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1
IMPROVEMENT COLLABORATIVE REPORT
NOVEMBER 2012 to MAY 2013
Any questions, suggestions, clarifications, etc., may be directed at ssodzi-tettey@ihi.org.
2
Table of Contents BACKGROUND .................................................................................................................................................. 3
IMPLEMENTATION ........................................................................................................................................... 3
RESULTS ............................................................................................................................................................ 3
WAVE 3 – NCHS SYSTEM .................................................................................................................................. 4
SUSTAINABILITY INITIATIVES ............................................................................................................................ 5
MATERNAL &NEWBORN HEALTH REFERRAL WORK ........................................................................................ 5
DISSEMINATION ............................................................................................................................................... 9
KEY ENABLING FACTORS .................................................................................................................................. 9
KEY CHALLENGES AND STRATEGIES TO ADDRESS THEM ................................................................................. 9
PREPARATION FOR NATIONAL SCALE-UP ...................................................................................................... 10
CONCLUSION .................................................................................................................................................. 10
APPENDICES ................................................................................................................................................... 11
Wave 1 Sustainability Results .................................................................................................................... 11
Wave 2 District-Wide Improvement Collaborative Network Results ........................................................ 12
Wave 3........................................................................................................................................................ 19
MNH Referral Work .................................................................................................................................... 20
3
BACKGROUND
In 2008 the Institute for Healthcare Improvement (IHI) and the National Catholic Health Service (NCHS)
launched Project Fives Alive!– a five-year initiative to accelerate Ghana’s efforts to achieve Millennium
Development Goal Four (MDG 4) of reducing under-5 mortality by 67% from its 1990 baseline (110-120
deaths per 1000 live births) by 2015. Supported by the Bill & Melinda Gates Foundation (BMGF) and
partnering closely with the Ghana Health Service, Project Fives Alive! (PFA) has worked closely with
communities, frontline workers, and health system leadership to improve performance of maternal and
child health programs across Ghana – first in the nation’s challenged three northern regions, and now
scaling up across the remaining seven regions of the country. This report winds up the pre-national scale-
up activities of the Project, highlights the ongoing referral project, and describes initial steps taken to roll
out the national scale-up.
IMPLEMENTATION
Between July 2008 and September 2009, PFA! worked across the continuum of care in three innovation
districts in the Northern region in the first Wave. Afterwards, key learning on high-impact interventions for
improving early antenatal care, skilled delivery, and postnatal care were documented into a sub-district
change package and scaled up across all 38 districts in the three regions of the North to mark the second
Wave. This second Wave continued until the first quarter of 2013, when planning for national scale-up
started. To learn about changes for improving safety and reliability of hospital-based care processes, a
learning collaborative network of nine NCHS hospitals was run between October 2009 and June 2011 in a
third Wave, leading to the development of a hospital change package that has since been scaled up to the
remaining 29 NCHS hospitals and 36 hospitals in Wave 2.
In August 2013, to address the role of faulty referral processes in adverse maternal and neonatal
outcomes, the project commenced innovative referral work in six districts in Ghana’s Central and Northern
regions after securing additional funding from the Bill & Melinda Gates Foundation. According to design,
four of the six districts have formed Community-Facility Collaborative learning networks to amplify the
community voice in improving health outcomes, while two maintained the more traditional Facility-only
network. Across both regions, a total of 41 QI teams have been formed consisting of 30 sub-district teams,
five hospital teams, and six district-level referral teams. The innovative phase of the referral work is
expected to run until February 2014, after which effective referral solutions will be scaled up to the rest of
the PFA! platform.
RESULTS
PFA has demonstrated a strong track record of implementing and scaling up its programming according to
design using a quality improvement (QI) approach and has shown significant impact on improving
processes of care. Across the 38 districts in the three northern regions, significant improvements have
been achieved: 10% increase in the proportion of pregnant women receiving antenatal care in the first
trimester, 20-30% increase in skilled deliveries, 40-70% increase in the proportion of neonates receiving
postnatal care on day one or two of life (highest region recording 86%), and 20-60% increase in the
proportion of neonates receiving postnatal care on day six or seven (highest region recording 57%).
4
Concerning under-5 mortality in the three regions, the Upper East region (UER) and Upper West region
(UWR) reduced institutional under-5 mortality by 33% and 39% respectively from January 2009 to March
2013. The Northern region (NR), however, has not shown significant improvement in the overall reduction
of under-5 mortality, despite recording a 34.5% reduction in the 12- to 59-month age group.
Analysis of results from the Northern region ought to take into account the contextual realities of the
region in comparison to the other two. This is important in two specific regards: health system challenges
and a possible inadequate “dose” of the QI approach. While the Upper East and Upper West regions have
doctor-to-population ratios of 1:54,234 and 1:21,472 respectively, Northern region’s ratio is 1:80,000.
Compounding this is the sheer land size of the region, forming a third of the entire country. The total
number of districts in UER and UWR (24) is less than the number in NR (26), with the total number of
hospitals in both regions (12) also being less than the total number of hospitals in NR (18). In the NR it has
taken longer to reach full scale to support all 115 QI teams (vs. UER 71 teams and UWR 72 teams); using a
phased scale-up approach, the project struggled to adequately staff the project needs for certain periods,
which further complicated scheduling conflicts and delayed project implementation. All these factors
contributed to delayed implementation of learning sessions and site visits and inadequate numbers of
fully trained change agents compared to the other regions.
The above notwithstanding, disaggregated analysis clearly shows specific areas of improvement in
Maternal and Child Health indicators in the Northern region: 5%, 20%, and 40% increases in the early
antenatal attendance, skilled delivery, and the proportion of neonates seen within the first two days of life
respectively, and 34.5% reduction in mortality in the 12- to 59-month age group. Further, the general
stagnation in neonatal mortality rates across all three regions notwithstanding, it is noted that Northern
region has the lowest neonatal mortality rate – 3.8 deaths per 1000 live births, compared to 5.4 and 3.9
for Upper West and Upper East respectively.
