improvement collaboratives
TRANSCRIPT
Quality Improvement Quality Improvement CollaborativesCollaboratives
GH Mini UniversityGH Mini UniversityOctober 27, 2006October 27, 2006
James HeibyJames HeibyMedical OfficerMedical Officer
GH/HIDN/HSGH/HIDN/HS
Session OutlineSession Outline
Measuring how good health care isMeasuring how good health care is Established approaches for improvingEstablished approaches for improving Continuous Quality Improvement modelContinuous Quality Improvement model How the collaborative methodology How the collaborative methodology
modifies CQImodifies CQI Results so far in developing countriesResults so far in developing countries Issues with the collaborative methodologyIssues with the collaborative methodology DiscussionDiscussion
A scenario:A scenario: A mother brings her 8 month old girl to a A mother brings her 8 month old girl to a
MOH clinic in rural AfricaMOH clinic in rural Africa She is very thin, has a high fever, labored She is very thin, has a high fever, labored
breathing, and is not breast feedingbreathing, and is not breast feeding 4 years earlier, you were on a team that 4 years earlier, you were on a team that
designed a health project that was designed a health project that was implemented in this regionimplemented in this region
Project supplies basic drugs/supplies Project supplies basic drugs/supplies The health worker enters the exam room The health worker enters the exam room
A Systems View of QualityA Systems View of Quality Inputs/structure: The resources deemed Inputs/structure: The resources deemed
necessary to provide health carenecessary to provide health care Drugs, equipmentDrugs, equipment Competent providerCompetent provider Guides, job aids, recording formsGuides, job aids, recording forms
Process: The activities of providing health care Process: The activities of providing health care are carried out correctly are carried out correctly Compliance with clinical standardsCompliance with clinical standards Interpersonal elementsInterpersonal elements Systems to support patient care efficientlySystems to support patient care efficiently
Outcomes: The results of the health care process Outcomes: The results of the health care process meet expectationsmeet expectations Mortality, morbidityMortality, morbidity Completed immunizationsCompleted immunizations
Impact of an EBG for Impact of an EBG for Diarrhea in malnourished Diarrhea in malnourished
children in Dhakachildren in Dhaka(Ahmed, et al, Lancet, 1999)(Ahmed, et al, Lancet, 1999) Following Following
standardized standardized clinical protocol:clinical protocol: Mortality 9%Mortality 9% Oral fluids only 60%Oral fluids only 60% Antibiotics used Antibiotics used
18%18%
Following usual Following usual practice at practice at ICDDR,B Hospital:ICDDR,B Hospital: Mortality 17%Mortality 17% Oral fluids only 29%Oral fluids only 29% Antibiotics used Antibiotics used
40%40%
How well do providers follow How well do providers follow evidence-based guidelines?evidence-based guidelines?
How do programs know about this?How do programs know about this? What do we find when we look?What do we find when we look? What are the trends for the future?What are the trends for the future?
JHU Uganda Performance JHU Uganda Performance According to Standards According to Standards
Survey (2001)Survey (2001) National sample, 30 health centersNational sample, 30 health centers 81 indicators grouped into indices; 81 indicators grouped into indices;
published MOH standardspublished MOH standards IMCI assessment: 47%IMCI assessment: 47% IMCI treatment: 35IMCI treatment: 35 Malaria treatment: 70Malaria treatment: 70 Antenatal care: 35Antenatal care: 35 Family Planning: 44Family Planning: 44 STI STI 14 14
Moderate variation among districtsModerate variation among districts
How do programs traditionally How do programs traditionally try to improve compliance with try to improve compliance with
EBGs?EBGs? What approaches are widely used?What approaches are widely used? How are these approaches working?How are these approaches working? What have we learned about What have we learned about
improving compliance?improving compliance?
The Basic Principles of Continuous The Basic Principles of Continuous
Quality Improvement (CQI)Quality Improvement (CQI) The delivery of modern health services The delivery of modern health services
is complex and dynamicis complex and dynamic It is feasible to study the process of It is feasible to study the process of
health care and find ways to improve ithealth care and find ways to improve it Our hypotheses about how to improve Our hypotheses about how to improve
health care should be tested before we health care should be tested before we accept themaccept them
Regular health workers can do most of Regular health workers can do most of this workthis work
Basic Principles, continuedBasic Principles, continued
Improvement work consumes health Improvement work consumes health resources, and should be accountableresources, and should be accountable Benefits should exceed the costsBenefits should exceed the costs Current investments areCurrent investments are
Extremely smallExtremely small Primarily the time of health staffPrimarily the time of health staff
The benefits of successful improvement The benefits of successful improvement work grow as it is:work grow as it is: Extended into the futureExtended into the future Spreads geographicallySpreads geographically
How do we change the system? The Model for Improvement
What are we trying to
accomplish?
