urc-chs - using quality assessment to improve maternal ......using quality assessment to improve...

Using Quality Assessment toImprove Maternal Care in

Nicaragua

May 2003

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Q U A L I T Y A S S E S S M E N T A N D I M P R O V E M E N T C A S E S T U D Y

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The Quality Assurance Project (QAP) is funded by theU.S. Agency for International Development (USAID) underContract Number GPH-C-00-02-00004-00. The projectserves developing countries eligible for USAID assistance,USAID Missions and Bureaus, and other agencies andnongovernmental organizations that cooperate with USAID.QAP offers technical assistance in the management ofquality assurance and workforce development in healthcare,helping develop feasible, affordable approaches tocomprehensive change in health service delivery. Theproject team includes prime contractor University ResearchCo., LLC (URC), Initiatives Inc., and Joint CommissionResources, Inc. The work described in this report wascarried out by the Quality Assurance Project under USAIDContract Number HRN-C-00-96-90013, managed by theCenter for Human Services, URC’s nonprofit affiliate, inpartnership with Joint Commission Resources, Inc. andJohns Hopkins University.

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About this series

The Case Study Series presents real applications of qualityassurance (QA) methodologies in developing countries atvarious health system levels, from national to community. Theseries describes QA applications in maternal and reproductivehealth, child survival, and infectious diseases. Each case studyfocuses on one or more major QA activity areas, such as qualitydesign, quality improvement, the development and communica-tion of standards, and quality assessment. This case studyfocuses on quality assessment and improvement.

Quality assessment is the measurement of the quality ofhealthcare services: it measures the difference betweenexpected and actual performance. Information gained from anassessment can be used to identify opportunities for improve-ment. Performance standards can be established for mostdimensions of quality, such as technical competence, effective-ness, efficiency, safety, and coverage. Where standards areestablished, a quality assessment measures the level ofcompliance with standards. Where standards are more difficultto articulate, such as the quality dimensions of continuity of careand accessibility, a quality assessment describes the currentlevel of performance with the objective of improving it. A qualityassessment can use various data collection methods toovercome the intrinsic biases of any method alone. Thesemethods include direct observation of patient-provider encoun-ters, staff interviews, patient focus groups, record reviews, andfacility inspections. The assessment is often the initial step in alarger process that may include providing feedback to healthworkers on performance, training and motivating staff toundertake quality improvements, and designing solutions tobridge the quality gap.

Quality improvement is a systematic process of addressingthe gaps between current practices and desired standards.Effective approaches to quality improvement include individualproblem solving, rapid team problem solving, systematic teamproblem solving, and process improvement. These methodsvary in the time and resources required and the number of

Improving Maternal Care in Nicaragua

people who participate. Regardless of the rigor and intensity ofthe method used, quality improvement approaches usually sharefour basic steps: identification of opportunity for quality improve-ment, analysis of improvement area, development of possibleinterventions to address a need for improvement, and testing andimplementing interventions. Sometimes, when the potentialsolutions to a problem are clearly defined, a shorter qualityimprovement activity focused on testing the alternatives is used.

This case study describes how healthcare providers inNicaragua worked together to improve the quality of obstetriccare at their health centers and posts. They began by measuringthe extent to which staff performed according to standards. Onceaware of the quality gaps, they formed QI teams and used rapidteam problem solving to implement quality improvements so thathealthcare providers could perform according to obstetricstandards. Continuous monitoring shows their success inmeeting the standards and improving health outcomes.

AcknowledgmentsThe Nicaraguan Ministry of Health implemented the QA efforts de-scribed in this case study. Jorge Hermida (QA Project Regional Direc-tor), Filiberto Hernández (QA Project/Central America), Oscar Nuñez(QA Project/Nicaragua), and Luis Urbina (QA Project/Nicaragua)collaborated with Ya-Shin Lin (QA Project Communication and ResearchSpecialist) to write this case study. They wish to express their apprecia-tion to members of the QI teams who assessed and monitored quality attheir health centers and posts to improve maternal care: Javier Alfaro,Julio Barba, César Rodríguez, Gelmi García Martínez, Paula López,Ernesto Marenco, and Suhey Rodríguez. Filiberto Hernández and DianaSilimperi (QA Project Deputy Director) provided technical review.

Recommended citationLin Y, J Hermida, F Hernández, O Nuñez, and L Urbina. 2003. UsingQuality Assessment to Improve Maternal Care in Nicaragua. QualityAssurance Project Case Study. Chevy Chase, MD: Published for the U.S.Agency for International Development (USAID) by the Quality AssuranceProject.

