-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
1/14
Monitoring data to drive country-
level improvement: lessons
learned in Ecuador and ways
forward
Dr. J orge Hermida
Regional Director, LAC programs
The USAID ASSIST Project, University Research Co., LLC
Global Newborn Health Conference
JOHANNESBURG, SOUTH AFRICA. April 2013
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
2/14
The place of quality of care indicators in the QI process
We use indicators toidentify deficiencies and
set our aims
We develop indicators toassess if process changes
result in improvements
Indicators help us monitorimprovements over time
and assess sustainability3
How do we improve processes of care?
The Model for Improvement
What are we
trying toaccomplish?
What changescan we make
that will result
in an
improvement?
How will we
know that a
change is an
improvement?
PLAN
DO
STUDY
ACT
1.
2.
3.
PDSA Cycle
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
3/14
A system to manage EONC quality based on indicators
Provincial MOHMNCH person
County Hospital
Ambulatory care facilities
QI
team
QI
team
QI
team
QIteam
Analyze indicators by provinceSupervision to provincial offices
Analyze EONC indicators byfacilitySupervision following indicatorsAggregate indicators and report to
central MOH
Clinical records audit Analyze EONC indicators Implement PDSAs to improveprocesses
Report indicators to provincialMOH office
National MOHMNCH team
Provincial referralHospital
QI
team
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
4/14
Quality standards
Indicator
Runchart
Data from sample ofclinical records
Enter data on data base
Analysis and action
Aggregation of datafrom facilities atprovinciallevel
Runchart
Analysis and action
Aggregation of datafrom facilities atnational level
Runchart
Analysis and action
A user-friendly information system for continuous quality
improvement at facility, provincial and central levels, Ecuador
Facility Provincial Central
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
5/14
NORMS, QUALITY STANDARDS AND DATA SOURCES FOR QUALITY MEASUREMENT
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
6/14
Indicator1 % Antenatal care in compliance with standard.
2 % deliveries with partograph correctly used
3 % deliveries with an abnormal partograph where adecision was made
4
% deliveries with AMTSL
5 % postpartum care in compliance with standard..
6 % of immediate newborn care in compliance withstandard.
7A % deliveries attended by a doctor or midwife.
7B % of newborns attended by a doctor or midwife
8A % of cases ofpreeclampsia, eclampsia care in
compliance with standard.8B % of cases ofHemorrhage care in compliance with
standard..
8C % de cases of sepsis care in compliance withstandard.
8D % preterm deliveries treated with corticosteroids forfetal lung maturation
8F % premature rupture of membranes care in
compliance with standard.
1
2 y 3
4
5
6
7a 7b
8a y 8b
8d
8f
The perinatal clinical record is the main source of data for quality indicators
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
7/14
Measuring compliance with standards: auditing records
QI team members meet oncea month and audit records,
following a standard
procedure
QI team: doctors, nurses,auxiliary nurses
QI team enters numeratorsand denominators in an Excel
spreadsheet that produces
runcharts
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
8/14
Data base for entering numerators and denominators at facili ty, provincial or central levels
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
9/14
Using indicators to identify deficiencies and to
trigger improvement interventions at the facility
QI teams identify deficientprocesses based on
indicators
Building on their ownexperience, literature and
lessons learned, QI teams
decide to test
interventions.
QI teams assess the impactof the intervention using
indicators
Continuous Quality Improvement teams at work:
WHAT ARE WE TRYING TO ACCOMPLISH ?
HOW WILL WE KNOW A CHANGE MADE AN IMPROVEMENT ?
WHAT SPECIFIC, CONCRETE CHANGES CAN WE MAKE TO THEPROCESS ?
Plan
IMPLEMENT
AND TEST THE
INTERVENTIONDo
Study
Act
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
10/14
E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D
2008 2009 2010 2011
% 0.0 0.0 0.0 5.0 25. 10. 15. 22. 26. 42. 41. 53. 58. 33. 28. 81. 72. 54. 60. 57. 71. 69. 65. 72. 64. 64. 65. 61. 66. 68. 76. 70. 75. 73. 85. 73. 66. 77. 71. 81. 73. 64. 77. 77. 71. 73. 60. 85.
Num 0 0 0 1 4 14 17 29 33 31 33 22 93 57 67 203 68 68 90 86 105115 88 95 112107115115105 99 125122 88 87 78 84 130108115120119 94 103103 87 79 40 30
Den 18 12 16 20 16 129107129123 73 79 41 159168239 70 94 125150150146165134132175165176187157144163174116146134114195140160148163146133133121107 66 35
0
10
20
30
40
50
60
70
80
90
100
PERCENTAGE
Percentage of Premature Rupture of Membranes (PROM), managed inaccordance to standards, 97 hospitals and health centers. Ecuador, 2008-2011
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
11/14
Monitoring and reporting indicators from facilities to
provincial MOH offices
Monitoring quality indicators for facilities in a region
through runcharts
QAP, 2004
Reporting made mandatoryby Ministerial decree
One person of QI team in
charge of sending themonthly report
Report sent mostly by emailusing Excel spreadsheet
Supervisory visits tofacilities late in reports
Indicators used in maternaland newborn mortality
audit process
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
12/14
Aggregated data and analysis at provincial level
J l-03
AgSp Ot NvDc EnFb MrABMyJ n J l AgSpOc NvDc EnFb MrAbMy J n J l AgSp Oc NvDc EnFb MrAbMyJ n J l AgSpOc NvDc
2003 2004 2005 2006
% 25 70 64 54 64 75 70 65 70 68 72 74 78 81 84 89 87 84 74 84 82 83 82 84 86 87 90 86 87 86 84 82 84 88 85 85 88 87 89 93
0
10
20
30
40
50
60
70
80
90
100
PERCENTAG
E
Percentage of deliveries in which the newborn was provided with essential
standardized care (11 standard activities)Fourteen hospitals in 2003, scaled up to 89 hospitals in 2006
1. Weight2. Height
3. Cephalic perimeter4. Apgar score5. Registration of need for HBB/action6. Physical exam7. Vitamin K 1 mg8. Ocular disinfection drops9. Skin-to-skin contact
10. Immediate and exclusivebreastfeeding
11. Baby and mother together in ward
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
13/14
Using regional indicators at central MOH to monitor
national progress
Antonio Recalde,MOH staff in charge ofnational database
E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D
2008 2009 2010 2011
% 0.0 0.0 0.0 0.0 0.0 10. 32. 30. 47. 64. 63. 81. 64. 63. 71. 84. 89. 86. 75. 72. 82. 85. 84. 85. 82. 83. 85. 76. 89. 87. 93. 92. 91. 92. 90. 95. 81. 90. 90. 93. 88. 92. 92. 92. 90. 90. 92. 97.
Num 0 0 0 0 0 20 45 61 86 65 65 57 159147151 49 137136188191153205200218237222267236273255253247246218151285222331362321252275250213158161 88 83
Den 18 12 16 19 12 189140202181101102 70 247233212177153158248262185 240238254286265314307305291272267269 246238299271367402343286296270230175178 95 85
0
10
20
30
40
50
60
70
80
90
100
PERCENTAGE
Percentage of pr eterm deli veries in w hich dexamethasone wasadmini stered for fetal lung maturation. 97 hosp itals and health
centers, Ecuador, 2008 to 2011
-
7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador
14/14
Challenges ahead
Integrating QI indicators system with regular MOHManagement Information System
Linking QI indicators with MOH system to reimburse
costs for services Developing an ongoing system to monitor quality of
data at provincial and local levels
Introducing mHealth
Stepping-up from a measuring system to amanaging one