1.

• Implementing a Systems-Oriented Morbidity and Mortality Conference in Remote Rural Nepal for Quality Improvement

• Duncan Maru, MD, PHD Co-Founder, President| Nyaya Health

• Resident, Internal Medicine and Pediatrics

• June 15, 2011

2. The Problem: Quality Chasm in Global Health Delivery The ease with which young people die in Achham and the ease with which it is accepted continues to horrify me. -Ruma Rajbhandari, MD, MPH March 22, 2011 Brigham Internal Medicine Resident Global Health Equity Fellow Nyaya Health Board of Advisors Member

3. Study Aim To develop a systems-oriented morbidity and mortality conference (M&M) quality improvement initiative in a remote rural resource-denied setting, aimed at facilitating structured dialogue of hospital operations and identifying barriers to providing quality care.

4. Setting: Nepal Achham District, Far Western Region

5. Setting: Nyaya Health

• Social justice-oriented mission:

• To provide free community-based healthcare in rural Nepal that strengthens the public sector

• To develop and disseminate effective strategies of healthcare delivery in resource-poor settings throughout the world

• Started working in Achham in 2006; public-private partnership with Nepali Ministry of Health & Population since 2009

• Nyaya Team:

• • 29 full-time employed Nepali staff + ~50 CHWs

• • 1 full-time US-based Executive Director

• • Volunteer Executive Team, Board of Directors and Board of Advisors

• Core Approach: Transparency, Public-Private Partnerships, and Community-Based Care

6. Setting: Bayalpata Hospital

• Mission: infrastructure development in collaboration with the government, not only care provision

• Government partnership contract for 5 years signed June, 2009 June, 2014

• Over 60,000 patients treated to date

• Approximately $200,000 operating budget annually

7. Bayalpata Hospital Team

8. Intervention: The M&M Conference

• Weekly M&M conferences with the following features:

• All clinical and non-clinical staff are invited to participate

• Structured dialogue using seven domains of analysis

• Protected time for staff to participate

• Engagement of senior management via telemedicine consultants over email

• Publishing of transcripts publicly online

9. Analysis

• Qualitative observational study of a pilot program

• Number of conferences conducted

• Staff response via interviews and feedback sessions

• Staff attendance and participation

• Reviews of cases for suggestions for improvement and their implementation

10. Outcomes Measures

• Qualitative observational study of a pilot program

• Number of conferences conducted

• Staff response via interviews and feedback sessions

• Staff attendance and participation

• Reviews of cases for suggestions for improvement and their implementation

11. Results: Selection of Cases

12. Results: Overview of Cases Recommendations

• Full transcripts of all cases available at wiki.nyayahealth.org

• 41-year-old woman with status epilepticus and obtundation referred to hospital 12 hours away discussion about exam findings, referral given lack of lumbar puncture tests, head CT

• 17-year-old woman with perineal laceration, repaired and did well discussion about lighting and cleanliness of the delivery room, need for blood transfusion, outreach for preventing young pregnancies

• 8-month-old boy with pneumonia, septic shock who died discussion about CPR techniques, oxygen and ambu bag availability

• 25-year-old woman with eclampsia, seizures, broke with diazepam and magnesium sulfate discussion about trainings, screenings for eclampsia, stocking of anti-epileptics

13. Results: Staff Reception

• Performed 19 of 35 weeks (54%).

• 80-85% attendance of staff members

• Cases are only managed by a few personnel and are not well understood by the rest of the staff, so these M&Ms help us to learn from the lessons of the other staff in those cases. Laboratory Assistant

• It is frustrating to keep discussing the same issues, but they are not yet resolved. We know some things take long times, but the management should be faster and more effective about addressing these problems. -Nurse

14. Conclusions and Next Steps

• Our systems-oriented, inclusive M&M tool was feasible, useful, and well-received by staff, though challenging to implement and even more challenging to utilize effectively for systems-level change.

• Continue to use and evaluate the program through upcoming leadership changes at the hospital

• Improve follow-up and accountability regarding suggestions made at the conferences

• Ongoing discussions via Nick Simons Institute/Rural Staff Support Program to bring the strategy to other hospitals

15. Implications

• To do better at medicine in places where resources are limited, where training is subpar, where patients are disempowered, and where accountability mechanisms are lacking, we need to develop simple, practical tools for transparency, accountability, and quality improvement. Then we need to study rigorously the outcomes of these tools and identify strategies for bringing them to scale

16. Acknowledgements

• The staff of Bayalpata Hospital & the people of Achham, Nepal

• The volunteers and individual donors of Nyaya Health

• The Nepali Ministry of Health & Achham District Health officials

• Institutional Supporters Including: Abbot Laboratories, AMD and the Open Architecture Network, America Nepal Medical Foundation (ANMF), BWH COE in Quality and Safety, Buddha Air, Cents of Relief, Child Health Foundation, CIWEC Clinic (Menlha Nursing Home), Editage, Ella Lyman Cabot Trust, EquityEditors Association, Ford Foundation, Fred Lovejoy Education and Research Foundation, Google Grants, Martin P. Solomon Foundation , MEMC Foundation, Nepal Ministry of Health and Population (MOHP), New Aid Foundation , Partners in Health , ProEdit Japan, QBC Diagnostics, Quidel Corporation, Singapore Internet Research Center, Ten Friends, The Hunger Site, The International Foundation, The Shelley and Donald Rubin Foundation, Until There's a Cure Foundation, UpToDate, William Prusoff Foundation, Wizfolio, Yale University

17. Questions, Reflections, Comments?

• www.nyayahealth.org

18. Achham: Demographics

• • ~270,000 people

• • 99.6% Hindu

• • 60% agricultural

• • >80% of men migrate to India, and 35% of families rely on remittances from India

• • 33% adults literate: 54% men, 14% of women

• • 90% of houses did not have electricity

• • 45% had access to clean water 2.5x worse than national average

• • Hydroelectric plant functioning