Quality Improvements HBBIndia Experience

Dr. Anju Puri

HBB Review Meeting17th July 2012

Burden More than 2·3 million

children die annually 1.1 million occur in

neonatal period Million Death Study

investigated 10892 neonatal

deaths 12260 deaths in 1-59

monthsRef: Report on causes of Death 2001-2003,

RGI 2009

0-28 days – 3 causes (78%) Prematurity & LBW

32% N. Infections - 26.7% B. asphyxia & trauma

18.8% 1-59 months – 2

causes (50%) Pneumonia 27.7% Diarrheal diseases

22.3%

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Our overall goal is MDG 4 ENC/R Goal: Support the MOHFW, State

health departments, USAID bilateral health programs and the new National Newborn Care and Resuscitation Initiative (NSSK) to strengthen and expand access to ENC and teach basic resuscitation technique.

3

Uttar Pradesh

Gonda

Deoghar

Jamtara

Jharkhand

GiridihSimdeg

aChaibasaImmunization focus districts

Integrated districts

Geographic presence to support and influence implementation

Landscape of program inputs Facility readiness assessment using 8 parameters was conducted in

Oct 2010 using a structured questionnaire and 75 indicators generated.

KAP performance for maternal and newborn care especially neonatal resuscitation was mapped.

District mapping of the gaps generated and facility wise plan made for realistic program. Based on this implementation included provider mapping,

3- Day skill based training in essential newborn care and resuscitation skills of all district level primary providers conducted (250)

Job-aides and skill lab of key providers (28) in the demo-facilities. Supportive supervision involving quantitative and qualitative

checklists was used to provide on-going hand holding. Involving district authorities at each step was critical to success of the program.

Strengthening of health information systems by improved reporting and feedback mechanism,

Follow up of facility births of birth asphyxia newborns conducted in the community.

Quality Improvement

Quality Improvement (QI) approach is being used to analyse performance of the providers during training; and thereafter using systematic effort to improve the competence for the skill proficiency on neonatal resuscitation for improved outcomes.

QI areas Criteria Tools Purpose Measured ResultsSkill acquisition

Knows the steps and their sequence to perform the required skill but needs assistance

Quality Assurance Checklist (QAC) Performance checklist (PC)

QAC is used to document the inputs and process followed during the training Skill rating (Mega-Score) using pre-post checklist

During training

QAC results Pre-post test results

Skill competency

Knows the steps and their sequence and can perform the skill

Read and Do tools (R&D) Supportive supervision (SS)

Health worker with a step by step outline of the procedure for use during the practice phase of lesson. Standard checklist used during supervisory visits regular intervals

During mentoring

Self – Practice observations SS checklist

Skill Proficiency

Knows the steps and their sequence and effectively performs the required skill

Cross-learning visits Knowledge attitude Practice (KAP) HIMS trends

Best Practices are focused Change in behaviour & practice Survival rates

During bench-marking exercises

Facility Readiness

Skill Acquisition - QI

Quality Assurance Checklist Been used to assess

and adhere to a minimum standard for quality of process during the training.

10 observation questions

Score less than 80, training is repeated.

Pre-Post Performance checklist Pre-post test scores are

used to rate the training and provide feed-back to the providers.

Measure changes in both the knowledge and skill acquisition by the health providers as a result of the training.

S no Field for scoring. Scoring by observer/participants Total

score Average

score Ideal score Trainee 1 2 3 4 5 6

1 Facilitator to participants ratio District A 5 5 5 5 5 - 25 4.2 5 District AI 0 0 0 0 0 0 0 0.0 5 District B 5 5 5 5 5 5 30 5.0 5 District BI 5 5 5 5 5 25 4.2 5

2 Whether planning session conducted before the start of the training?

District A 0 NA NA NA NA 0 0.0 5 District AI 5 NA NA NA NA NA 5 0.8 5 District B 5 0 NA NA NA NA 5 0.8 5 District BI 5 NA NA NA NA 5 0.8 5