Regarding data quality improvement (DQI) work in the 38 Wave 2 districts, a) average timeliness of
reporting has decreased from seven to three days, b) completeness of data summary sheets has increased
from 78-80% to 95-98%, and c) data accuracy has improved from inaccurate levels at 85-150% and was
restored to 100% accuracy for selected indicators such as first trimester registration and skilled delivery.
For DQI training, UWR had four sessions and UWR had three sessions, while NR had two sessions.
WAVE 3 – NCHS SYSTEM
Between October 2009 and May 2013, the nine prototype NCHS hospitals reduced their overall under-5
mortality by 28% – a significant further improvement on the 18% mortality reduction recorded at the end
of the innovation phase in June 2011. Seven out of the nine hospitals are now showing significant
improvement. These include St. Martin de Porres Hospital, Eikwe (29% reduction); Catholic Hospital,
Battor (41% reduction); Mathias Hospital, Yeji (42% reduction); Holy Family Hospital, Berekum (43%
reduction); St. Francis Xavier Hospital, Assin Foso (50% reduction); Margret Marquart Hospital, Kpando
(54% reduction); and Our Lady Of Grace Hospital, Breman Asikuma, leading with 86% reduction in
mortality. Of the seven, Holy Family Hospital, Berekum only showed improvement after the end of the
scale-up phase. Interventions in the other two continue, as does monitoring. Between January 2010 and
May 2013, the 19 scale-up hospitals in the NCHS showed 33% reduction with seven out of the 19 now
showing significant improvement.
5
By the end of the project, PFA expects to deliver significantly lower under-5 mortality across Ghana,
through improvements in access to and delivery of care that is safe, reliable, and of the highest quality.
SUSTAINABILITY INITIATIVES
The project’s approach to sustainability has been anchored on three pillars: capacity building in QI, hard-
wiring successful changes into the health system, and development of responsive information systems.
By late 2011, when the project was on the verge of national scale-up, the first External Advisory Board
meeting advised on a year’s extension within the Northern regions in order to better integrate successful
QI practices. This sparked a year-long effort to more deliberately implement a sustainability plan
subsequently developed in active partnership with the three Regional Directors of Health Services, while
also implementing the provisions of a Memorandum of Understanding (MoU) signed between the
project and the Regional Health Directorate (RHD) with specific roles and responsibilities assigned.
By April 2013, health staff participation in Learning Sessions (LSs) for the district-wide ICN increased to
2,576 at the collaborative level (all three regions), while site visits by POs increased to 2,156 as shown in
the monthly breakdown in Figure 5. By April 2013, all the planned LSs for the hospital ICN were
successfully concluded, and a total of 572 health staff had participated in all of them across the three
regions. The regional breakdown by LS is indicated in Figure 12. Intensity of site visits from core project
staff decreased, and health staff from the health system were selected and trained as change agents to
support QI work at regional and district levels. Under this sustainability work, integration of QI into district
and hospital review meetings grew from 33% in 2010 to 93% (2012 half year) in UER, 20% to 93% in UWR,
and remained unchanged at between 10-35% in NR (Figure 20). Complete data is being collected to
complete the 2012 full year.
Regarding integration of QI support visits into District and Hospital routine monitoring, planning for such
visits increased from 20% to 69% in UER and remained unchanged at 33% in UWR and NR (Figure 21), out
of which 50%, 33%, and 75% visits were actually done in UER, UWR, and NR respectively (Figure 22).
Logistical support for conducting planned site visits improved to 69%, 33%, and 77% respectively in UER,
UWR, and NR (Figure 23). Regarding integration of QI feedback into district and hospital routine feedback
systems, the proportion of actually delivered feedback to planned feedback to managers grew from a
minimum of two out of four planned feedback systems in first quarter of 2011 to a maximum of 13 out of
17 such plans across all three regions (Figure 24). Integration of DQI updates was, however, not very
successful in the Northern and Upper West regions (median of between 10-20%), unlike the Upper East
region in which it grew from 33% in 2011 to about 87% by 2013 (Figure 25). This was because DQI in UE
was properly aligned with the activities of the data validation team at the regional health directorate and
reported quarterly, unlike UWR and NR where updates were mostly done in preparation for DQI trainings.
MATERNAL &NEWBORN HEALTH REFERRAL WORK
The following table shows key activities planned and the state of their execution from January 2012 to
April 2013.
6
Category Activities Comments
Pre-launch
Selection of innovation regions & districts Successfully completed
and on schedule
Working out detailed design of community-health
facility ICN & facility-only ICN; plus community and
stakeholder engagement on design and application
of QI with non-literate groups
Successfully detailed
design and engaged
stakeholders as planned
Literature & development of draft change package Developed a structured
draft
Launch and LS1 scheduling plus budgeting with
GHS partners
Successfully completed
and on schedule
Health records review Was done in one district
each in the NR & CR
Drafted concepts & strategies for BMGF-funded
MNH referral projects community of practice
Carried out as planned
Participation in first community of practice
meeting
Carried out as planned
Post-launch
Launch Durbars in Community-Facility ICN districts Carried out as planned
Learning Session 1 in all 6 innovation districts Carried out as planned
Activity Period 1 site visits Happened in all districts,
but with variation in the
number of visits per team
between NR & CR
Training of regional, district, & hospital information
officers in data quality improvement focusing on
MNH referral data system
First training executed as
planned
Improvement Coaches Training Carried out as planned in
the Central Region
Northern Region training
delayed
Development of an indicator dashboard for
monitoring project implementation progress,
process and outcome performance
Dashboard has been
developed and is being
used
7
Baseline data collection of the monitoring
indicators
Completed for indicators
in DHIMS; mopping up for
non-routine indicators
Learning Session 2 Complete for CR; NR
outstanding
Activity Period 2 site visits Yet to begin in both
regions
Other operational issues
Budgeting for launch Durbars and LSs Completed for all districts
Financial reporting with GHS on 1st tranche of
transfers for durbars and LS1
Completed for all districts
Other highlights include the following:
The project has designed, printed, and deployed a standard referral register in collaboration with the Ghana Health Service, with prospects for national adaptation after the innovation phase.
