The Need for Quality Improvement : Challenges and Options
Indira Narayanan, MDConsultantMCHIP
Two Golden Truths
2
• Mere PRESENCE of skilled birth attendants does not guarantee quality newborn care
• Mere TRAINING of skilled birth attendants (even if competency based) does not guarantee quality newborn care
EVOLUTION OF SKILLS OF PROVIDERS IN 10 HZ(DRC) (At end of training all providers scored at least 80% ( most near 100%) when
evaluated with checklists)
AMTSL ENC RESUSC. PP CARE EXAM NB MINOR INF MAJOR INF0
10
20
30
40
50
60
70
80
90
100
72
92
62
74
62
91
49
8386
61
8388
61
75
9497
78
94 9296
84
Aug/Sept 09 (n= 47) Feb/May 10 (n= 24) Juin/Sep 10 (n=36)
PERC
ENTA
GE
Providers who gained skills through interaction with trained health workers gained similar competence
AMTSL ENC RESUSC. PP CARE EXAM NB MINOR INF
MAJOR INF
0
20
40
60
80
100
72
92
6274
62
91
49
83 86
61
83 88
61
75
94 97
78
94 92 9684
Aug/Sept 09 (n= 47) Feb/May 10 (n= 24) Juin/Sep 10 (n=36)PE
RCEN
TAG
E
AMTSL ENC RESUSC. PP CARE EXAM NB MINOR INF
MAJOR INF
020406080
100 8495
5467
57
94
40
Aprl/May 10 (n= 19)
PER
CEN
TAG
E
Supervision is not always in the job description of hospital staff Self learning and mentoring cultures limited Supervisors are in govt. offices - limited clinical skills, poor
motivation for visits to peripheral centers – want incentives Supervision often considered long after training Peripheral centers are scattered and not sufficiently staffed Clinical competence needs support of commodities +referral
system – inadequate cases necessitates more mannequins Some NB indicators are not in HMIS –therefore not collected Baseline / end-line surveys are costly
23
Maintaining and improving quality of care through supervision: Challenges
Possible options to improve quality: Before training
Policies Follow HBB guidelines for adapting Advocate early for key indicators to be in HMIS
–can serve as benchmarks for assessing quality of care /results• Drying/stimulation/warmth – regular part of ENC• Airway Clearing• Ventilation• Outcome
Plan for having key Information in delivery registers – case sheets/partographs more likely to be lost/ misplaced
Possible options to improve quality
Before Training (Cont’d) Develop consensus on major issues with existing
programs Plan/get in place
• Equipment, supplies and mannequins. Allow time for procurement in planning program activities
• Resources for M & E – commence with additional columns/note books - plan use of benchmarks
During training course Use terminologies that are widely understood in the
country including peripheral health workers Brainstorm+ develop plans for quality+ M & E Brainstorm on how to get help for resuscitation
Possible options to improve quality During and after training
During training and evaluation including in OSCE 2 Monitor method of placement of mask to get a
better seal Monitor (a) the health worker looks for appropriate
chest expansion and (b) the facilitator verifies expansion
After training, while individual assessment through visits is ideal, it is time consuming and does not permit many workers to be covered, especially in peripheral centers. Additional methods of supervision include Internal supervision for larger centers/hospitals Group supervision for health centers with few staff.
Explore innovative methods such as use for m Health for both M & E and quality of care
Late acquisition of equipment and insufficient number of cases may have resulted in decrease in competence at the
first supervisory visit –improved with further support
Group supervision: more workers are targeted (5 S1 compared to 12 S2 and 13 S3) – USAID/BASICS)
Pretest (N:19) Oct 08
Post test (N:18)
Suivi 1 (N:5) Dec 08
Suivi 2 (N:12) Fev 08
Suivi 3 (N:13) Mar 08
0102030405060708090
100
66.3
95.57
68.81
88.22 90.98
Compétences en Réanimation des agents de santé de Betioky (Madagasdcar)
Pour
cent
age
des
moy
enne
s de
not
esSkills of Betioky (Madagascar) health workers on resuscitation
techniques
Perc
enta
ge o
f ave
rage
scor
es
Follow-up 1 (N=5) Dec 08
Follow-up 2 (N:12) Feb 08
Follow-up 3 (N:13) Mar 08
Group supervision (modified collaborative approach): Advantages
More agents are covered in a shorter time Agents help and motivate each other Fruitful exchanges on problems encountered in practice and
possible solutions Opportunity for supervisors to provide suggestions for
improvement to the group Easier to take decisions, define priorities, try solutions (PDSA) Useful for reviewing skills relating to cases that are infrequent
such’ birth asphyxia’ or an sick newborn in health centers) Rotating sites can be useful to inspect other centers Facilitation by NGO’s helpful
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Two Golden Rules
Training alone not enough. We must consider : Capacity building for
provision of documented good quality HBB care
Definition and documentation of the results