dr. ziaul matin, unicef
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Dr. Ziaul Matin Health Specialist, UNICEF
8 April 2015
Using 5S-CQI-TQM Approach For Improving Quality of Newborn Care In Bangladesh
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Outline
Background of Quality Improvement Initiative Different QI approaches for MNCH services 5S-CQI-TQM Approach for QI Applying 5S-CQI-TQM approach for Quality
Improvement of Newborn Care Findings from 11 hospitals under 5S-CQI-TQM Challenges and Way forward
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Context and Background
Substantial efforts have been taken so far to improve MNH services
There are still concerns regarding the quality and safety of services
Poor quality leads to medical errors, waste Currently the quality of services in the
hospitals is unsatisfactory and lead to client/consumer dis-satisfaction and mistrust
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Context and Background
The basic characteristics of service delivery in our hospitals are characterized by: Long waiting time Overcrowding Unhygienic and disorganized work environment Wastage
Many of our hospitals ignore the non-healtrh expectations of the people: Dignity Basic human needs Prompt attention for care and treatment Communication Confidentiality
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Lot of problems in The Hospital
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Current Efforts of the MoHFW for QI MoHFW has incorporated Quality Improvement programme in the Health
Sector Programme 2011-16 5S-CQI-TQM approach scaled up in 97 facilities BFHI/WFHI (21 hospitals) accredited Development of National Strategic Framework for QI Development of National Health Care Standards and guidelines for 5S-CQI-
TQM Regulatory framework for the private sector/ NGO hospitals/
clinics/laboratories Introduction of standard waste management system Development of guidelines and national standards of clinical care following
WHO guidelines/protocols Regional quality assurance system for family planning services etc. Other agencies/NGOs adopted different approaches for QI- SBMR, ISO,
COPE etc. 6
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Partnership and collaboration in QI MoHFW: Implementation through DGHS, DGFP and HEU (QIS) Partner Agencies: WHO, UNICEF, JICA, GIZ, USAID, MCHIP, SC, FHI
Policy advocacy QI Strategic Planning Resources Knowledge management on QI Technical assistance on 5S-CQI-TQM Capacity building South-South collaboration
icddr,b; CIPRB: Assessment, monitoring and mentoring, HMIS, MPDR Professional bodies and Academia: SOP development, Strategic
planning, mentoring/monitoring Technical agency: Supply Chain Mangement, equipment maintenance, NGOs: BRAC, Engender Health, others
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Improved Outcome of MNCH/FP/N Services
Step 1: 5 S Step 2: KAIZEN
Step 3: TQM
Work environment Problem solving Quality services & customer satisfaction
Competency Based
Training SBM-R
Regional Roaming QI
Teams
Joint Supervisory
Visits (Supportive Supervision)
MPDR MNCH/FP/N Clinical services at facility & community
MaMoni HSS Projects Integrated QI Approaches
PresenterPresentation Notes5S: Sort, Set, Shine (clean), Standardize, Sustain. KAIZEN: Continuous Quality Improvement (Japanese) TQM: Total Quality Management SBM-R: Standard Based Management and Recognition RRQIT: Regional Roaming Quality Improvement Team MPDR: Maternal & Perinatal Death Review JSV: Joint Supervisory Visits.
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TQM Approach
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What is 5S?
Sort Remove un-necessary items from your work place and reduce clutter
Set Organize everything needed in proper order for easy operation
Shine Maintain high standard of cleanliness
Standardize Set up the above 3 Ss as norms in every section of your work place
Sustain Train and maintain discipline of the personnel engaged
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Quality Improvement Process
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KA
IZEN
LEA
DER
SHIP
Wat
er Tru
nk
Root
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Implementation Steps of 5S-CQI-TQM
Advocacy and sensitization workshop at facility
Assess situation/ baseline
Develop WIT Action Plans and monitoring framework
Implement WIT Action Plans; track progress; Monitoring by QIT
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Formation of QIT/WITs
5S-CQI-TQM
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5S Activities: Implementation
Work Improvement Team
[3 - 5 persons]
Quality Improvement
Team [5 - 15 persons]
Top management
Work Improvement Team
[3 - 5 persons]
Work Improvement Team
[3 - 5 persons]
Taking leadership & support for 5S activities. Learn and practice 5S principles by him/herself
Train the hospital staff
Support implementation of 5S activities
Monitor & assess achievements of WITs Coaching the WITs
Implement 5S in respective work units/dept. Develop WIT Action Plans Conduct periodical monitoring Reporting to QIT
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Improving Newborn Care in UICEF Supported 11 Hospitals with 5S-CQI-TQM
Medical College Hospital
District Hospital
Upazila Health
complex
Funding
Chittagong and
Mymensing
Bandarban, Coxsbazar, Kishorganj, Netrokona
GoJ
Moulavibazar, Narail
Kalia, Barolekha
DFATD (MNHI)
Tangail UNICEF/KOICA
2 7 2
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Introducing the 5S-CQI-TQM approach Strategic planning and orientation
workshops organised in the targeted hospitals. QIT and WITs formed and QI plan was developed and has been implemented.