The project has drafted PFA! concepts and strategies to guide cross-site learning among the three MNH referral projects funded by BMGF in Ghana, Ethiopia, and Nigeria. Following this, we will participate in two referral Community of Practice meetings in May 2012 and May 2013 in Ethiopia with many useful lessons for the project.
The project has written a separate report on key learnings and insights on the referral Community of Practice.
Attached as an appendix to this report is a table showing a summary of all the changes being tested to date in the six districts to improve the referral system.
The project has outlined a set of high-level referral process indicators to track the effect of changes tested by teams to improve the key drivers of faulty referrals. It is planned that subsequent reports will share data on some of these indicators. This is still very much a work in progress.
No Data Elements Measurement Numerator Denominator Chart type
Individual and Family Barriers
1 Pregnant women with danger signs at informal care settings TBAs
Proportion of
pregnant women
with danger signs
identified by TBA
Number of
women with
pregnancy related
danger signs
identified by TBAs
Total # of women
seeking care with
TBAs P-chart
2
Neonatal /Maternal referrals
by Community-based primary
care providers(TBAs, LCs, Pc)
Proportion of
neonates /
mothers referred
by Community-
No. of neonates / mothers referred by Community-based primary care
Total # of cases seen by CBPP
Run-chart
8
based primary care
providers(TBAs,
LCs, Pc)
providers(TBAs, LCs, Pc)
3 ****1ST Trimester registrants
identified by CBV
Proportion of 1ST
Trim registrants
identified by CBV
No. of 1ST Trim registrants identified by CBV
No. of ANC
registrants
identified by CBVs P-chart
Transportation and Communication Barriers
4
Emergency obstetric
cases/neonates transferred by
CTS (community transport
solution )(bicycle, motorbike,
taxis, private cars) from
community level to health
centres
Rate of Emergency
obstetric
cases/neonates
transferred by CTS
(community
transport solution
)(bicycle,
motorbike, taxis,
private cars
No. of Emergency
obstetric
cases/neonates
transferred by CTS
(community
transport solution
)(bicycle,
motorbike, taxis,
private cars
Total No. of Emergency obstetric cases/neonates transferred by transport solution
U-chart
5
Call notification before
emergency referrals to next
level
Proportion of
emergency cases
for which a health
center/hospital
make calls to next
level prior to
referral
No. of emergency
cases for which a
health
center/hospital
make calls to next
level prior to
referral
Total No. of
emergency cases
referred to next
level
P-chart
Inadequate Clinical Skills and Management
6
Adequate referral
documentation (Adequate:
referral indication and
treatment provided)
Proportion of
referred
mothers/neonates
with adequate
referral
documentation
No. of maternal
cases/neonates
with adequate
referral
documentation
Total No. of
mothers/neonates
with referral
documentation
P-chart
7 Referral Feedback
Proportion of cases for which CHPS/HC receive feedback
No. of maternal cases/neonates cases with referral feedback
Total No. of referrals
P-chart
Governance and Accountability
8
Referral forms stock outs
Proportion of sub districts without referral forms
No. of facilities without referral forms
Total No. of facilities in the districts
P-chart
9
DISSEMINATION
The project has had phenomenal success in writing and presenting posters at various international fora,
but more limited output in peer-reviewed publications. To ameliorate this, a one-week writing retreat
was organized in April 2013 with two consultants in attendance. An additional week in dedicated time
was given to Project Officers to improve various manuscripts. Weekly calls have also been arranged for
additional technical guidance to be provided. The project currently has seven fairly advanced
manuscripts, which it plans to complete by the end of the year.
ISQua held its first regional meeting in Africa in February 2013, and the project had the opportunity to do
four oral presentations and 10 poster presentations. Three executives of ISQua also visited two project
sites. One of the project directors was also invited to take part in a debate, speaking to the effectiveness
of hospital to hospital partnerships in improving health outcomes and patient safety.
The project presented 19 posters at the 2013 International Conference in London, and the Project
Director co-facilitated a session on the “Three Delays” model. The project has submitted three speaker
proposals to teach three sessions at the next International Forum in 2014.
KEY ENABLING FACTORS
The main enabling factors are:
High level of commitment and well-engaged RHDs
High level of commitment from frontline staff and Change Agents
Peer-to-peer learning and data-driven feedback at Learning Sessions across all three regions
Strong sense of teamwork and commitment among project staff
Continuous technical guidance and support from Steering Committee/faculty members
KEY CHALLENGES AND STRATEGIES TO ADDRESS THEM
The first challenge is project-wide, while the other three are specific to the referral work.
I. Delays in funds transfer to the regions for the completion of LSs was a major challenge in the period under review. This led to the cancellation and rescheduling of some of the LSs and is partly responsible for the delayed LS4 for the districts in NR (Gushegu, Karaga, and East Gonja). Discussions have started to include Wave 2 teams in referral work that is ongoing in the region, in addition to providing some ongoing site visit support to the Northern region in particular. Additionally, the project has drawn up its programme of work until 2015 in an attempt to better align budgets to planned activities, while taking measures to ensure prompt submission of financial reports from the various regions to facilitate further transfer of funds.