Improving Maternal Care in Nicaragua 1

Using Quality Assessment to ImproveMaternal Care in Nicaragua

Q U A L I T Y A S S E S S M E N T A N D I M P R O V E M E N T C A S E S T U D Y

BackgroundNicaragua’s maternal mortality ratio climbedsteadily in the 1990s, jumping from 87 maternal deaths per100,000 live births in 1994 to 156 in 1998.1 Hurricane Mitchexacerbated problems related to healthcare delivery in1998 by increasing poverty, damaging health units, andreducing access. The profile of maternal deaths in Nicara-gua suggested that improving the quality of maternal careservices at government health centers and posts (referredto here as “health units”) could help to reverse the climbingmaternal mortality rates. For instance, “institutional defi-ciencies” had caused 82 percent of the country’s deaths in1998 from direct obstetric causes.2

The Ministry of Health (MOH) had published NationalStandards for Prenatal, Low-Risk and Puerperal Healthcare,establishing standards for quality care in maternal andchild health, but the standards had not been systematicallyimplemented. To restore and improve maternal healthservices in Hurricane Mitch-affected areas, the U.S.Agency for International Development (USAID) invited theQuality Assurance (QA) Project to collaborate with the MOHat the health unit level. The strategy was to prioritizeselected quality areas, then to have local quality improve-ment teams monitor those areas to identify and addressproblems. The overarching goal was to work with local

Improving Maternal Care in Nicaragua2

healthcare providers to establish a sustainable system ofimproved maternal and neonatal care.

Two departments were selected for the collaboration:Matagalpa and Jinotega, which had among the highestmaternal mortality ratios in the country: 260 and 382,respectively.3 Two municipalities were selected in eachdepartment: El Cua and Bocay in Jinotega, and Waslalaand Río Blanco in Matagalpa. Each municipality had five toeight health units serving between 30,000 and 40,000people.

Deciding What to AssessNicaragua’s MOH had previously issued standards in theStandards publication mentioned above, but they had notbeen systematically implemented, and indicators tomeasure performance according to those standards hadnot been developed. Since the MOH standards were sonumerous, MOH and QA Project staff first defined the scopeof their effort by helping staff at each health unit to identifya smaller number of standards to implement. They wantedto identify those standards that, if implemented correctly,would have the greatest impact on maternal care. Theystarted by visiting the health units, reviewing medicalrecords, learning about the current system, interviewingstaff from the Sistema Local de Atención Integral en Salud(SILAIS), and talking with staff and clients.

Visiting health units. To assess current practices, MOHand QA Project staff toured health units in the four munici-palities. Observations and informal interviews revealed thatthe health units had deteriorated physically: furniture was indisrepair, supplies were lacking, and protocols for patientcare were not available. They saw that the obstetric careprocess had not been given a high priority: no specialattention was given to pregnant women, who were simplytreated along with all other patients. These conditionsappeared to diminish staff motivation, which underminedclient-provider relationships.


Healthcarefacilities andfurnishings werein disrepair.

Reviewing medical records. MOH and QA Projectstaff also performed a rapid medical record review toassess the quality of obstetric care from the clinicalperspective. Several records from the birth register wererandomly selected for each month in 1999. The examina-tion revealed that most basic neonatal and obstetric carewas poorly documented, so that the quality of care couldnot be accurately assessed or monitored from the records.Staff gave numerous reasons why documentation waslacking:

■ The forms were not available

■ They had not been taught how to complete the forms orhad forgotten how to do so

■ No importance was given to this activity during supervi-sion sessions

■ The forms were too difficult to fill out

Assessing client satisfaction, demands, andrequirements. While performing according to standardsis critical in improving health outcomes, client satisfactionis also important. No one had analyzed what pregnantwomen want when they seek prenatal care—or why theydon’t seek such care. To understand client needs andbarriers at each health unit, MOH and QA Project staffcollected information using: (a) key informant interviewswith community leaders, (b) interviews and structured focus

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groups with both clients at the health unit and women in thecommunity, (c) an opinion survey, and (d) observations ofpatient flow.4

These efforts revealed opportunities for improvement in theflow of obstetric care, waiting times, interpersonal relations,and the availability of medications. Clients asked that:

■ They be identified to receive priority care upon enteringthe waiting area

■ The waiting room be physically improved

■ Clinics for integrated care for women have better visualand auditory privacy

■ A separate postpartum room be created

■ Midwives accompanying pregnant women beaccommodated5

Several causes for the low number of prenatal care visitsbecame apparent: poor treatment, long distances to theclinic, lack of privacy, and lack of confidence that theywould be seen, due to busy schedules or doctor absences.

