involve key actors

Set improvement objectives

Put an organizational structure in place

Review evidence and agree on the change package &indicators

Determine capacity building & resource needs toimplement change package

Adapt proven standards to country context

-OH ARMMImprovemen

Collaborative


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Preparatory phase 2

Choose initial sites

Develop spread & sustainability strategy

Develop implementation plan & timeline

Develop & test monitoring system

Define communication & sharing mechanisms

Design training strategy for QI & tech contentbased on improvement objectives

Develop tools (monitoring, coaching, job aids)

-OH ARMMImprovemen

Collaborative


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Implementationphase

Form QI teams

Ensure basic resources needed to implement norms

Develop QI team coaching plan

Organize LS content, methods, & roll-out

Ensure clinical & QI competencies via training & coaching

Ensure validity of monitoring data

Determine best time to synthesize best practices & move tospread.

-OH ARMMImprovemen

Collaborative


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Define team

A team is a high-performing task groupwhose members areinterdependent and sharea common performance

objective

Francis & Young

-OH ARMMImprovemen

Collaborative


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Who Should Bea Coach?

Must be able to visit siteregularly

Highly motivated and engagedin the activity

Necessary skills Coaching strategy changes

throughout collaborative

-OH ARMMImprovemen

Collaborative


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Thank You

-OH ARMMImprovemen

Collaborative

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2 Session 1b May 22 2011 FINAL

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