What change can 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.
Standards for Neonatal Resuscitation will be Standards for Neonatal Resuscitation will be Applied at Each DeliveryApplied at Each Delivery
Percentage of deliveries in which neonatal resuscitation guidelines were applied correctly
0
20
40
60
80
100
120
%
Mpumalanga TB Data: Case Mpumalanga TB Data: Case finding per quarter finding per quarter
(Data from 30 clinics: 10 per district)(Data from 30 clinics: 10 per district)
240 238289
516 502472
524
0
100
200
300
400
500
600
1st Qtr02
2nd Qtr02
3rd Qtr02
4th Qtr02
1st Qtr03
2nd Qtr03
3rd Qtr03
QI started
Salima: Improving Patient Salima: Improving Patient Compliance - MalariaCompliance - Malaria
ProblemProblem High rate of malariaHigh rate of malaria
“re-attendants”“re-attendants” Cause AnalysisCause Analysis
Discarded drugs Discarded drugs 23% of patients re-23% of patients re-
attendants (n=761)attendants (n=761) 84% of patients 84% of patients
“forgot” “forgot” instructions (n=43)instructions (n=43)
InterventionsInterventions DOT dose of SPDOT dose of SP Blood smear for all Blood smear for all
re-attendants re-attendants Educate the Educate the
community on community on importance of importance of following treatment following treatment instructionsinstructions
Result: Decreased Result: Decreased Re-attendant Malaria PatientsRe-attendant Malaria Patients
22.7
7.3 7.1
3.31.9
0.5
0
5
10
15
20
25
Feb. March April May June July% r
e-a
tte
nd
an
t m
ala
ria
pa
t
DOT implemented
Why isn’t everyone doing this?: Evaluation of Why isn’t everyone doing this?: Evaluation of Zambia QA ProgramZambia QA Program
Findings from a field evaluation one year after the end of Findings from a field evaluation one year after the end of USAID assistance, based on a sample of 25 clinicsUSAID assistance, based on a sample of 25 clinics
Motivation for doing additional work: many teams stopped Motivation for doing additional work: many teams stopped after first problemafter first problem
Poor choice of problem, few clinical issuesPoor choice of problem, few clinical issues Inefficiency: minimal spread of innovations among teamsInefficiency: minimal spread of innovations among teams Documentation weakDocumentation weak Slow pace of improvementSlow pace of improvement Training costs high relative to improvementsTraining costs high relative to improvements Leadership among senior MOH management lackingLeadership among senior MOH management lacking
What does the field of modern quality improvement have to What does the field of modern quality improvement have to offer that might address these problems?offer that might address these problems?
The Improvement The Improvement Collaborative MethodologyCollaborative Methodology
Traditional QI teams and methodsTraditional QI teams and methods Organized around a specific topicOrganized around a specific topic Many teamsMany teams Technical experts provide a model of Technical experts provide a model of
care feasible for the system, with care feasible for the system, with indicatorsindicators
High level sponsorsHigh level sponsors Frequent communications among teamsFrequent communications among teams Wide experience in developed countriesWide experience in developed countries
Value Added of Multiple Teams Value Added of Multiple Teams Working on a Single Problem:Working on a Single Problem:
More rapid progressMore rapid progress Each team learns from work of the others: Each team learns from work of the others:
don’t re-invent the wheeldon’t re-invent the wheel Peer group provides motivation for QI workPeer group provides motivation for QI work facilitates spread of improvements--more facilitates spread of improvements--more
efficientefficient Pressure for better, quantitative recordsPressure for better, quantitative records Can focus on priority issuesCan focus on priority issues Framework for scaling upFramework for scaling up
Collaborative Improvement Model as Adapted by QAP
Country andProvince Selection
Orientation of Country
Leader Teams
BaselineAssessment
IdentifyCountryTeam
CQI Teams
FinalizeTechnical Content/Change Package
A D
P
S
A D
P
S
A D
P
S
Conclusion of Collaborative