Training on Hospital Change Management through 5S-CQI-TQM approach was organised jointly with JICA in Sri Lanka during 2013.
Various QI activities such as clinical case review and continuous medical education sessions were supported.
Bi-annual and annual QI review workshop were organised by DGHS with joint support from UNICEF and JICA.
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PresenterPresentation Notes
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5S Activities (SORT) in Coxs Bazar District Hospital
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5S Activities (SET) activities Nurses station in Newborn Care Unit
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BEFORE 2011 AFTER 2014
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3S: Shining
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3S: Shining
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4S: Standardize
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Various QI activities (5S: Sustain)
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CQI in SCANU Before
After
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Renovation Works of SCANU in Mymensing Medical College Hospital
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237 medical officers and around 580 nurses were trained in the Emergency Triage and Treatment for sick newborns (ETAT) at BSMMU and other institutes in 2013-2014
A visual learning tool explaining
Standard Operating Procedures for use and maintenance of selected essential newborn equipment was developed with technical support from BSMMU.
Strengthen Service Delivery Capacity Development of Human Resource
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Strengthen Service Delivery SCANU Establishment
Renovation works of SCANU by the Public Works Department and Health Engineering Department under MoHFW
Quality assurance of the renovation works by Technical agency Procurement of Essential newborn care equipment Technical agency for installation, commissioning, user training and
maintenance of the equipment
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Small CQI/KIZEN
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Example of CQI/KIZEN Activity
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Waste disposal at the Bandarban District Hospital, before 5S implementation - first monitoring visit in August 2013
CQI/KIZEN activity at Bandarban District Hospital, after 5S implementation (and after building waste disposal system0, fourth monitoring visit in April 2014
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CQI In HMIS of Newborn Care
2011
2012
2013
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Policy Advocacy Through Demonstrating Impact of Innovations For Improved Quality of Newborn Care in SCANU
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Quality Improvement of services adopting TQM
approach
Competency based training and use of audio-
visual tools for skill development
Paper-based record keeping and reporting to Dashboard and individual
case-tracking through web-based MIS
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Radar diagram showing overall quality of management of MNH and support services at selected hospitals during baseline assessment
(2011)
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Overall outlook
Provision of Responsive HealthServices
Infection Control and Wastemanagement
Out-patient Department:Maternal
Out-patient Department:Neonatal
Pharmacy Management
Emergency Management
Indoor Management: Maternal
Indoor Management: Neonatal
Pathology Management
Store Management
Diet and Kitchen Mangement
Human Resource Managementand Leadership
Maintenace of Equipments
Record Keeping
QA Activities
Bandarban DH
Barlekha UHC
Chittagoong MCH
Cox's Bazar DH
Kalia UHC
Kishoregonj DH
MoulviBazar DH
Mynenshigh MCH
Narail DH
Netrokona DH
Tangail DH
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Radar diagram showing overall quality of management of MNH and support services at selected hospitals during end line assessment
(2014)
34
0%10%20%30%40%50%60%70%80%90%
100%Overall outlook
Provision of Responsive HealthServices
Infection Control and Wastemanagement
Out-patient Department:Maternal
Out-patient Department:Neonatal
Pharmacy Management
Emergency Management
Indoor Management: MaternalIndoor Management: Neonatal
Pathology Management
Store Management
Diet and Kitchen Mangement
Human Resource Managementand Leadership
Maintenace of Equipments
Record Keeping
Bandarban DH
Barlekha UHC
Chittagoong MCH
Cox's Bazar DH
Kalia UHC
Kishoregonj DH
MoulviBazar DH
Mynenshigh MCH
Narail DH
Netrokona DH
Tangail DH
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Sick Newborn Admission during 2013-2014
8007
7178
2947
99
1541
9960
7560
3785
138
2140
0
2000
4000
6000
8000
10000
12000
MMCH CMCH KDH BDH CDH
2013 2014
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Measuring KIZEN/CQI
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17.2 14.4
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2013 2014
SCANU Case fatality rate in 2013 and 2014
19772
3405
27996
4041 0
5000
10000
15000
20000
25000
30000
Total Admission Total mortality
SCANU total admission in 2013 and 2014
2013 2014
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Window for Policy Support of Strengthening National Capacity Building for QI
QI Secretariat at HEU, MoHFW
Divisional QI Committee
QI Assessor team
District/Upazila QI Committee
QIT/WIT
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Lessons Learned
This initiative has demonstrated evidence of changes resulting from the QI interventions in a small unit of targeted hospitals and documented those changes and processes for knowledge and evidence generation.