Compiling standards. MOH and QA Project staffcompiled a short list of standards for the health units thatwere derived from the review of MOH priorities, the clientneeds assessment, health unit visits, and medical recordreview. For each standard, they defined at least oneindicator that could be used both to assess the currentlevel of care and, later, to monitor care as quality improve-ments were implemented.

The list of standards and indicators was presented to eachof the four municipalities. In a two-stage process, staff ateach municipality prioritized the indicators that they weremost interested in and that seemed most achievable basedon their understanding of their situation. Target thresholdsfor each indicator were determined using a similar partici-pative process. The general director of each departmentalhealth system approved the selected standards andindicators. Table 1 presents the standards and theirindicators, the targets for those indicators, and the sourceof information to measure the indicators.


Table 1. List of Standards Monitored in 2000 and CorrespondingIndicators (Matagalpa and Jinotega)

Standard

1. All pregnantwomen willreceive carein which theperinataltechnologytools* arecorrectlyapplied.

* Perinatal technologies, such as the partograph with alert curve and the basic perinatal clinical history (BPCH), are low-cost tools ofproven effectiveness that are included in the National Standards for Prenatal, Low-Risk and Puerperal Healthcare. The adequate andcomplete interpretation of the BPCH requires the correct use and interpretation of other perinatal tools, such as the gestogram, thefundal height measuring tape, the perinatal card, and the table of maternal weight and height.

Indicator

1) Percentage ofpregnant womencared for whohave a correctlycompleted BasicPerinatal ClinicalHistory (BPCH)form

2) Percentage ofclients in laborwho receive acorrectlyinterpretedpartograph withalert curve

Numerator/Denominator

Number ofcorrectlycompletedBPCHs/

Total number ofpregnant womenattended

Target

60%

Source

Clinical filesof pregnantwomenattended

Periodicityof Collection

Monthly

2. Each pregnantwoman willreceive at least4 prenatal carevisits.

Number ofpartographs withalert curves filledout and correctlyinterpreted/

Number of birthsattended

Total number ofprenatal carevisits for allpregnant womenseen at thehealth unit/

Total number ofpregnant womenseen for prenatalcare for the firsttime

Number ofprenatal clientswho reportsatisfaction withthe care theyreceived/

Total number ofprenatal careclients

60% Obstetric files Monthly

Monthly3) Averagenumber ofprenatal carevisits per pregnantwoman seen atthe health unit

3 prenatal carevisits perpregnant woman

Consolidatedregistry forintegratedmaternal care

Quarterly3. Prenatal careclients will be20% moresatisfied withthe care theyreceived,compared tobaseline.

4) Percentage ofprenatal careclients who reportsatisfaction withthe care theyreceived

Bocay: 61%Rio Blanco: 75%Waslala: 68%El Cua: 75%

Exitinterviewsandsuggestionboxes

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Standard

4. Obstetricemergenciesreferred to thesecond level ofcare will beanalyzed bythe advisingphysician, withspecial emphasison the causes oftransfer andadequate care.

Indicator

5) Percentage ofemergencyobstetric casesreferred to thesecond level ofcare that areanalyzed by theadvising physician

Numerator/Denominator

Number ofobstetricemergencycases referred tothe second levelof care that areanalyzed by theadvisingphysician/

Total number ofobstetricemergenciesreferred to thesecond level ofcare

Number ofemergencyobstetric clientswho receive careaccording tostandards for thediagnosis andtreatment ofobstetricemergencies/

Total number ofobstetricemergencies

Number ofbabies born inthe health centerwho receive careaccording to thestandards forimmediatenewborn care/

Total number ofnewborns whoreceive care

Target

80%

Source

Registry oftransfers tosecond levelof care andminute bookof analysis ofobstetricemergenciesreferred tosecond levelof care

Periodicityof Collection

Monthly

60% Clinicalrecords ofpatients withobstetricemergencies

Monthly

Table 1. List of Standards Monitored in 2000 and CorrespondingIndicators (Matagalpa and Jinotega) continued