II. There is substantial non-routine data for monitoring the progress of referral work, thus making baseline data collection and subsequent updates very labor intensive.
III. The request of some frontline staff and community members for motivation/refreshment after QI meetings is the practice with other projects, but contrary to PFA! practices has proved somewhat sensitive for us. Project staff have always been very careful to explain what activities can be supported by PFA! and appropriately refer such requests to health managers.
QI work began; NHIfree
for maternity &early
infant care
10
IV. Availability of Improvement Coaches for joint site visits does not always coincide with the project
officers’ plan because of other commitments of the former, leading to rescheduling and attendant delayed execution.
PREPARATION FOR NATIONAL SCALE-UP
The following activities, among others, were undertaken in the first quarter of 2013 in preparation for
national scale-up.
To prepare the seven regions for national scale-up, the project embarked on a comprehensive leadership engagement exercise comprising meetings with Regional Directors of Health services and the management of District Health Directorates and District Hospitals across all seven regions. The Monitoring & Evaluation team of the project also used data accessed from the District Health Information Management Systems 2 to rank districts and prioritize same for inclusion in the national scale-up effort. Further, a new ten-week curriculum for training of Improvement Coaches in the health system in anticipation of a leveraged approach was tested and finalized. Finally, the Project had critical technical meetings to standardize indicators internally and align same with indicators routinely collected by the Ghana Health Service (GHS) to ensure internal consistency and external validity.
CONCLUSION
The next Collaborative Report, scheduled for the last quarter of 2013, will focus on the ongoing national scale-up effort, plans by the project to tackle stagnating neonatal mortality, and the MNH referral work.
11
APPENDICES
Wave 1 Sustainability Results
Figure 1:Wave 1 Improvement Collaborative Network – Early Registration of ANC, 4th ANC Visit &Skilled Delivery Coverage: Jan.’08 to March’13
37.0%
0%
10%
20%
30%
40%
50%
60%
Ja
n-0
8M
ar-
08
May-0
8Ju
l-08
Sep
-08
No
v-0
8Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
WAVE 1 COLLABORATIVE - EARLY REGISTRATION OF ANC
Aim: ≥80% OF ANC REGISTRANTS IN 1ST TRIMESTER
Subgroup Center
UCL LCL
0.5
0
0.2
0.4
0.6
0.8
1
1.2
Ja
n-0
8M
ar-
08
May-0
8Ju
l-08
Sep
-08
No
v-0
8Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2
Aim: ≥0.9 ANC REGISTRANTS ATTENDING ANC CLINICS FOR 4TH TIME BEFORE DELIVERY
PER EXPECTED PREGNANCY
Subgroup Center
UCL LCL
58.6%
80.5%88.8%
0%
20%
40%
60%
80%
100%
Ja
n-0
8M
ar-
08
May-0
8Ju
l-08
Sep
-08
No
v-0
8Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
WAVE 1 COLLABORATIVE - SKILLED DELIVERY COVERAGE
AIM: ≥75% OF DELIVERIES CONDUCTED BY SKILLED PERSONNEL
Subgroup Center
UCL LCL
Figure 2: Wave 1 Improvement Collaborative Network –Stillbirth Rate, Neonatal Death, Jan’08 to March’13
16.7
0
10
20
30
40
50
Ja
n-0
8M
ar-
08
May-0
8Ju
l-08
Sep
-08
No
v-0
8Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
Wave 1 Collaborative - Stillbirth RateAim: <10 stillbirths per 1000 skilled deliveries
Subgroup CenterUCL LCL
4.8
UCL
LCL0
2
4
6
8
10
12
14
16
Ja
n-0
8M
ar-
08
May-0
8Ju
l-08
Sep
-08
No
v-0
8Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
Wave 1 Overall Collaborative - Neonatal DeathsAim: <2 facility-based neonatal deaths per 1000
deliveries
Subgroup Center
UCL LCL
12
Wave 2 District-Wide Improvement Collaborative Network Results
Figure 3: Scale-up from Wave 1 to Wave 2 Collaborative, Jul’08 to April’13
0
50
100
150
200
250
300
Jul'0
8
Sep
t'0
8
No
v'0
8
Jan
'09
Mar
'09
May
'09
Jul'0
9
Sep
t'0
9
No
v'0
9
Jan
'10
Mar
'10
May
'10
Jul'1
0
Sep
t'1
0
No
v'1
0
Jan
'11
Mar
'11
May
'11
Jul'1
1
Sep
t'1
1
No
v'1
1
Jan
'12
Mar
'12
May
'12
Jul'1
2
Sep
t'1
2
No
v'1
2
Jan
'13
Mar
'13
Wave 1 Wave 1+2
Nu
mb
er
Progress in Scale-up from Wave 1 to Wave 2
# of sub-district QI teams# of hospital QI teams# of districtsWave 2 sub-district QI team aimWave 2 hospital QI team aimWave 2 district aim# of QI teams
Figure 5:Site Visit Frequency in Waves 1 & 2, July’08 to April’13
0
20
40
60
80
100
120
140
160
Mar
-…M
ay…
Jul-
10
Sep
-…N
ov-
…Ja
n-1
1M
ar-…
May
…Ju
l-1
