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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
15
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
16
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
17
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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18
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
19
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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27
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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30
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