5. Emergencyobstetricstandards will becorrectly appliedby the end of2000.

6) Percentage ofemergencyobstetric clientswho receive careaccording tostandards for thediagnosis andtreatment ofobstetricemergencies

6. Standards for theimmediate careof newborns willbe correctlyapplied.

7) Percentage ofbabies born in thehealth center whoreceive careaccording to thestandards forimmediatenewborn care

60% Clinicalrecords ofneonates

Monthly


The missionstatement fromRio Blanco

Training in Standards and Quality AssuranceOnce standards were identified, defined, and approved,staff at the health units needed knowledge and skills toperform according to those standards. The MOH and QAProject staff conducted workshops on the clinical standards(perinatal tools, essential obstetric care [EOC], andimmediate care of newborns) and on quality awareness.

All health unit staff—from the director to the janitor—wereintroduced to quality principles during a quality awarenessseminar. Basic quality concepts were explained: definingquality, the purpose of indicators and how they are moni-tored, client satisfaction, human relations, empathy forclients, increasing client and institutional self-esteem,teamwork, and rapid team problem solving. Formallyintroducing quality assurance to staff helped them realizethat improving quality was within their power; allowing themto discuss quality-related issues and make decisions abouttheir processes motivated them to try to achieve thestandards.

During the training, each municipal health unit incorporatedquality concepts into its vision and mission statements.Upon returning to their work places, they were ready tostart building quality improvement (QI) teams that wouldimplement QI projects at each health unit. Teams hadapproximately five members: all staff interested in partici-pating in QI efforts. Members were usually from the healthcenters (sometimes from health posts) and could includethe health center director, doctors and nurses, health

Ya-S

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Lin


The teamsworkedrapidly toimprovehealthcarefacilities andfurniture,including thisbed.

education specialist, gynecologist (one team), and admis-sions personnel. To share responsibilities, teams formedsubcommittees, with each subcommittee taking responsi-bility for monitoring a different indicator.

Implementing Quality ImprovementAddressing client demands for improvedfacilities. The QI teams determined which of the mainclient needs could be implemented rapidly. They institutedimmediate changes to improve the patient flow andambiance at the health centers: the client satisfactionsurvey had called attention to the need for efficiency andcomfort for pregnant women. The teams also arranged forsigns identifying different clinical departments to helporient clients; to paint waiting rooms, wards, and beds; andto supply mattresses, sheets, screens, fans, and patientgowns.6

Increasing skills in using perinatal technology.Lack of obstetric care documentation makes it difficult toassess the quality of care and identify areas for improve-ment. The importance of having such documentation isreflected in the first standard in Table 1: All pregnantwomen will receive care in which the perinatal care toolsare correctly applied.

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Completing the partograph (partograma) was one aspect of assuring quality care forwomen in delivery.

A workshop for first-line service providers explained theuse and interpretation of the perinatal care tools requiredby the first standard. This session also covered prenatalcare and risk detection. Most importantly, the trainingtaught staff how the indicators would be monitored andlinked the indicators to the standards. Participants learnedhow quality monitors would be applied: that staff compli-ance with standards would be monitored and that staffcould contribute to the quality of care by performingaccording to the standards.

To maximize learning, participants received CLAP7 litera-ture on the use of perinatal tools a month before theworkshop so they could study the material beforehand.During the workshop, participants measured their knowl-edge of the tools in a pretest and worked in groups onhypothetical cases. At the end of the workshop, staff fromeach municipality received a supply of the tools presentedduring the workshop.


Healthcareproviders usea babymannequinduring trainingon theimmediatecare ofnewborns.

Building capacity in immediate care of new-borns. To increase staff competence in standards for theimmediate care of the newborn (standard number 6),clinical training was offered to staff from each municipality.The curriculum covered the main conditions that causenewborn morbidity and mortality, early identification ofintrapartum risk factors, and neonatal resuscitation. Stafflearned to follow and interpret algorithms to reinforce thestandards. Staff also learned about the parameters of theindicator for newborn baby care: heart rate, respiratoryrate, gestational age, etc.

Building staff capacity in emergency obstetriccare. To address standard number 5 relating to emer-gency obstetric care, the teams had to wait for the MOH torelease standards for obstetric care, the result of a collabo-rative effort with international agencies such as the PanAmerican Health Organization. Once this work was com-pleted, the QA Project and MOH developed obstetric carealgorithms and job aids.

