standards-based management: an innovative approach to improving performance and quality at facility...
TRANSCRIPT
Standards-based Management:
An Innovative Approach to Improving
Performance and Quality at Facility Level in Low
Resource Settings
JHPIEGO/Johns Hopkins University
Stephane Legros, the World Bank
Presentation Road Map PQI model,
PQI tool
Standardization of Care
PQI team outcomes
Honduras: Reception/triage Conclusion
CONTINUOUS LEARNING AND IMPROVEMENT
MEASURED BASED MANAGEMENT
OPERATIONAL ASSESSMENT TOOLOPERATIONAL ASSESSMENT TOOLDesired
Performance
Actual Performance
Gap Cause Analysis
Intervention Implementation
Evaluation
Intervention Identification
and Design
Performance and Quality Improvement Model
Model Adapted from the International Society for Performance Improvement
A D
P
C
A D
P
C
Desired Performance
Client PreferencesClient Preferences
Provider InputsProvider Inputs
Technical Norms and GuidelinesTechnical Norms and Guidelines
National Policies/PrioritiesNational Policies/Priorities
PQI Operational Assessment Tool
Baseline Assessment
Consists of the determination of the actual level of performance using the performance assessment tool
Helps to identify performance gaps
Once gaps are identified the next step is to identify their causes
Standards-based Managementof Health Service Delivery
Set Standards
1
Implement
Standards
2 4
Reward Achievemen
ts
3
Measure Progress
PQI Operational Assessment Tool Description
Areas include clinical services and support functions
Criteria - 77
Multi-level
Baseline assessment
Potential for self assessment
Recognition:
Accreditation, certification, award
PQI Operational Assessment Tool:Scope
Clinical Services
CEmergency care (pregnancy)
CNewborn care
CLabor, delivery
Support Functions
C
Infrastru
cture
C
Man
agem
ent system
s
C
IEC
, dem
and
pro
mo
tion
C
Blo
od
ban
k, labo
ratory
CIn
fection
preven
tion
PQI Operational Assessment Tool: 7 Areas
AREAS CRITERIA
Emergency care during pregnancy 03
Labor, delivery, post-partum, newborn care 12
Support services (laboratory, blood bank) 07
Infection prevention 11
IEC and demand promotion 04
Human resources, materials and logistics 28
Management systems 12
Total 77
Area: Operation Room
Criteria Verification Means Y, N, N/A Comments
1. The cleaning equipment is decontaminated, cleaned and dried before reuse or storage according to the standards.
Observe if the mops, buckets, brushes and cleaning cloths are:
• Decontaminated by soaking for 10 minutes in 0.5% chlorine solution or other approved disinfectant.
• Washed in detergent and water.
• Rinsed in clean water.
• Dried completely before reuse or storage.
Assessment Tool
Operational Assessment Tool
Area: Pregnancy care
Criteria Verification means Y, N, NA Comments
1. The facility conducts a routine rapid assessment of pregnant women
Observe in the reception area or waiting room if the person that receives the pregnant woman:
• Asks if she has or has had:
- Vaginal bleeding
- Headache or visual changes
- Breathing difficulty
- Severe abdominal pain
- Fever
• Immediately notifies the health provider if any of these conditions is present
PQI Operational Assessment Tool:Criteria
Area: labor, delivery, post-partum and newborn care
Criteria Means of Verification Y, N, NA Comments
10. The provider performs an adequate resuscitation of the newborn
Observe provider performance of resuscitation of newborn:
Prepared set for resuscitation including:- Mask #1 and ambu- Aspiration canula - Oxygen
Place the newborn on back on a clean, dry and warm surface
Cover the newborn quickly
Explain to the mother what is ocurring
Gently extend the newborn’s head
LEVEL TOOL PROCESS MOTIVATION
Individual Operational assessment tool (OAT)
Self-learning Satisfaction, professional development
Team OAT Teamwork, on-the-job training (OJT)
Better work environment, support
Facility Manager OAT Feedback, monitoring Better service, recognition
Client Exit interviews, suggestions box, IEC
Feedback, informed demand
Better care
Community OAT, IEC Community participation and mobilization
Better care
Health System OAT Feedback, support, evaluation
Better health results and outcomes
Multi-level Implementation
PQI Operational Assessment Tool: Main Features
• Proactive and positive (gap focused)
• Systemic/holistic
• Large Scope of Standards with criteria to fulfill
• Sequential intuitive process
• Skills oriented
• Easy to replicate and institutionalize
Standardization of Care
Exists when Standardized Skilled Providers complying with updated standards through adequate processes achieve a recognized level of Performance and Quality of Care.
Importance of Standardization of Care
Quality of care for clients
Guidance for providers
Increased coordination reduces medical errors
Accountability
Quality improvement
Measurement, comparisons and benchmarking
Cost reduction
Development/Dissemination of Evidenced Based
Service Delivery Guidelines• IMPAC series in collaboration with WHO/PAHO/ICM
Managing Complications in Pregnancy and Childbirth (MCPC)
Antenatal Care Newborn Care
• Adopting SDGs (Guatemala)
• Adapting SDGs based on MCPC (Honduras)
An Integrated Strategy to Reducing the Performance Gap
main
Recognition
Official
Community Involvement
Standardized Clinical Training
Pre/In Service
Clinical Standards/MCPC
Evidence Based
Measurement based
Management/PQI
Features of the Approach
Takes full advantage of standardization of care
Focus on desired performance
Uses detailed process and outcome standards: what to do and how to do
Uses dichotomous indicators (yes/no)
Systemic approach
Holistic
Gradual development of change management skills
Use of measurement for monitoring and decision-making
Relies on continuous self and internal assessments
Emphasis on creating consequences of performance
Quality is incorporated as a regular, on-going managerial function
Total de Servicios Áreas PSMN
Hospitales = 10 Centros de Salud = 44Puestos de Salud = 97Maternidades = 3
TOTAL = 154
Total de Servicios Áreas EXPANSIÓN
Hospitales = 15Centros de Salud = 66
Puestos de Salud = 141
TOTAL = 222
GRAN TOTAL
Hospitales = 25 / 69%Centros de Salud = 110 / 43%Puestos de Salud =238 / 25.6%Maternidades = 3 / 19%
TOTAL = 376 / 30.4%
Project Area in Guatemala
Guatemala Achievement of Quality Criteria (Total %)
Seven Hospitals
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Baseline (2001) 1st External Eval (2002)
Guatemala Achievement of Quality Criteria (Total %)
11 Health Centers
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Baseline (2001) 1st External Eval (2002)
Measurement Results from Six Hospitals Initial Phase - 2004
0
10
20
30
40
50
60
70
80
90
100
HPX HPI HPQ HPT HPP HGM REF
August December
Achievement of IP Performance Standards in %