Ongoing exchange of experiences:-- Website/Extranet-- Coaching visits-- Periodic meetings of teams-- Telephone calls
ExpertMeeting
LEARNING SESSION 2
LEARNING SESSION 3
LEARNING SESSION 4
LEARNING SESSION 1
PreparatoryPreparatory
Stage at local
Stage at local
levellevel18-24 months
Monthly reporting on indicators
RwandaRwanda Malaria Collaborative Malaria Collaborative OverviewOverviewGeographical Scope
• 4 districts (Gisenyi, Kibungo, Muhima, Ruhengeri)
• 23 teams and sites•19 health centers•4 district hospitals
Progress• baseline study in 2 districts completed Nov 2002
• quality improvement (QI) changes and indicators proposed by level of care
• 70% of sites used flowcharts to analyze their problems
• QI changes made and results monitored
• Mortality impact in both simple and severe malaria
Exampless of Findings from Exampless of Findings from Initial Assessment (2 district Initial Assessment (2 district
sample)sample) no children were (case) managed no children were (case) managed
according to norms according to norms only 29% of children treated only 29% of children treated
according to norms according to norms mothers wait an average of 3 days mothers wait an average of 3 days
before going to health centre before going to health centre 31% of health centres have had 31% of health centres have had
stock-outs during the 30 days stock-outs during the 30 days before assessmentbefore assessment
Key ChangesKey Changes For malaria in children 0-4 yearsFor malaria in children 0-4 years Decision to seek care within 24 Decision to seek care within 24
hourshours Diagnosis and treatment at health Diagnosis and treatment at health
centers and hospital according to centers and hospital according to national standardsnational standards
No stockouts of drugs or supplies No stockouts of drugs or supplies at districtat district
Appropriate and successful Appropriate and successful referral of serious casesreferral of serious cases
MeasuresMeasures Numbers of children treated in health Numbers of children treated in health
centerscenters Numbers of severe cases treated in district Numbers of severe cases treated in district
hospitalhospital Number of deaths due to malaria in hospitalNumber of deaths due to malaria in hospital Hospital case fatality rate for child malaria Hospital case fatality rate for child malaria
cases cases Percent of children treated according to Percent of children treated according to
national norms in HC and hospitalnational norms in HC and hospital Error rate of lab tests on quality control Error rate of lab tests on quality control
exercisesexercises Stockouts of drugs or supplies at HC/hospStockouts of drugs or supplies at HC/hosp
RWANDA MALARIA COLLABORATIVE: RWANDA MALARIA COLLABORATIVE: IMPROVEMENTS IN CARE-SEEKING BY MOTHERS (19 IMPROVEMENTS IN CARE-SEEKING BY MOTHERS (19
HEALTH CENTERS)HEALTH CENTERS)
0
10
20
30
40
50
60
70
80
90
100
0
500
1000
1500
2000
2500
% children age 0-5 presenting with malaria who were taken to consultation within 24h
53 56 63 66 69 78 79 82 81 79 77 76
a) Number of children under 5 years admitted with signs of malaria
1505 1384 1450 1538 1705 2295 2160 2264 2244 2262 2144 1777
J A S O N D J F M A M J 2004 2005
%
Changes tested by the teamsChanges tested by the teams CHWs motivated and included in CHWs motivated and included in
teamsteams CHWs organized their own meetingsCHWs organized their own meetings Bonus for CHW performanceBonus for CHW performance Educational materials distributed in Educational materials distributed in
community churchescommunity churches Presentations at community meetingsPresentations at community meetings Discount on clinic fee for bringing child Discount on clinic fee for bringing child
within 24 hourswithin 24 hours
RWANDA MALARIA COLLABORATIVE: RWANDA MALARIA COLLABORATIVE: IMPROVEMENTS IN CASE MANAGEMENT OF IMPROVEMENTS IN CASE MANAGEMENT OF
CHILDREN < 5 YEARS (19 HEALTH CENTERS)CHILDREN < 5 YEARS (19 HEALTH CENTERS)
0
10
20
30
40
50
60
70
80
90
100
0
100
200
300
400
500
% children age 0-5 with malaria who were managed according
to norms at health centres
43 60 73 79 85 88 90 91 91 92 92 93