Staff from each municipality attended a workshop andlearned to use the algorithms. Topics included the manage-ment of abortion and its complications, hemorrhage duringpregnancy, pre-eclampsia and eclampsia, obstructed orprolonged labor, etc. Once again, information linking theobstetric standards and the monitoring of the obstetric careindicators was stressed. A sample monitoring form ispresented in Appendix 1.

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Monitoring Compliance with StandardsWhile training workshops can impart information and skillsto perform a task, they cannot sustain change in providerpractices. The QI teams would fill this gap by monitoringresults from those changes and applying problem solvingto the standards where results were unsatisfactory.

Role of the QI teams. Each team had the assignment ofmonitoring performance according to standards by usingthe selected indicators. If standards were not met, theteams would address the causes using the problem-solvingmethodology.8 To monitor compliance with standards, eachteam met monthly to review the source records (noted inthe “Source” column of Table 1) and assess how its healthcenter performed against the indicators. During thesemeetings, teams would tabulate, present, review, anddiscuss the results of the monitoring. They also discussedthe results of exit surveys, which were conducted quarterlyat some facilities. Appendix 2 is an example of a meetinglog.

The first set of monitoring data (Table 2) served as thebaseline for the teams to measure their progress. Standardnumber 1 was initially modified to reflect only whether formshad been filled out or not. Once forms were being com-pleted regularly, accuracy was also monitored.

Increasing compliance with standards usingrapid team-based problem solving. Continuousmonitoring started about a month after training. Whereverstandards were not met, the QI team was responsible forproblem solving and implementing measures to meetstandards. An example of the rapid problem-solving cycleis in Appendix 3.


Table 2. Selected Results of Baseline Medical Record Review(February 2000; N=120 Medical Records)

Indicator* Baseline

1) Percentage of pregnant women cared for at the facility for whom a BPCH form 3%was correctly completed

2) Percentage of mothers in labor who received a correctly interpreted partograph 0%with alert curve

3) Average number of prenatal care visits per pregnant woman seen at the health unit 1.9

4) Percentage of clients who report satisfaction with the prenatal care they received Río Blanco: 63%Waslala: 57%El Cua: 62%Bocay: 51%

5) Percentage of emergency obstetric cases referred to the second level of care that 0%are examined by the advising physician

6) Percentage of emergency obstetric patients who received care according to the 0%standards for the diagnosis and treatment of obstetric emergencies

7) Percentage of babies born in the health center who received care according tothe standard for immediate newborn care <3%

* Numerators and denominators are defined in Table 1.

ResultsEight months after training, the teams found significantimprovements in the seven indicators that were monitoredto assess performance according to the six standards (seeTable 3).

Information was posted to inform staff and clients of theprogress that had been achieved toward reaching thetargets shown in Table 3. As data developed over time, theteams displayed run charts at the health units for both staffand the public to see. The charts showed the progressbeing made each month toward meeting the goal for eachindicator. Figures 1 and 2 are compilation run charts: theyshow monthly data from all four sites.

Reduction of maternal deaths. While the sevenindicators measure the degree to which healthcare is


Table 3. Monitoring Indicators for All Health Units

Baseline: Results:Indicator* May 2000 Target May 2001

1) Percentage of pregnant women cared for at the May: <3% 60% 88%facility for whom a BPCH form was correctlycompleted

2) Percentage of clients in labor who received a May: 0% 60% 70%correctly interpreted partograph with alert curve

3) Average number of prenatal care visits May: 1.9 3 2.5per woman

4) Percentage of clients who reported satisfaction Río Blanco: 63% Rio Blanco: 76% 93%with the prenatal care they received Waslala: 57% Waslala: 68%

El Cua: 62% El Cua: 74%Bocay: 51% Bocay: 61%

5) Percentage of obstetric emergency cases referred 0 80% NAto the second level of care that were analyzed bythe advising physician

6) Percentage of emergency obstetric clients who 0 60% NAreceived care according to the standards for thediagnosis and treatment of obstetric emergencies

7) Percentage of babies born in the health center May: <3% 60% 82%who receive care according to the standards forimmediate newborn care

Note: “NA” indicates results were not available.* Numerators and denominators are defined in Table 1.

delivered according to standards, the ultimate goal was todecrease maternal mortality. Figure 3 shows the reductionin maternal deaths during 1999 and 2000.9

Monitoring and Improving Quality: InsightsThe Nicaraguan health units made great strides in theirefforts to monitor standards to improve health outcomes.Once the standards were in place—whether promulgatedby the Ministry of Health or developed by the healthcareproviders—these facilities showed that they could imple-ment monitoring systems to measure their efforts to close


