Quality improvement and innovation in low resource settings

1. Quality Improvement and Innovations
In Low Resource Settings
Geetanjli Kalyan
National Institute of Nursing
Education, PGIMER,
Chandigarh
.

2. “Crossing the Quality
Chasm”
• In 2001 IOM published a report “Crossing the Quality Chasm”
• Report highlighted that though providers have more research
findings and more technology available to them than ever
before still quality is in doubt.
• This report was an urgent call for fundamental change to close
the quality gap

3. Quality Improvement
• Quality is related to
• level of improved health services and the desired health outcomes
• Quality improvement (QI):
• Is systematic and continuous actions that lead to measurable
improvement in health care services and the health status of targeted
patient groups.
Institute of Medicine (IOM)

4. Crossing the Quality Chasm: Six dimensions
of high-quality
• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient centered
Special emphasis to
• Value (ratio of cost, quality care and equity)
• Access
• Prevention

6. Research Quality improvement
The purposes of generalizing findings to a
population
It aims to improve care, processes, or outcomes
within an organization
Answers a question or hypothesis to advance
general knowledge
Improves performance or processes to
strengthen patient care.
Findings contribute to generalized knowledge
outside of the hospital
Findings used for internal improvement.
Subjects may not directly benefit from
knowledge gained
Implementation will result in direct benefit
Follows a research design (e.g. randomization),
rigid protocols
Follows the plan, do, study, act cycle, flexible
Large sample Test on small sample
Research vs Quality Improvement

7. High vs low income nations
• In developed economies/ high income nations all we can do is
process improvement
• Low resource setting there are many barriers and we need to
find out measures to overcome them and we also need to learn
from the success stories of such setting.

8. Let us see the barriers

9. Limited Human Resources/Skills
• Low ratio of HCP : Patient
• Workload
• Poor patient care
• Poor training
• Poor staff attitude
• No time to explain the patient
• Weak adherence to treatment protocols
• Poor staff performance
Josephine Nana Afrakoma Agyeman-Duah etal. BMC Health Serv Res. 2014
Advancing Quality Improvement Research

10. Lack of resources
• Major Problem
• Access
• No means of carrying a labouring women living in an oversea territory where
mainland is separated by a river
(Sodzi Sodzi-Tettey, MD, MPH; IHI Senior Technical Director for the Africa Region)
• Scarcity of important tools, and resources

11. Lack of Dedicated Research Teams contd….
• Lack motivation and attitude
• Limited knowledge related to the methods of quality
improvement
• High quality care definition differ from individual to individual
• People consider such initiatives as a waste
• Many junior residents don’t feel them as part of the organisation
• View point of juniors not considered by senior clinicians

12. Lack of dedicated research teams
• Nurses are not considered part of team
• Conflicting views on who is responsible for change
• Lack of time
• The failed history of initiatives/
• No examples of benefit
• Not trained in change management
• No trust on management
• Problems with group dynamics

13. Limited Data and Evidence Related Sources
• Limited knowledge how to access information
• No access to the evidence

14. Limited Funding and Related Awareness
• Funding awareness is very poor
• In case aware don’t know the how to write and go about it.
• Don’t guide others about funding and process

15. Organizational barriers
• Technical and structural,
• Poor maintenance of costly equipment
• Limited infrastructure
• Psychosocial
Ziegenfuss JT Jr. Qual Assur Util Rev. 1991
• Poor patient referral system
• Poor performance of primary and secondary Health care system

16. Organizational barriers
• Frequent system breakdowns because of
• combination of resource constraints
• limitations of the health workforce
• poorly developed management systems.
• Weak accountability of staff
• Weak leadership structure

17. Barriers to QI as per Patients
• Some patient don’t take responsibility of their own health
• Poor amenities and services
• Weak adherence to treatment protocols
• Patients not involved in their own care
• Delayed treatment, long waiting time
• Wrong treatment
• Whom you know service
• Poor understanding of patients
Josephine Nana Afrakoma Agyeman-Duah etal. BMC Health Serv Res. 2014