1Se
p-…
No
v-…
Jan
-12
Mar
-…M
ay…
Jul-
12
Sep
-…N
ov-
…Ja
n-1
3M
ar-…
Frequency of Site Visits to Support QI teams in Waves 1 & 2 Collaboratives (as of March, 2013
No
. of
Site
Vis
its
Figure 4:Wave 2 Collaborative – LS Participants by Region, Sept’09 to April’13
0
50
100
150
200
250
300
350
UE UW NR
L1 L2 L3 L4
No
. of
Par
tici
pan
ts
13
Institutional stillbirth rates remain above 10 per 1000 skilled deliveries across the three regions. The UER is at a
rate of 20 per 1000 skilled deliveries, compared with a regional target of 10 per 1000 skilled deliveries (Figures
8)
Figure 7: Wave 2 Improvement Collaborative Network – Skilled Deliveries as Percentage of Total Deliveries, Jan’09 to April’13
72.2%
82.9% 87.1%
92.1%
50%
60%
70%
80%
90%
100%
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% OF TOTAL DELIVERIES THAT ARE ATTENDED BY SKILLED HEALTH
PERSONNEL IN UE REGION
Subgroup Center
UCL LCL
54.2%
63.6%72.0%
84.4%
30%
40%
50%
60%
70%
80%
90%
100%
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% OF TOTAL DELIVERIES THAT ARE ATTENDED BY SKILLED HEALTH
PERSONNEL IN UW REGION
Subgroup CenterUCL LCL
38.2%
56.7%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% OF TOTAL DELIVERIES THAT ARE ATTENDED BY SKILLED HEALTH
PERSONNEL IN NORTHERN REGION WAVE 2A
Subgroup CenterUCL LCL
Figure 8: Wave 2 Improvement Collaborative Network – Facility-Based Stillbirth Rate, Jan’09 to April’13
18.6
0
5
10
15
20
25
30
35
40
45
50
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF STILLBIRTHS PER 1000 SKILLED DELIVERIES IN UE REGION
Subgroup Center
UCL LCL
27.6
21.5
0
5
10
15
20
25
30
35
40
45
50
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF STILLBIRTHS PER 1000 SKILLED DELIVERIES IN UW REGION
Subgroup Center
UCL LCL
24.2
19.2
0
5
10
15
20
25
30
35
40
45
50
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF STILLBIRTHS PER 1000 SKILLED DELIVERIES IN NORTHERN
REGION WAVE 2A
Subgroup Center
UCL LCL
Figure 6:Wave 2 Improvement Collaborative Network – ANC registration in first trimester, Jan’09 to April’13
34.9%
45.5%
10%
20%
30%
40%
50%
60%
70%
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% OF ANC REGISTRANTS IN 1ST TRIMESTER AT REGISTRATION IN UER
Subgroup Center
UCL LCL
42.6%
52.1%
10%
20%
30%
40%
50%
60%
70%
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% OF ANC REGISTRANTS IN 1ST TRIMESTER AT REGISTRATION IN UW
REGION
Subgroup CenterUCL LCL
28.0%33.9%
10%
20%
30%
40%
50%
60%
70%
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% OF ANC REGISTRANTS IN 1ST TRIMESTER AT REGISTRATION IN
NORTHERN REGION WAVE 2A
Subgroup Center
UCL LCL
14
Wave 2 Hospitals Improvement Collaborative Network
As noted earlier, the LS2 for hospitals in the NR was completed in this period and increased the number of
health staff participating in LS2 of the hospital ICN to 212 with the regional breakdown indicated in figure 12.
The low participation in LS1 from the UWR is because the participant’s evaluation form, which is the main
source of this data, was not filled by majority of the participants.
Figure 11: Wave 2 Improvement Collaborative Network – Facility-Based Neonatal Mortality Rate, Jan’09 toApril’13
3.9
0
2
4
6
8
10
12
14
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF INSTITUTIONAL NEONATAL MORTALITY IN UE REGION
Subgroup CenterUCL LCL
5.4
0
2
4
6
8
10
12
14
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF INSTITUTIONAL NEONATAL MORTALITY IN UW REGION
Subgroup Center
UCL LCL
1.7
0
2
4
6
8
10
12
14
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF INSTITUTIONAL NEONATAL MORTALITY IN NORTHERN REGION
WAVE 2A
Subgroup Center
UCL LCL
Figure 9: Wave 2 Improvement Collaborative Network – Early Postnatal Care for Neonates, Jan’08 to April’13
21.6%
85.5%
0%
20%
40%
60%
80%
100%
Ja
n'0
8M
ar'08
May'0
8Ju
l'08
Sep
t'08
No
v'0
8Ja
n'0
9M
ar'09
May'0
9Ju
l'09
Sep
t'09
No
v'0
9Ja
n'1
0M
ar'10
May'1
0Ju
l'10
Sep
t'10
No
v'1
0Ja
n'1
1M
ar'11
May'1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% of Neonates who Received PNC on Day 1 or 2: UER
Subgroup Center
UCL LCL
8.2%
81.0%
0%
20%
40%
60%
80%
100%
Ja
n'0
8M
ar'08
May'0
8Ju
l'08
Sep
t'08
No
v'0
8Ja
n'0
9M
ar'09
May'0
9Ju
l'09
Sep
t'09
No
v'0
9Ja
n'1
0M
ar'10
May'1
0Ju
l'10
Sep
t'10
No
v'1
0Ja
n'1
1M
ar'11
May'1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% of Neonates who Received PNC on Day 1 or 2: UWR
Subgroup CenterUCL LCL
2.1%
27.0%
57.1%
43.6%
0%
20%
40%
60%
80%
100%
Ja
n'0
8M