Figure 1. Percentage of Clients in Labor WhoReceived a Correctly Interpreted Partograph withAlert Curve

M A M J J A S O N D J F M A M2000 2001

100

90

80

70

60

50

40

30

20

10

0

Percent

Rio Blanco Waslala El Cua Bocay

Figure 2. Percentage of Babies Born in the HealthCenter Who Received Care According to theStandards for the Immediate Care of Newborns

M A M J J A S O N D J F M A M2000 2001

100

90

80

70

60

50

40

30

20

10

0

Percent

Rio Blanco Waslala El Cua Bocay


Figure 3. Reduction of Maternal Deaths

35

30

25

20

15

10

5

0

Percent

Matagalpa Jinotega

quality gaps. They used their measurements to identifyopportunities for improvement, applied rapid team problemsolving, and significantly improved the health outcomes intheir communities.

Evidence-based standards provided by the Ministry ofHealth ensured positive health outcomes, while a focus onclient satisfaction increased utilization of health services,such as prenatal visits. Several processes and factorscontributed to these gains:

Team building. Monitoring and problem solving in teamsforced all involved staff to think about and seek solutions ata systems level, rather than through the lenses of theirindividual roles. In addition, the team meetings helpedmembers sustain their focus and motivation. The teams’sense of ownership of the monitoring and QI functionscontributed to the health units’ institutional memory. Suchownership minimized the negative effects of staff turnover.

Resources. The quick fixes to repair furniture andfacilities and ensure stocks of basic supplies ignited staffmotivation for the more significant changes that wouldcome later. Such changes are concrete and visual, remind-ing both staff and the public of the new effort to improve

1999 2000 1999 2000


obstetric care. In the long run, the health units will have tofind alternative methods of funding QA Project support forbasic supplies (e.g., medical record forms). However, theexternal support allowed the health units to focus onimproving maternal care during the 14-month project.

Goal setting. Setting goals that were specific andachievable helped to focus the direction of staff’s efforts.First, this involved prioritization of standards by identifyingand prioritizing a limited number of standards from theMOH obstetric standards. Second, staff had to define howthese standards would be measured, identifying preciseindicators and targets, including where data would beobtained and how indicators would be calculated.

Before, even though there were standards we weresupposed be following, no one talked about them. . . .So the impression was that they weren’t that important.

Health center quality improvement team member

Client focus. Work such as undertaking client surveysand developing community-based standards stimulatedhealthcare providers to change their attitudes, whichimproved provider-client interactions, technical compe-tency, and other dimensions of quality.

The community outreach work sensitized staff tounderstand the issues of poverty and difficult accessthat clients face, . . . which was emphasized during thefirst staff training on self-esteem and human relations.The training led staff to reflect on how they treat clients.This training, in turn, conditioned them to receivetechnical training.

Deputy Director, El Cua Health Center

Frequent feedback. Monthly sessions to calculate anddiscuss the indicators provided a forum for feedback,which, like scorekeeping, motivated staff to improve theirperformance. Since indicator measurements were collectedby different QI team members and reviewed by the entire


team, the team could quickly problem solve to find ways toaddress any problems that arose. Teams also closelymonitored maternal deaths; members knew how many hadoccurred and whether they had decreased.

Many people believe that to make change happen,money is necessary. This is not true. What is needed isa change in attitude in management and in the staffwho see clients. Two things are necessary to generatechange: a motivated staff and basic conditions.

Deputy Director, El Cua Health Center

Consistent coaching. Coaches helped to set up teamsand served as resource guides as they accompanied theteams’ work. By attending meetings, coaches motivatedteams, increased the teams’ legitimacy, and reinforced theimportance of increasing compliance with standards.

Linking training in the use of technology andquality assurance. As healthcare providers learned howto use technology and implement the new standards ofcare, they also learned how those features were linked tothe data that would be collected for various indicators. Thelinkage helped them to see how their individual behaviorhad an impact not only on the level of care, but also on theindicator measurement results and, ultimately, the maternalmortality rate outcome. A clear understanding of cause-and-effect relationship brought a sense of importance tothe quality improvement efforts.

Sustaining QA. As teams gained experience, theylearned how to apply QA methods more effectively, knowl-edge that can benefit future efforts in Nicaragua. Forinstance, teams can identify what factors have successfullymotivated teams, such as inter-team competition, publicrecognition, and opportunities for training at a different site.From this experience, teams intend to incorporate innova-tions, such as involving more people in QI at the outset andusing primary school teachers to do exit surveys to reducebias.


