Nyaya Health 2011 Implementing a Systems-Oriented Morbidity and Mortality Conference in Remote Rural Nepal for Quality Improvement Duncan Maru, MD, PHD Co-Founder, President| Nyaya Health Resident, Internal Medicine and Pediatrics June 15, 2011
Transcript
1.
Implementing a Systems-Oriented Morbidity and Mortality
Conference in Remote Rural Nepal for Quality Improvement
Duncan Maru, MD, PHD Co-Founder, President| Nyaya Health
Resident, Internal Medicine and Pediatrics
June 15, 2011
2. The Problem: Quality Chasm in Global Health Delivery The
ease with which young people die in Achham and the ease with which
it is accepted continues to horrify me. -Ruma Rajbhandari, MD, MPH
March 22, 2011 Brigham Internal Medicine Resident Global Health
Equity Fellow Nyaya Health Board of Advisors Member
3. Study Aim To develop a systems-oriented morbidity and
mortality conference (M&M) quality improvement initiative in a
remote rural resource-denied setting, aimed at facilitating
structured dialogue of hospital operations and identifying barriers
to providing quality care.
4. Setting: Nepal Achham District, Far Western Region
5. Setting: Nyaya Health
Social justice-oriented mission:
To provide free community-based healthcare in rural Nepal that
strengthens the public sector
To develop and disseminate effective strategies of healthcare
delivery in resource-poor settings throughout the world
Started working in Achham in 2006; public-private partnership
with Nepali Ministry of Health & Population since 2009
Nyaya Team:
29 full-time employed Nepali staff + ~50 CHWs
1 full-time US-based Executive Director
Volunteer Executive Team, Board of Directors and Board of
Advisors
Core Approach: Transparency, Public-Private Partnerships, and
Community-Based Care
6. Setting: Bayalpata Hospital
Mission: infrastructure development in collaboration with the
government, not only care provision
Government partnership contract for 5 years signed June, 2009
June, 2014
Over 60,000 patients treated to date
Approximately $200,000 operating budget annually
7. Bayalpata Hospital Team
8. Intervention: The M&M Conference
Weekly M&M conferences with the following features:
All clinical and non-clinical staff are invited to
participate
Structured dialogue using seven domains of analysis
Protected time for staff to participate
Engagement of senior management via telemedicine consultants
over email
Publishing of transcripts publicly online
9. Analysis
Qualitative observational study of a pilot program
Number of conferences conducted
Staff response via interviews and feedback sessions
Staff attendance and participation
Reviews of cases for suggestions for improvement and their
implementation
10. Outcomes Measures
Qualitative observational study of a pilot program
Number of conferences conducted
Staff response via interviews and feedback sessions
Staff attendance and participation
Reviews of cases for suggestions for improvement and their
implementation
11. Results: Selection of Cases
12. Results: Overview of Cases Recommendations
Full transcripts of all cases available at
wiki.nyayahealth.org
41-year-old woman with status epilepticus and obtundation
referred to hospital 12 hours away discussion about exam findings,
referral given lack of lumbar puncture tests, head CT
17-year-old woman with perineal laceration, repaired and did
well discussion about lighting and cleanliness of the delivery
room, need for blood transfusion, outreach for preventing young
pregnancies
8-month-old boy with pneumonia, septic shock who died
discussion about CPR techniques, oxygen and ambu bag
availability
25-year-old woman with eclampsia, seizures, broke with diazepam
and magnesium sulfate discussion about trainings, screenings for
eclampsia, stocking of anti-epileptics
13. Results: Staff Reception
Performed 19 of 35 weeks (54%).
80-85% attendance of staff members
Cases are only managed by a few personnel and are not well
understood by the rest of the staff, so these M&Ms help us to
learn from the lessons of the other staff in those cases.
Laboratory Assistant
It is frustrating to keep discussing the same issues, but they
are not yet resolved. We know some things take long times, but the
management should be faster and more effective about addressing
these problems. -Nurse
14. Conclusions and Next Steps
Our systems-oriented, inclusive M&M tool was feasible,
useful, and well-received by staff, though challenging to implement
and even more challenging to utilize effectively for systems-level
change.
Continue to use and evaluate the program through upcoming
leadership changes at the hospital
Improve follow-up and accountability regarding suggestions made
at the conferences
Ongoing discussions via Nick Simons Institute/Rural Staff
Support Program to bring the strategy to other hospitals
15. Implications
To do better at medicine in places where resources are limited,
where training is subpar, where patients are disempowered, and
where accountability mechanisms are lacking, we need to develop
simple, practical tools for transparency, accountability, and
quality improvement. Then we need to study rigorously the outcomes
of these tools and identify strategies for bringing them to
scale
16. Acknowledgements
The staff of Bayalpata Hospital & the people of Achham,
Nepal
The volunteers and individual donors of Nyaya Health
The Nepali Ministry of Health & Achham District Health
officials
Institutional Supporters Including: Abbot Laboratories, AMD and
the Open Architecture Network, America Nepal Medical Foundation
(ANMF), BWH COE in Quality and Safety, Buddha Air, Cents of Relief,
Child Health Foundation, CIWEC Clinic (Menlha Nursing Home),
Editage, Ella Lyman Cabot Trust, EquityEditors Association, Ford
Foundation, Fred Lovejoy Education and Research Foundation, Google
Grants, Martin P. Solomon Foundation , MEMC Foundation, Nepal
Ministry of Health and Population (MOHP), New Aid Foundation ,
Partners in Health , ProEdit Japan, QBC Diagnostics, Quidel
Corporation, Singapore Internet Research Center, Ten Friends, The
Hunger Site, The International Foundation, The Shelley and Donald
Rubin Foundation, Until There's a Cure Foundation, UpToDate,
William Prusoff Foundation, Wizfolio, Yale University
17. Questions, Reflections, Comments?
www.nyayahealth.org
18. Achham: Demographics
~270,000 people
99.6% Hindu
60% agricultural
>80% of men migrate to India, and 35% of families rely on
remittances from India
33% adults literate: 54% men, 14% of women
90% of houses did not have electricity
45% had access to clean water 2.5x worse than national
average