ar'08
May'0
8Ju
l'08
Sep
t'08
No
v'0
8Ja
n'0
9M
ar'09
May'0
9Ju
l'09
Sep
t'09
No
v'0
9Ja
n'1
0M
ar'10
May'1
0Ju
l'10
Sep
t'10
No
v'1
0Ja
n'1
1M
ar'11
May'1
1Ju
l'11
Sep
t'11
No
v'1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% of Neonates who Received PNC on Day 1 or 2: NR
Subgroup CenterUCL LCL
Figure 10: Wave 2 Improvement Collaborative Network – Neonates who Received Second Postnatal Care within First Week of Life, Jan’08 to April’13
47.4%
62.9%
0%
20%
40%
60%
80%
100%
Ja
n'0
8M
ar'08
May'0
8Ju
l'08
Sep
t'08
No
v'0
8Ja
n'0
9M
ar'09
May'0
9Ju
l'09
Sep
t'09
No
v'0
9Ja
n'1
0M
ar'10
May'1
0Ju
l'10
Sep
t'10
No
v'1
0Ja
n'1
1M
ar'11
May'1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% of PNC Registrants who Received Follow-up Care on Day 6 or 7: UER
Subgroup Center
UCL LCL
30.2%
54.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Ja
n'0
8M
ar'08
May'0
8Ju
l'08
Sep
t'08
No
v'0
8Ja
n'0
9M
ar'09
May'0
9Ju
l'09
Sep
t'09
No
v'0
9Ja
n'1
0M
ar'10
May'1
0Ju
l'10
Sep
t'10
No
v'1
0Ja
n'1
1M
ar'11
May'1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% of PNC Registrants who Received Follow-up Care on Day 6 or 7: UWR
Subgroup CenterUCL LCL
18.6%
37.6%
22.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Ja
n'0
8M
ar'08
May'0
8Ju
l'08
Sep
t'08
No
v'0
8Ja
n'0
9M
ar'09
May'0
9Ju
l'09
Sep
t'09
No
v'0
9Ja
n'1
0M
ar'10
May'1
0Ju
l'10
Sep
t'10
No
v'1
0Ja
n'1
1M
ar'11
May'1
1Ju
l'11
Sep
t'11
No
v'1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
% of PNC Registrants who Received Follow-up Care on Day 6 or 7: NR
Subgroup Center
UCL LCL
15
Wave 2 Hospitals Improvement Collaborative Network
Figure 13: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Deaths among Children 0-11 Months Old: Jan’09 to April’13
39.2
26.6
0
20
40
60
80
100
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF INSTITUTIONAL DEATHS AMONG 0-11 MONTH OLD INFANTS PER 1000
ADMISSIONS, UE REGION
Subgroup Center
UCL LCL
25.1
13.4
0
20
40
60
80
100
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF INSTITUTIONAL DEATHS AMONG 0-11 MONTHS OLD INFANTS PER 1000
ADMISSIONS, UW REGION
Subgroup CenterUCL LCL
38.5
0
20
40
60
80
100
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF INSTITUTIONAL DEATHS AMONG 0-1 1 MONTHS OLD INFANTS PER 1000
ADMISSIONS, NORTHERN REGION
Subgroup CenterUCL LCL
Figure 12:Wave 2 Hospitals ICN – LS Participants by Region
0
20
40
60
80
100
120
140
UE UW NR
L1 L2 L3
Figure 14: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Deaths among Children 12-59 Months Old: Jan’09 to April’13
15.5
9.3
0
10
20
30
40
50
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF INSTITUTIONAL DEATHS AMONG 12-59 MONTHS OLD CHILDREN PER 1000
ADMISSIONS, UE REGION
Subgroup Center
UCL LCL
14.6
8.5
0
10
20
30
40
50
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF INSTITUTIONAL DEATHS AMONG 12-59 MONTHS OLD CHILDREN PER 1000
ADMISSIONS, UW REGION
Subgroup Center
UCL LCL
20.3
0
10
20
30
40
50
Ja
n-0
9M
ar-
09
May-0
9Ju
l-09
Sep
-09
No
v-0
9Ja
n-1
0M
ar-
10
May-1
0Ju
l-10
Sep
-10
No
v-1
0Ja
n-1
1M
ar-
11
May-1
1Ju
l-11
Sep
-11
No
v-1
1Ja
n-1
2M
ar-
12
May-1
2Ju
l-12
Sep
-12
No
v-1
2Ja
n-1
3M
ar-
13
RATE OF INSTITUTIONAL DEATHS AMONG 12-59 MONTHS OLD CHILDREN PER 1000
ADMISSIONS, NORTHERN REGION
Subgroup Center
UCL LCL
16
Figure 15: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Deaths among Children Under 5 Years Old: Jan’09 to April’13
Figure 16: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Malaria Case Fatality Among Under 5s, Jan’09 to April’13
Figure 20: Sustainability of Wave 2: Integration of QI into District and Hospital review meetings
17
Figure 21: Sustainability of Wave 2: Integration of QI support visits into District and Hospital routine monitoring
20
69
0
20
40
60
80
100
Jan
-11
Ap
r-1
1
Jul-
11
Oct
-11
Jan
-12
Ap
r-1
2
Jul-
12
Oct
-12
Jan
-13
Ap
r-1
3
Jul-
13
Oct
-13
Planned site visits UER
% Planned Median
33
0
20
40
60
80
100
Jan
-11
Ap
r-1
1
Jul-
11
Oct
-11
Jan
-12
Ap
r-1
2
Jul-
12
Oct
-12
Jan
-13
Ap
r-1
3
Jul-
13
Oct
-13
Planned site visits UWR
% Planned Median
33
0
20
40
60
80
100
Jan
-11
Ap
r-1
1
Jul-
11
Oct
-11
Jan
-12
Ap
r-1
2
Jul-
12
Oct
-12
Jan
-13
Ap
r-1
3
Jul-
13
Oct
-13
Planned site visit NR
% Planned Median
Figure 23: Sustainability of Wave 2: Integration of QI support visits into District and Hospital routine monitoring
69
0
20
40
60
80
100
Jan
-11
Mar
-11
May
-11
Jul-
11
Sep
-11
No
v-11
Jan
-12
Mar
-12
May
-12
Jul-
12
Sep
-12
No