Figure 4. Defining, Measuring, and ImprovingQuality: The Three Core Activities of QualityAssurance

ConclusionWhile this case study essentially describes how health unitteams monitored the performance at their facilities, all threecore quality assurance activities played a role in Nicara-gua. First, MOH and QA Project staff defined quality byselecting standards and defining indicators. Then, afterstaff training to increase clinical capacity in the areas of theselected indicators, QI teams monitored the quality of careaccording to those indicators. Finally, when the indicatorsshowed that staff were not performing according tostandards, the teams applied rapid team problem solvingto identify, test, and implement solutions.

DefiningQuality

Policy Making

Quality (Re)-Designing

Benchmarking

Problem Solving

Management Actions

MeasuringQuality

ImprovingQuality

Structural Re-Organization

Incentives

Motivation

Standards Setting

Monitoring Systems

Supervision

Quality Regulation Accreditation AuditEvaluation

QualityAssurance

Improving Maternal Care in Nicaragua

Appendix 1: Quality Indicator Monitoring FormThe following is a translated segment of a form used by the quality improve-ment team in Rio Blanco to record the percentage of Basic Prenatal ClinicalHistory forms that were correctly completed (see Table 1, Indicator 1).

Republic of NicaraguaMinistry of Health

Monitoring of the Basic Prenatal Clinical History FormDepartment: Matagalpa City: Rio Blanco Year 2000

MONTH

September October November December(Percentage) (Percentage) (Percentage) (Percentage)

1. IDENTIFICATION

City 80 100 80 70

State 80 100 100 70

Education 80 90 90 100

SUBTOTAL 80 97 90 80

2. MEDICAL HISTORY

Family History 100 100 100 100

Personal History 100 100 100 100

Obstetric History 53 100 90 100

Previous 60 100 100 100Pregnancies

SUBTOTAL 78 100 98 100

3. CURRENT PREGNANCY

Weight 40 100 80 90

Rh Factor 0 60 30 20

Clinical exam 80 90 90 80

Cervix 20 70 50 30

Hemoglobin 0 60 70 0

General Exam 0 60 50 0

ITEMSCORRECTLYCOMPLETED

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Appendix 2. Quality Improvement Team Meeting Log(Translated Excerpt)10

El Cua, August 8th, 2000

Meeting to review points brought up in opinion survey and to evaluatehealth personnel in management of standards

1) Lack of prioritization

Agreements: Statistics manager will conduct orientation session for admis-sions officers so that pregnant women and children are prioritized for care.The statistics manager should review the data on integrated care forwomen every day and enter the data in the computer between 11:00 and12:30 (time allotment to be increased if necessary). The OB/GYN shouldprioritize first-time clients, those who are on their last prenatal visit, and thehealth problems that they present. All doctors should follow IMCI standardsfor children younger than 5 years old.

2) Deficiency in the management of standards

Agreements: Monitoring and supervision at the health units should involveall doctors who received training in monitoring the use of perinatal tech-nologies. All records of women who gave birth at the health unit and thosewho were admitted for any health reason during pregnancy were identified.Standards will be given to health personnel before training on managementof standards so that they can be discussed during training. On Monday,staff will be notified of the date to discuss these standards. The schedulefor using the computer for entering data on standards will be put in writing.This afternoon the memo regarding the priority admission of pregnantwomen and children will be circulated. The lab manager should registerroutine examinations of each pregnant woman in a notebook. Childhoodimmunization cards should be assured at labor and delivery so that birthdata are recorded and children are referred for BCG vaccination.

El Cua, August 16th, 2000

Using the monitoring sheet, the basic perinatal clinical history and thepartograph of 10 obstetric records were reviewed. Using the calculationparameters listed on the monitoring sheet, the records scored 71 percentcompliance with standards.

Exit interviews are being conducted. About 10 to 15 out of 50 interviewsremain to be conducted.

General doctor, nurse, and OB/GYN need to complete the EOC analysisand record it in this notebook. Monitoring of newborn care needs to bedone.


Appendix 3. Example of Rapid Team Problem Solving atRío Blanco Health CenterThe Río Blanco team meets once a month at the health center. The mem-bers consist of the medical director, the training doctor, the assistantdoctor, assistant nurses, the medical record administrator, and the QAProject facilitator.