18. What makes QI a failure

19. Causes of failure of QI Initiatives
• Narrowly focused, outcome-oriented quality improvement initiatives
• Investments in health systems strengthening without continuous quality
improvement
• Only focusing on quality improvement in a resource-poor context
without engaging the broader health system for support

20. How to overcome

21. Improvement begins from with in
• True Indian Story: Dashrath Manjhi living in
Gehlaur village, near Gaya in Bihar, India who spent 22
years chiselling this massive gap through a mountain out of
love for his dead wife, who died because the 34-mile route
round to the nearest town was too far to take her for urgent
medical care
The Mountain Man

22. How to overcome contd….
• Address problems such as:
• High adverse event rates
• Too few and poorly trained providers
• Limited diagnostic tools and equipment
• Delays in accessing medications and other treatments

23. How to overcome contd….
• Build a widely focused systems for ongoing, operational monitoring
and response
Mark Durand. International Journal for Quality in Health Care
• Major Key driver is organizational support
• Five elements:
• (i) systems thinking
• (ii) stakeholders’ participation
• (iii) accountability
• (iv) evidence-based interventions
• (v) innovative evaluation
Bejoy Nambiar et al. Bull World Health Organ. 2017

24. Strategies for improving the quality of health
care in LMIC
• Overview of 27 Systematic review on the strategies for improving
the quality of health care in LMIC
Fernado A. etal. Perinatal Reasearch unit and Institute forclinical effectiveness and
health polcy. WHO- RPC Meeting
• Important is “Know-do-gap”: how to make the intervention of
known efficacy

25. Use of known effective intervention
• Fact (globally)
• Use known intervention to manage neonatal hypothermia are used in
20%
• Administration of antenatal steroid in no more than 5%
Jones G etal. Child Survival Study group. Lancet. 2003
• Already known interventions can reduce neonatal and child mortality by
40-70%
Compell O, Ghraham W. Strategies for reducing maternal mortality:getting on what works. Lancet 2006

26. Helpful/not helpful techniques
• Distribution of educational material: not effective alone
• Audit and feedback: small to moderate positive effect
• Reminder: low cost, small to moderate positive effect
• Educational meetings: small to moderate positive effect:
interactive workshops useful
• Educational outreach visits: effective but are costly

27. Helpful/not helpful techniques
• Local opinion leaders: small to moderate positive effect
• Patient mediated and mass media: less effective and costly.
• Multifaceted interventions are helpful
• Organizational and financial support

28. At national level helpful
• Developing capacity: education and training of all stakeholders
• Encourage engagement
• leaders must set: clear goals and priorities
• Create an environment for improvement
• Translate and communicate national priorities
• Inform who are the key role player to play vital roles for
improving care
• Identify the champions, involve and recognize them

29. Quality improvement through nursing ( as per ICN)
QI by nursing:
Setting the
Standards
LEADERSHIP
STAFFING
LEVELS
CULTURE
SKILL MIX
INTER-
DISCIPLINARY
CARE
RESEARCH
INFORMATICS
EDUCATION

30. • The 'Indian Pediatrics" Journal has come out with a Special Issue on "Better
Healthcare Through Quality Improvement
• This journal issue contains papers that
• (i) illustrate the key principles of QI implementation;
• (ii) provide practical examples of how this approach has been used to address the six
dimensions of quality in the Indian context; and
• (iii) describe some resources that can support health workers in using quality improvement
methods.
• The articles can be accessed online here -
https://www.indianpediatrics.net/sep2018/current.htm
Sethi A, Joshi M, Thukral A, Singh Dalal J, Kumar Deorari A. A Quality Improvement Initiative:
Improving Exclusive Breastfeeding Rates of Preterm Neonates. Indian J Pediatr. 2017
Apr;84(4):322–5.
Learn form success stories

31. Our success stories
• Assessment of efficacy of “Aseptic Intravenous line
insertion and maintenance bundle” on reduction of
incidence of phlebitis and infiltration in children: A Quality
improvement study
• A quality improvement study to evaluate the effectiveness of
noise reduction package in reducing the level of noise and stress
of health care providers in NICU, PGIMER, Chandigarh