3 Items present at the training District A 2 2 2 2 2 10 1.7 5 District AI 2 2 2 2 2 2 12 2.0 5 District B 2 2 2 5 5 5 21 3.5 5 District BI 2 2 2 2 2 10 1.7 5

4 Number of participant’s for whom both pre & post test was conducted

District A 5 5 5 5 5 25 4.2 5 District AI 5 5 5 5 5 5 30 5.0 5 District B 5 5 5 5 5 5 30 5.0 5 District BI 5 5 5 5 5 25 4.2 5

5 Whether the performance list was correctly used

District A 5 0 5 5 5 20 3.3 5 District AI 5 5 5 5 5 5 30 5.0 5 District B 5 0 5 5 5 5 25 4.2 5 District BI 5 5 5 0 5 20 3.3 5

6 Feedback given using performance checklist

District A 0 0 5 5 5 15 2.5 5 District AI 5 5 0 5 5 5 25 4.2 5 District B 5 0 5 5 5 5 25 4.2 5 District BI 5 5 5 0 5 20 3.3 5

7 List of skill demonstrations District A 45 35 45 50 50 225 37.5 50 District AI 40 35 40 40 40 40 235 39.2 50 District B 40 45 45 50 50 45 275 45.8 50 District BI 45 45 45 40 40 215 35.8 50

8 Good quality video used in the training (Thermal protection and feeding)

District A 10 10 10 10 10 50 8.3 10 District AI 5 5 5 5 5 5 30 5.0 10 District B 10 10 10 0 10 10 50 8.3 10 District BI 0 0 0 0 0 0 0.0 10

9 Mega code score conducted correctly (Performed for all 5 bold items)

District A - 10 10 - - - 20 3.3 10 District AI 10 10 - 10 10 10 50 8.3 10 District B - - - - 10 10 20 3.3 10 District BI 10 0 - 10 - - 20 3.3 10

10 Number of participant’s with less than minimum passing score (optional)

District A 4 4 District AI 3 3 District B 3 3 District BI 3

Total score District A 72 67 87 82 82 - 390 65 100 District AI 77 72 62 77 77 82 447 70 100 District B 72 62 72 70 90 85 451 80 100 District BI 82 77 70 85 72 386 57 100

Pre-post test scores - trainings

Skill Competency – QIPractice exercises at skill labs

Skill Competency – QIRead and do tools

Supportive supervision A structured guide & training methodology for

supportive supervision was prepared An “yes and no “simple checklist” is being used for

regular supervision & feedback. Each skill is only scored, if all the steps is followed for

the skill. The checklist has two copies, one for the health

provider being supervised and the other for the one who supervises the activity. By this mean we assured that the provider who was supervised knows the misses and can be motivated to improve his performance.

Month/ year Jan-12 Mar-12 May-12

Interventions No

of o

bser

vatio

ns

At-le

ast on

e

None

All

No o

f obs

erva

tions

At-le

ast on

e

None

All

No o

f obs

erva

tions

At-le

ast on

e

None

All

Befo

re D

elive

ry

Provision of warmth 21 7 14 1 28 13 15 7 30 15 15 9

Infection prevention 20 15 5 3 30 21 7 9 30 23 7 11

Neonatal kit 20

12 20

16 28

16

Functioning of B&M 23 3 6 3 23 17 6 3 23 23 6 3

Effective partograph use 23 3 12 7 23 11 16 17 24 12 12 4

Looked for meconium 24

20 24

20 25

21

Imm

edia

te n

ewbo

rn

care

Immediate warmth 24 2 22 22 28 2 22 22 28 28 0 10

1-3 cord clamp 23 24 0 6 27 27 0 27 25 16 12 1

Skin to skin contact 21 12 12 0 25 13 12 1 27 16 12 1

Breast feeding initiation 24 24 0 2 26 26 0 0 18 18 0 4

Post

nata

l Car

e

Newborn examination 14 14 0 0 15 15 0 0 18 18 0 4

Vaccination 27 27 0 0 29 29 0 0 29 29 0 1

Counselling 28 16 12 0 29 21 12 0 27 22 5 5

Skill

stat

ion

dem

o

% Demo mannequin 11 68.2 14 74.3 16 77.5

Skill Competency QI Questionnaire and exercise methodology developed to focus on the

“preparedness” of the health facilities to deliver newborn care services as per the national guidelines.