This has facilitated the programme managers to adopt the 5S-CQI-TQM as a feasible and doable approach for improving the quality of maternal and newborn care services at Primary/Secondary/Tertiary level hospitals within the HSS framework..
This has led to useful learnings and strategic directions to the policy makers and programme managers to further scale-up any Quality Improvement Initiatives/ in Bangladesh.
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Challenges
Poor institutional mechanism and organogram for QI Inadequate institutional capacity at national and sub-
national level for QI programme management Lack of effective coordination, harmonization and
integration among different programmes and agencies for Quality Improvement (QI)
Operationalize the national strategic framework and comprehensive Action Plan for QI
Shortage of human resources in number and skills Inadequate monitoring & supervision system Poor motivation of service providers for compliance
of clinical standards and protocols
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Way Forward
Capacity building of Quality secretariat and Qi committees both at national and Sub-national levels
Develop a realistic implementation plan with costing based on the national strategic framework for QI
Bring synergy, harmonisation and effective partnership under different QI programmes
Scale-up 5S-CQI-TQM sequentially from MNCH to cover whole hospital services leading to TQM
Develop assessors team at divisional level and conduct periodic assessment of facilities
Integrate core sets of quality indicators in the DHIS 2 (web-based HMIS)to monitor the quality of care
Institute comprehensive QI/QA system at all levels of health facilities leading to formal accreditation and reporting mechanism
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Systematic Approach For Total Quality Management (5S-CQI-TQM) Introduced in 11 Hospitals
After
Slide Number 1OutlineContext and BackgroundContext and BackgroundLot of problems in The HospitalCurrent Efforts of the MoHFW for QIPartnership and collaboration in QISlide Number 8TQM ApproachWhat is 5S?Slide Number 11Quality Improvement ProcessSlide Number 13Slide Number 14Implementation Steps of 5S-CQI-TQM5S Activities: ImplementationImproving Newborn Care in UICEF Supported 11 Hospitals with 5S-CQI-TQMIntroducing the 5S-CQI-TQM approach5S Activities (SORT) in Coxs Bazar District Hospital5S Activities (SET) activitiesNurses station in Newborn Care Unit3S: Shining3S: Shining4S: StandardizeVarious QI activities (5S: Sustain)CQI in SCANURenovation Works of SCANU in Mymensing Medical College HospitalSlide Number 27Slide Number 28Small CQI/KIZENExample of CQI/KIZEN ActivitySlide Number 31Policy Advocacy Through Demonstrating Impact of Innovations For Improved Quality of Newborn Care in SCANURadar diagram showing overall quality of management of MNH and support services at selected hospitals during baseline assessment (2011)Radar diagram showing overall quality of management of MNH and support services at selected hospitals during end line assessment (2014)Sick Newborn Admission during 2013-2014Measuring KIZEN/CQIWindow for Policy Support of Strengthening National Capacity Building for QILessons LearnedChallengesWay ForwardSystematic Approach For Total Quality Management (5S-CQI-TQM) Introduced in 11 Hospitals
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