32. POCQI
• https://aiimsqi.org/point-of-care-quality-improvement-
pocqi/

33. Generate certificate

34. Download workbook POQCI
• http://workbook.pocqi.org/

35. Online courses
• https://www.ontop-in.org/

36. Apps

37. Conclusion
• No magic bullet or simple solutions to improve quality
• We have to try and test as no single solution is applicable to all
problem
• Each setup has its own problem most appropriate tools has to be
selected out of broad categories of interventions
• Requires governance structure that assign responsibility for quality
improvement, priority setting, selection of designed interventions

38. Conclusion
• A multifaceted interventions integrated with interactive
workshops, distribution of simple printed material, and
application of manual reminders can be help.
• Conducting small quality improvement projects at own setup can
rewarding.

39. References
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income countries. AIDS Lond Engl. 2015 Jul;29 Suppl 2:S179-186.
2. Sethi A, Joshi M, Thukral A, Singh Dalal J, Kumar Deorari A. A Quality Improvement Initiative: Improving Exclusive Breastfeeding Rates of Preterm
Neonates. Indian J Pediatr. 2017 Apr;84(4):322–5.
3. Thukral A, Joshi M, Joshi P, Prakash V, Adkoli BV, Deorari AK. Apps for management of sick newborn: evaluation of impact on health care professionals. J
Trop Pediatr. 2014 Oct;60(5):370–6.
4. Manu A, Arifeen S, Williams J, Mwasanya E, Zaka N, Plowman BA, et al. Assessment of facility readiness for implementing the WHO/UNICEF standards
for improving quality of maternal and newborn care in health facilities – experiences from UNICEF’s implementation in three countries of South Asia and
sub-Saharan Africa. BMC Health Serv Res. 2018 Jul 9;18(1):531.
5. Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018 May 17;361:k2014.
6. Stokes T, Shaw EJ, Camosso-Stefinovic J, Imamura M, Kanguru L, Hussein J. Barriers and enablers to guideline implementation strategies to improve
obstetric care practice in low- and middle-income countries: a systematic review of qualitative evidence. Implement Sci IS [Internet]. 2016 Oct 22 [cited 2018
Nov 2];11. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5075167/
7. the AHI PHIT Partnership Collaborative, Wagenaar BH, Hirschhorn LR, Henley C, Gremu A, Sindano N, et al. Data-driven quality improvement in low-and
middle-income country health systems: lessons from seven years of implementation experience across Mozambique, Rwanda, and Zambia. BMC Health Serv
Res [Internet]. 2017 Dec [cited 2018 Nov 2];17(S3). Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2661-x

40. References
8. Deorari A, Livesley N. Delivering Quality Healthcare in India: Beginning of Improvement Journey. INDIAN Pediatr. 2018;55:3.
9. Chandrasekaran A, Thukral A, Deorari AK. E-learning in newborn health - a paradigm shift for continuing professional development
for doctors and nurses. Indian J Pediatr. 2014 Dec;81(12):1376–80.
10.Liu F, Han S-P, Yu Z-B, Zhang J, Chen X-H, Wu W-M, et al. [Effect of breastfeeding quality improvement on breastfeeding rate in
very low birth weight and extremely low birth weight infants]. Zhongguo Dang Dai Er Ke Za Zhi Chin J Contemp Pediatr. 2016
Oct;18(10):937–42.
11. Sivanandan S, Sethi A, Joshi M, Thukral A, Sankar MJ, Deorari AK, et al. Gains from Quality Improvement Initiatives - Experience
from a Tertiary-care Institute in India. Indian Pediatr. 2018 Sep 15;55(9):809–17.
12. Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care. 2007
Feb;16(1):2–3.
13. Hirschhorn LR, Ramaswamy R, Devnani M, Wandersman A, Simpson LA, Garcia-Elorrio E. Research versus practice in quality
improvement? Understanding how we can bridge the gap. Int J Qual Health Care. 2018 Apr 20;30(suppl_1):24–8.

41. Improvement begins from with in