Step 1: Identify problem: During one of its early meetings, the RíoBlanco team examined the health center performance in the area of the sixindicators they monitored every month. The team found that not only hadthe number of prenatal care visits per pregnant woman not improved, but itwas actually decreasing. Consequently, they gave high priority to thisproblem.

Step 2: Analyze: In this step, a team usually selects an indicator that willmeasure an improvement in the problem area, so that they will know if theirquality improvement effort was successful by monitoring the indicator.However, in this case, the problem was identified from the indicator, whichhad already been defined as: the total number of prenatal care visits in amonth divided by the number of first-time prenatal care visits during sameperiod.

The Río Blanco team met to investigate why there was a reduction in theprenatal care visits indicator. First, the team brainstormed a list of reasonsthat could have caused this reduction and grouped related ideas. Next, foreach reason, the team asked the question why, probing for a root cause byusing a tree diagram as a guide.

The team quickly decided that among the possible causes identified, amain problem seemed to be that doctors and nurses did not have theappropriate forms for registering prenatal care visits. Since they had run outof forms, they were registering prenatal care visits on any type of paper,which made it difficult for the statistics department to consolidate theinformation. On the other hand, even when they had the forms, they wereoften simply filed away and not sent to statistics for consolidation.

Steps 3 and 4: Develop, Test and Implement Solution: Since theteam agreed that the cause of the problem was obvious, it requested thatthe QA Project provide prenatal care visit forms. Once the forms wereobtained, the team distributed them to all staff providing prenatal careservices.

The team also decided that the archives clerk would collect the forms,check whether they were filled out correctly, and deliver them to the


statistics department. The clerk and the health center director would thencross-check the information collected from the prenatal care medical staffwith the information consolidated by the statistics department. From this thevalues for the construction of the indicator will be obtained.

With this exercise, the team implemented the changes in data collectionand consolidation, and in the following meetings, the team noted that theindicator had improved.


Endnotes1 “Maternal mortality ratio” refers to the number of maternal deaths per

100,000 live births. “Maternal death” is the death of a woman, whilepregnant or within 42 days of termination of pregnancy, from any causerelated to the pregnancy but not from accidental causes.

2 Ministerio de Salud de Nicaragua y UNICEF. 1998. Mortalidad Materna.Un análisis de las muertes ocurridas en Nicaragua en 1998.

3 Ministerio de Salud de Nicaragua y UNICEF. 1998.

4 Client perception about maternal healthcare services at the health unitlevel was assessed at 675 households, 4 health centers, and 14 healthposts in the four selected municipalities.

5 See Nuñez, O. and Hernández F. 2000. Satisfacción, demandas yrequerimientos de beneficiarias de los servicios de salud maternal encentros y puestos de salud de Río Blanco, Waslala, El Cua y Bocay. Unainvestigación social cualitativa. Chevy Chase, MD: Quality Assurance Project.

6 Some of the funds to cover costs for these repairs and other improve-ments were provided by the QA Project and other local nongovernmentalorganizations, such as PROSALUD and CARE.

7 Centro Latinoamericano de Perinatología y Desarrollo Humano(Latin American Center for Perinatology and Human Development).

8 The QA Project has developed a problem-solving methodology over thecourse of its work in developing countries. The methodology is describedin many QA Project publications, particularly “A Modern Paradigm forImproving Healthcare Quality,” available in English, French, Russian, andSpanish from <www.qaproject.org>.

9 Other simultaneous projects with similar goals make it impossible toattribute all the decrease in maternal deaths to the quality assessmentand improvement.

10 Text was modified slightly to facilitate comprehension.

Using Quality Assessment to ImproveMaternal Care in Nicaragua: SummaryThis case study describes the work of qualityimprovement (QI) teams working in four municipalitiesin Hurricane Mitch-damaged areas of Nicaragua. Theteams monitored the quality of care by gathering datarelating to seven indicators, such as the number ofprenatal care visits and applying emergency obstetriccare. To the extent the monitoring indicated thatstandards of care were not being met, the QI teamsapplied rapid team problem solving to redirect thehealthcare providers toward achieving performanceaccording to standards.

Performance improved in all indicators during the yearof monitoring, and maternal mortality rates improvedduring that same period. This work led to insightsfinding that QI teams can set goals for themselvesand monitor their progress in reaching those goals,that many improvements can be made with theinvestment of few resources, and that providerattitudes will change with information about clientneeds and expectations.

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