04/13/23 1

Improvement Basics and an Introduction to Collaborative

Improvement

CORE Group Fall Meeting: Collaborative Improvement Approaches at the Community Level

Lani Marquez, MHSDirector of Knowledge Management

USAID Health Care Improvement ProjectUniversity Research Co., LLC (URC)

USAID HEALTH CARE IMPROVEMENT PROJECT2

Outline of the session

• Basics of quality improvement in health care and the improvement collaborative approach (Lani)

• Case study: Community malaria collaborative in Benin (Judy)

• Case study: OVC collaborative in Ethiopia (Nicole)

• Plans for a community collaborative in Senegal (David)

• Discussion

USAID HEALTH CARE IMPROVEMENT PROJECT3

How have we traditionally tried to improve health programs?

• Standards and guidelines• More or new staff• Training• Supervision• More supplies and equipment• Regulations—licensing, accreditation

Evidence indicates that all are necessary…but not sufficient to achieve desired results

USAID HEALTH CARE IMPROVEMENT PROJECT4

Traditional approaches have often failed to address processes of care

Inputs OutcomesProcess

Mali MOH community maternal newborn program

Standards developedCHWs and traditional birth

attendants trainedCommunity health associations

formed

Mali community collaborative baseline13% of women reported ANC home/

community visit last pregnancy25% of CHWs provided birth preparedness

counseling42% women knew 2 newborn danger signsNo health commune had a community birth

emergency plan

USAID HEALTH CARE IMPROVEMENT PROJECT

The fundamental concept of improvement

“Every system is perfectly designed to achieve exactly the results it achieves”

“So if we don't change, we can't expect a different result.”

- President Barack Obama July 22, 2009

5

USAID HEALTH CARE IMPROVEMENT PROJECT

Quality improvement: Making changes in systems and processes to improve outcomes

– Understand the program in terms of processes and systems

– Implement high-impact interventions– Teams develop solutions– Focus on client needs– Test changes to see if they yield improvement– Teams manage data to measure results

6

7

Source:Langley et al. (1999), The Improvement Guide

8

Example: QI process followed by team in Uganda

Tracked results: Improved enrollment in HIV care from 33% to 100% in 5 months

Analyzed process, identified and

tested changes: peer escorts, daily cross-check of patient registers,

better counseling

Created aim: Increase follow-up

care for HIV-positive pregnant women

USAID HEALTH CARE IMPROVEMENT PROJECT

There are many improvement approaches out there; all have produced good results

• Client-Oriented, Provider-Efficient (COPE)• Facilitated Accreditation• Fully Functional Service Point• Improvement Collaborative• Partnership Defined Quality (PDQ)• Performance Improvement• Quality Design/Redesign• Standards-Based Management and Recognition

(SBM-R)

9

USAID HEALTH CARE IMPROVEMENT PROJECT

Common elements of effective improvement strategies

10

1. Standards

2. Champions

3. Analysis of gaps

4. Specific aims

5. Choose interventions

6. Implement interventions

7. Monitor and document results

8. Involve the community/clients

9. Use incentives and motivators

10. Plan for scale-up

11. Plan for sustaining the gains

Basics of collaborative improvement

QI team

site

Site-level summaryQI team

LearningSession

representative

Site-level testing of changes and analysis of results

11

QI team

site

QI team

site

QI team

site

QI team

site

QI team

siteQI team

site

QI team

site

Collaborative-level sharing and synthesis of best practices

QI team

site

QI team

site

Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care

USAID HEALTH CARE IMPROVEMENT PROJECT

QI team

site

LearningSession

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

LearningSession

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

LearningSession

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

LearningSession

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

Demonstration

Spread

Paths to scaling up improvements

12

USAID HEALTH CARE IMPROVEMENT PROJECT

Key concepts in collaborative improvement

• Harnesses the efforts of many teams making changes, aimed at same objectives

• Common “change” or implementation package

• Common set of measures to determine, are these changes yielding improvement?

• Learning sessions—encounters for teams to share and learn from each other

• Coaching and support to maintain the pace

• Synthesis of what was learned by teams

• Strategy for spread

13

USAID HEALTH CARE IMPROVEMENT PROJECT

Results from analysis of 135 time series charts from 27 collaboratives in 12 countries

Indicator Average for 135 time series charts

Reached 80% 88%

Reached 90% 76%

Absolute improvement 52%

Relative improvement 210%

Time to achieve 80% 9.2 months

Time to achieve 90% 14.3 months

Percentage months above 80% once reached 80%

69%

14

USAID HEALTH CARE IMPROVEMENT PROJECT

USAID HEALTH CARE IMPROVEMENT PROJECT

Community EONC Collaborative in Guatemala(16 districts in 7 health areas)

2436

5365

0

20

40

60

80

100

feb-10 may-10

Pregnant women who recognize at least 3 danger

signs during pregnancy, delivery, post-partum

N=304

Prioritized communities that have health commission with

emergency planN=180

Interventions:-Community mobilization: assemblies and training-Home visits-Mass media (radio, posters)-Group talks,-Posters in public places-Pregnant women clubs

04/13/23 17

How can collaborative improvement be applied to community level

programs and services?

What are the benefits?

What are the challenges?

17

USAID HEALTH CARE IMPROVEMENT PROJECT

The preceding slides were presented at theCORE Group 2010 Fall Meeting

Washington, DC

To see similar presentations, please visit:www.coregroup.org/resources/meetingreports