v-12
Jan
-13
Mar
-13
Logistical support UER
% support based on plan visit Median
35
0
20
40
60
80
100
Jan
-11
Mar
-11
May
-11
Jul-
11
Sep
-11
No
v-11
Jan
-12
Mar
-12
May
-12
Jul-
12
Sep
-12
No
v-12
Jan
-13
Logistical support UWR
% support based on plan visit Median
77
0
20
40
60
80
100
Jan
-11
Mar
-11
May
-11
Jul-
11
Sep
-11
No
v-11
Jan
-12
Mar
-12
May
-12
Jul-
12
Sep
-12
No
v-12
Jan
-13
Mar
-13
Logistical support NR
% support based on plan visit
Figure 22: Sustainability of Wave 2: Integration of QI support visits into District and Hospital routine monitoring
50
0
20
40
60
80
100
Jan
-11
Mar
-11
May
-11
Jul-
11
Sep
-11
No
v-11
Jan
-12
Mar
-12
May
-12
Jul-
12
Sep
-12
No
v-12
Jan
-13
Actual site Visit UER
% Actuals Median
33
0
20
40
60
80
100
Jan
-11
Mar
-11
May
-11
Jul-
11
Sep
-11
No
v-11
Jan
-12
Mar
-12
May
-12
Jul-
12
Sep
-12
No
v-12
Jan
-13
Actual site Visit UWR
% Actuals Median
75
0
20
40
60
80
100
Jan
-11
Mar
-11
May
-11
Jul-
11
Sep
-11
No
v-11
Jan
-12
Mar
-12
May
-12
Jul-
12
Sep
-12
No
v-12
Jan
-13
Actual site Visit NR
% Actuals Median
18
Figure 25: Sustainability of Wave 2: Integration of DQI updates into District and Hospital routine work
0
20
40
60
80
100
% DQI Updates (Completeness & Timeliness) UER
% DQI updates
0
20
40
60
80
100
Jan
-11
Mar
-11
May
-11
Jul-
11
Sep
-11
No
v-11
Jan
-12
Mar
-12
May
-12
Jul-
12
Sep
-12
No
v-12
% DQI Updates (Completeness & Timeliness) UWR
% DQI updates
0
20
40
60
80
100
Jan
'11
Mar
'11
May
'11
Jul'1
1
Sep
'11
No
v'11
Jan
'12
Mar
'12
May
'12
Jul'1
2
Sep
'12
No
v'12
% DQI Updates (Completeness & Timeliness) NR
% DQI updates
Figure 24: Sustainability of Wave 2: Integration of QI Feedback into District and Hospital routine feedback mechanisms
0
2
4
6
8
10
12
14
16
Q1(2011)
Q2(2011)
Q3(2011)
Q4(2011)
Q1(2012)
Q2(2012)
Q3(2012)
Q4(2012)
Q1(2013)
Quaterly feedback to Med. Dir./DDHS/DHMT UER
Planned Quaterly feedback to Med. Dir./DDHS/DHMT
Actual Quaterly feedback to Med. Dir./DDHS/DHMT
0
5
10
15
20
Q1(2011)
Q2(2011)
Q3(2011)
Q4(2011)
Q1(2012)
Q2(2012)
Q3(2012)
Q4(2012)
Q1(2013)
Quaterly feedback to Med. Dir./DDHS/DHMT UWR
Planned Quaterly feedback to Med. Dir./DDHS/DHMT
Actual Quaterly feedback to Med. Dir./DDHS/DHMT
0
5
10
15
20
Q1(2011)
Q2(2011)
Q3(2011)
Q4(2011)
Q1(2012)
Q2(2012)
Q3(2012)
Q4(2012)
Quaterly feedback to Med. Dir./DDHS/DHMT
Planned Quaterly feedback to Med. Dir./DDHS/DHMT
Actual Feedback to Med. Dir./DDHS/DHMT
Figure 26: Sustainability of Wave 2: Integration of QI feedback into District routine feedback mechanisms
0
5
10
15
20
Q1(2011)
Q2(2011)
Q3(2011)
Q4(2011)
Q1(2012)
Q2(2012)
Q3(2012)
Q4(2012)
Quaterly feedback to Subdistricts/Hos. Units UER
Planned Quaterly feedback to Subdistricts / Hos. Units
Actual Quaterly feedback to Subdistricts / Hos. Units
0
5
10
15
20
Q1(2011)
Q2(2011)
Q3(2011)
Q4(2011)
Q1(2012)
Q2(2012)
Q3(2012)
Q4(2012)
Q1(2013)
Quaterly feedback to Subdistricts/Hos. Units UWR
Planned Quaterly feedback to Subdistricts / Hos. Units
Actual Quaterly feedback to Subdistricts / Hos. Units
0
5
10
15
20
Q1(2011)
Q2(2011)
Q3(2011)
Q4(2011)
Q1(2012)
Q2(2012)
Q3(2012)
Q4(2012)
Quaterly feedback to Subdistricts/Hos.Units NR
Planned Quaterly feedback to Subdistricts / Hos. Units
Actual Feedback to Subdistricts / Hos. Units
19
Wave 3
0
5
10
15
20
25
30
Jan
-08
Ap
r-08
Jul-
08
Oct-
08
Jan
-09
Ap
r-09
Jul-
09
Oct-
09
Jan
-10
Ap
r-10
Jul-
10
Oct-
10
Jan
-11
Ap
r-11
Jul-
11
Oct-
11
Jan
-12
Ap
r-12
Jul-
12
Oct-
12
Jan
-13
Ap
r-13
Jul-
13
Oct-
13
Wave 3 Innovation Hospitals Showing Under 5 Deaths per 1000 Admissions (Jan 2008-May 2013) U Chart - 29% Reduction
Rate
launch: Wave 3innovation
Wave 3 Scale up
UCL
LCL
0
10
20
30
40
50
60
Jan
-08
Ap
r-08
Jul-
08
Oct-
08
Jan
-09
Ap
r-09
Jul-
09
Oct-
09
Jan
-10
Ap
r-10
Jul-
10
Oct-
10
Jan
-11
Ap
r-11
Jul-
11
Oct-
11
Jan
-12
Ap
r-12
Jul-
12
Oct-
12
Jan
-13
Ap
r-13
Jul-
13
Oct-
13
Under Five Deaths per 1000 Admissions in OLoGH, Breman Asikuma (Jan 2008 - May 2013) U Chart - 86% Reduction
Rate
launch: Wave 3 innovation
wave 3scale up
20
MNH Referral Work
Table 2: Summary of change ideas being tested
Primary
Driver
Change Ideas Stakeholder Number of
teams
testing
Socio-
cultural
barriers
During early ANC period, health providers counsel and
conduct site visits of the health facility to orient women
and reduce their fears and anxieties about facility
delivery or possible referral to hospital. Staff show the
women a new delivery bed to motivate them to deliver
at the facility.