# cases of malaria analysed in the month 385 393 390 391 396 398 394 399 393 381 346 310
J A S O N D J F M A M J
%
Changes tested by the Changes tested by the teamsteams
CM training during weekly staff CM training during weekly staff meetingsmeetings
Regular review of medical recordsRegular review of medical records Flow charts, other provider job aidsFlow charts, other provider job aids Improved patient registrationImproved patient registration Reorganization of servicesReorganization of services Started triage Started triage Extended lab availabilityExtended lab availability
Niger Pediatric Hospital Niger Pediatric Hospital Improvement CollaborativeImprovement Collaborative
Proportion of Pneumonia, Malaria and Diarrheal Disease Cases Managed According to WHO Standards
Jan 04 - Aug 05 (14 Nigerien District Hospitals)
0
10
20
30
40
50
60
70
80
90
100
Jan-
04M
arM
ay Jul
Sep Nov
Jan-
05M
arM
ay
Jul
Per
cen
tag
e o
f C
ases
Pneumonia
Malaria
Diarrheal Disease
Equipe de PMTCT de Equipe de PMTCT de KicukiroKicukiro
KICUKIRO Health Facility:Percentage of partners tested
0102030405060708090
Months - 2003
Changes tested:-Home visits and meetings by couples involved in the PMTCT program-Home visits by health providers -IEC on responsible paternity
LS1 LS2
Gihundwe Health Facility: % of partners tested
0
5
10
15
20
25
Jan Feb Mar Apr May June July Aug Sept Oct Nov
Months - 2003
Send invitation letters to partnersReinforce counselling
Rwanda PMTCT—Data Exported Rwanda PMTCT—Data Exported from Extranetfrom Extranet
% of Partners Tested (16 initial sites)
0
0.2
0.4
0.6
0.8
1
1.2
Butare
Byumba
Gikonko
Kicukiro
Gihundw e
Gisenyi
Muhima
Kanombe
Kabgayi
Kacyiru
Muhura
Nyagatare
Ruhengeri
Ruli
Kibuye
Kigeme
Percentage of partners of prenatal care women who were tested for HIV
Evolution of the Evolution of the CollaborativeCollaborative
Expected duration of 9-18 monthsExpected duration of 9-18 months Leaders schedule final meeting based on Leaders schedule final meeting based on
results: teams using a package of results: teams using a package of improvementsimprovements
Expansion (or Spread) Collaborative:Expansion (or Spread) Collaborative: high performers can each lead a new efforthigh performers can each lead a new effort change package requires minor adaptationchange package requires minor adaptation Rogers’ Rogers’ Diffusion of InnovationsDiffusion of Innovations
Potential for multinational sharing of best Potential for multinational sharing of best practicespractices
Late Majority
Early Majority
Early Adopters
Tradition-alists
Innovators
Successful Collaboration-Successful Collaboration-Identify and Make Use of Identify and Make Use of
the “Early Adopters”the “Early Adopters”
2% 13% 35% 35% 15%
Active Management of the Active Management of the Third Stage of LaborThird Stage of Labor
IND. # 4: Partos vaginales atendidos en los H. del País en los que se administró 10UI. de Oxitocina intramuscular dentro del minuto después del nacimiento del bebé y se registró en la HCP. Ecuador, Honduras y Nicaragua. J ulio/03 a Diciembre/05
0
10
20
30
40
50
60
70
80
90
100
ECUADOR 0 15 14 17 22 32 37 37 40 38 41 37 48 51 59 58 56 55 49 53 63 64 57 68 65 69 73 70 69 71
HONDURAS 92 99 100 99 100 96 94 95 100 96 98 93 95 99 98 99 98 94 99 100 100 100 100 100
NICARAGUA 69 76 86 86 88 92 93 93 94 99 92 95 94 97 98 99 96 97 99 99 98 100 98 99 97 97 98 98
Jl-03
Ag Sp Ot Nv Dc En Fb Mr AB My Jn Jl Ag Sp Oc Nv Dc En Fb Mr Ab My Jn Jl Ag Sp Oc Nv Dc
Some issues for discussionSome issues for discussion
How to maximize learning from this How to maximize learning from this experience (17 USAID supported experience (17 USAID supported collaboratives to date)collaboratives to date) Documenting and analyzing implementationDocumenting and analyzing implementation What’s working and what needs to be fixedWhat’s working and what needs to be fixed How to make this approach more cost-effective and How to make this approach more cost-effective and
simpler simpler Connecting collaboratives to the Connecting collaboratives to the
institutionalization of improvementinstitutionalization of improvement Leadership: countries, donors, othersLeadership: countries, donors, others Obstacles to wider useObstacles to wider use