The results framework is quantifiable in operational terms rather than health systems framework.

The analysis tool works on 75 broad indicators to generate color- codes to map the status of 8 parameters – Infrastructure, Delivery and Newborn Care services, Human resource, Essential drugs, equipment and supply, Register and client case record, Protocols and guidelines, universal precautions & infection prevention and Provider’s knowledge & competency on core skills.

A computerized SQL based analysis system has been developed to generate score based color-codes.

Implementing a planning exercise based after this exercise is found very useful and allowed us to bench mark the health facilities over a period of time.

Score-card and improvement scores

Graph showing change in knowledge on diagnosis of birth asphyxia

Graph showing change in provider’s knowledge & practice in using chronology of steps during resuscitation process

Sustaining and scaling efforts

Monthly HMIS data

HMIS Data ( Focus Facility Data) Year 1 Year 2Year 3*

Total number of deliveries 3354 3139 3107No. of Live births 3176 3034 3019No. of Still births 11 97 122No. of Neonatal deaths 0 0 2No. of full term deliveries NA 1020 3064No. of pre-term deliveries NA 6 41No. of neonates receiving vitamin K NA 0 455No. of newborns with weight <2.5kg 159 213 277No. of newborns breastfed within 1hr 3176 1918 2734No. of newborns requiring Bag & mask resuscitation 0 10 124No. of sick newborns referred to higher facility NA 8 30

District Hospital JamtaraYear 1 % Year 3* %

Total number of deliveries 1541   1510  No. of Live births 1275 82.7 1442 95.5

No. of Still births 246

16.2 (160 per 1000 LB) 68

4.5 (41 per 1000 LB)

No. of Neonatal deaths 0   0  No. of full-term deliveries NA   1477  No. of pre-term deliveries NA   18  No. of neonates receiving vitamin K 0   0  No. of newborns with weight <2.5kg 42 3.3 139 9.6No. of newborns breastfed within 1hr 1275 100 1263 87.6No. of newborns requiring Bag & mask resuscitation NA   86  No. of sick newborns referred to higher facility NA   12  

Consistency of reported Vs register data

HMIS Data Register Data Difference

N % N % Total number of deliveries 3107 2433 No. of Live births 3019 97.2 2351 96.6 0.5

No. of Still births 122 38.8 91 37.3 1.6

No. of Neonatal deaths 2 0.7 0 0.0 0.7

No. of full term deliveries 3064 98.6 2319 95.3 3.3

No. of pre-term deliveries 41 1.3 10 0.4 0.9

No. of newborns with weight <2.5kg 277 9.2 268 11.4 -2.2 No. of newborns requiring bag & mask resuscitation 124 4.1 86 3.7 0.4

Resuscitation Details

Resuscitation indicators

Non - breathing

Non - breathing or meconium or floppiness

% newborns with birth asphyxia 3.5 5.3

Proportion of "Non - breathing" newborns resuscitated with stimulation alone 9.8 6.5Proportion of "Non - breathing " newborns resuscitated with stimulation and suction 53.7 42.2Proportion of " Non- Breathing" resuscitated with stimulation, suction and bag and mask 35.4 48.2Proportion of "Non-breathing" newborns resuscitated successfully 98.8 96.9

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Lessons Learned Newborn care programs have tended to be

vertical, and slow to take up, have not considered or contributed to their quality.

It is feasible and beneficial to integrate ENC with Maternal Health programs and improve quality of care and have access to their concomitant resources.

The mother and baby dyad can be assessed and managed together.

The first week, especially the first three days, should be covered as a priority in the most feasible and effective manner at both facility and community levels with links between the two.