Health
professionals
NR = 1
Sub-district health committee members to promote
care-seeking for ANC, skilled delivery as well as male
involvement in ANC and skilled delivery care seeking.
Health
professionals &
community
NR = 1
Health staff announce at ANC and CWC that women can
register and leave their ANC cards at the facility if
carrying the card home is a barrier to early registration.
Staff and woman make a joint decision about keeping
ANC card at the health facility until such a time client is
comfortable keeping her card at home.
Health
professionals
NR = 1
Use existing community groups (mother to mother
support groups, TBAs, CBVs,) traditional leaders &
existing mechanisms/structures such as durbars, prayer
camps, FM station, community information centres for
reaching communities for health promotion on
importance of early ANC, Skilled delivery, early care
seeking, referral and other areas as needed.
Community and
Health staff
NR = 3
CR = 6
Form men fun club and use gospel rock shows to get men to listen to convincing messages.
Do intensive home visits to talk to men
Meeting with key opinion leaders, assemble man
CBVs reach out to men in their farms
Health staff &
community
CR = 1
Financial risk pooling for pre-financing emergency
transport (fueling of motorbikes for transporting
emergency maternal & newborns cases):
a. Contributions are collected from each house in a community. The motorbike owner pre-finances the fuel at the time of emergency and
Community NR = 1
CR = 1
21
Primary
Driver
Change Ideas Stakeholder Number of
teams
testing
Transport
&communic
ation
is reimbursed later from the emergency transport fund.
b. Monthly church collection to cater for those who cannot pay taxi fare
a. Engage chiefs, community leaders, social and religious groups to assume greater responsibility in liaising with motor-king, motor-bike and vehicle owners in the communities to make their motors or vehicles available for transporting maternal and neonatal referrals to health facilities. Disseminate to community members the willingness of motor and vehicle owners to volunteer this service using religious & other social gatherings.
b. QI teams contact transport owners directly and not through the community leadership.
Community &
health staff
NR = 9
CR = 2
District Director of Health Service facilitates finding
emergency transportation solutions by dialoguing with
NAS, district assemblies, private transport owners and
unions and community leaders; jointly identify local,
sustainable solutions for transport for health
emergencies (drivers, repairs, upkeep and maintenance,
etc).
Management &
leadership
NR = 1
Update list and contact numbers of taxi drivers, talk to
GPRTU leadership and share with them the current
response time to emergency calls, and hold a meeting
with the drivers to improve drivers’ response to
emergency calls.
Health staff &
community
CR = 1
Health staff, HEW or volunteer conducts follow up visits
to the homes of those referred to find out, if they
complied and what the feedback on final diagnosis is.
Health staff NR = 2
22
Primary
Driver
Change Ideas Stakeholder Number of
teams
testing
Transport &
communicat
ion
I.
During first ANC visits, ensure that all pregnant women
and their families develop and agree on a Birth
Preparedness Plan and Transport Plan, including
securing the necessary permissions for skilled delivery,
funds available for transportation and upkeep while in
health facility and preparedness for referral to hospital
should the need arise.
Health staff &
individual/family
NR = 2
CR = 4
Furnish all facilities in the district with the phone
numbers of the district ambulance service and selected
community drivers to call for means of transport for
MNH referrals.
Management &
leadership
CR = 1
Mobilize communal labour to do minor repairs of roads
linking community to the health facility, using local
resources.
Community CR = 1
Hospital health information officer collects completed
feedback forms, weekly, on all referrals received in the
various wards and sends to the DHMT to pass on to the
respective referring facilities. Facilities referring without
the necessary documentation are noted and feedback
given for them to improve.
Hospital & DHMT CR = 1
Procure low cost telephones (Vodafon landlines) for all
health facilities in the district to communicate with
referral facility when sending a case. Along with this,
phone numbers of facilities in-charges in the district is
compiled and shared with the district hospital.
Management &
leadership
CR = 1
I I . Inadequat
e clinical
skills &
manageme
nt
Organize periodic customer care orientation/training for
health care providers
Health Staff
CR = 1
Provider-patient communication: engage and
communicate directly with patients/family about the
Health staff NR = 2
23
Primary
Driver
Change Ideas Stakeholder Number of
teams
testing
condition being referred, allay their fears and get family
to accept for patient to go straight to the next level
while a family member goes back to the house to
prepare and meet at the referral facility.
Make feedback form available at the health facility and
train staff on how to complete it to improve giving
written feedback to lower referring facilities
Management
/leadership &
health staff
CR = 1
Governanc
e and
accountabi
lity
Support standardized systems for referral procedures by
removing barriers hindering staff’s ability to adhere. For
staff to accompany MNH clients to next level, provide
the following support:
Means of transport to the referral point
Negotiate fuel with the family if taking the H/C means
In-charge to provide staff with pocket money to support him/her while at referral point
Accommodation if needed
Management &
leadership and
health staff.
NR = 1
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