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Use of Plan-Do-Study-Act (PDSA) Cycles to Strengthen Routine Immunization in Ethiopia

  1. USE OF PLAN-DO-STUDY-ACT (PDSA) CYCLES TO STRENGTHEN ROUTINE IMMUNIZATION IN ETHIOPIA Operational Research Findings Universal Immunization through Improving Family Health Services (UI-FHS) project Adriana Almiñana, MPH February 20, 2018 Durban, South Africa
  2. Background • Quality improvement is a priority for the Ethiopian Federal Ministry of Health • Universal Immunization through Improving Family Health Services (UI- FHS) project: • Improve routine immunization in 6 regions; 103 districts • Operationalize national immunization strategy “Reaching Every District” (RED) by providing technical assistance for immunization, and the introduction of QI = “RED-QI” Photo: Bill & Melinda Gates Foundation
  3. Quality ImprovementTeams (QITs) • UI-FHS trained staff at district health offices, health centers (HCs) and select health posts (HPs) on RED-QI • District responsible for cascading training • Trained staff expected to activate QITs – focus on solving immunization problems through PDSA • Other support: reinforced during supportive supervision visits, review meetings, etc. Process • District and HC: approx. 4-6 people, including the immunization focal person, head of the facility, other health staff • Some HCs included community members • HP: 1-2 health workers plus 3-6 lay community members (usually an already existing group)People
  4. Study Methods • 3 districts: differing health system and demographic contexts • Case study; mainly qualitative: What is the experience of quality improvement teams in Ethiopia with using PDSA cycles to improve routine immunization service delivery? 24 Key informant interviews with facility staff 12 Focus group discussions with QITs 3 Interviews with UI-FHS staff Document reviews of facility documents on PDSA cycles
  5. Findings • Training: • Direct training with follow-up most effective • Cascade training limited by available resources • Uptake and Use: • More focus on “Plan” and “Do” phases of the PDSA cycle; “Study” was difficult • Indicators related to “aim,” not change idea; PDSA documentation overall incomplete/limited • Higher use of other QI tools (e.g. fishbone diagram) compared to PDSA We used fishbone more because it helped us to keep on asking why questions and find out causes. – District Office, Damboya The study part is a bit difficult [laughter], it needs sacrifice. – HealthWorker, HP, Damboya
  6. Findings • QITs: • HP: community members engaged for “Plan” and “Do” phases. QIT was a mechanism to better community engagement and linkage to health facility • HC: QITs more engaged throughout entire cycle • District: involved for parts of the PDSA cycle (barriers of competing priorities) • Benefits: • Increased partnership and communication with the community • Problem identification and testing solutions was valued The results out of these cycles encouraged us to use it further. – HealthWorker, Dubti They [QIT] mobilize the community during EPI, identify and solve problems in the community, and support [health post] activities in the community. – HealthWorker, HP,Tahtay Koraro
  7. Takeaways & Lessons Learned • The use of QI added focus to the quality of immunization services and health services in general; the idea of breaking down problems and focusing on processes is taking root • QI tools are useful at facility level for local problem solving • Streamlined, simplified approaches that integrate into the existing health system are critical • PDSA cycles require training; can still see process improvements with only part of the QIT formally trained • Need to explore ways of documenting PDSAs that are consonant with the skills and abilities of peripheral health workers • Strong linkages with the community helped improve immunization services. Peripheral health workers engaged QIT community members at specific points in the PDSA cycle, gathering feedback from them or leveraging their relationships with the larger community to enlist extra manpower for some activities
  8. Thank you! Icons: Andrejs Kirma, Jemis Mali, and Xinh Studio from The Noun Project