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Improvement Collaboratives


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Improvement Collaboratives

  1. 1. Quality Improvement Collaboratives GH Mini University October 27, 2006 James Heiby Medical Officer GH/HIDN/HS
  2. 2. Session Outline <ul><li>Measuring how good health care is </li></ul><ul><li>Established approaches for improving </li></ul><ul><li>Continuous Quality Improvement model </li></ul><ul><li>How the collaborative methodology modifies CQI </li></ul><ul><li>Results so far in developing countries </li></ul><ul><li>Issues with the collaborative methodology </li></ul><ul><li>Discussion </li></ul>
  3. 3. A scenario: <ul><li>A mother brings her 8 month old girl to a MOH clinic in rural Africa </li></ul><ul><li>She is very thin, has a high fever, labored breathing, and is not breast feeding </li></ul><ul><li>4 years earlier, you were on a team that designed a health project that was implemented in this region </li></ul><ul><li>Project supplies basic drugs/supplies </li></ul><ul><li>The health worker enters the exam room </li></ul>
  4. 4. A Systems View of Quality <ul><li>Inputs/structure: The resources deemed necessary to provide health care </li></ul><ul><ul><li>Drugs, equipment </li></ul></ul><ul><ul><li>Competent provider </li></ul></ul><ul><ul><li>Guides, job aids, recording forms </li></ul></ul><ul><li>Process: The activities of providing health care are carried out correctly </li></ul><ul><ul><li>Compliance with clinical standards </li></ul></ul><ul><ul><li>Interpersonal elements </li></ul></ul><ul><ul><li>Systems to support patient care efficiently </li></ul></ul><ul><li>Outcomes: The results of the health care process meet expectations </li></ul><ul><ul><li>Mortality, morbidity </li></ul></ul><ul><ul><li>Completed immunizations </li></ul></ul>
  5. 5. Impact of an EBG for Diarrhea in malnourished children in Dhaka (Ahmed, et al, Lancet, 1999) <ul><li>Following standardized clinical protocol: </li></ul><ul><ul><li>Mortality 9% </li></ul></ul><ul><ul><li>Oral fluids only 60% </li></ul></ul><ul><ul><li>Antibiotics used 18% </li></ul></ul><ul><li>Following usual practice at ICDDR,B Hospital: </li></ul><ul><ul><li>Mortality 17% </li></ul></ul><ul><ul><li>Oral fluids only 29% </li></ul></ul><ul><ul><li>Antibiotics used 40% </li></ul></ul>
  6. 6. How well do providers follow evidence-based guidelines? <ul><li>How do programs know about this? </li></ul><ul><li>What do we find when we look? </li></ul><ul><li>What are the trends for the future? </li></ul>
  7. 7. JHU Uganda Performance According to Standards Survey (2001) <ul><li>National sample, 30 health centers </li></ul><ul><li>81 indicators grouped into indices; published MOH standards </li></ul><ul><ul><li>IMCI assessment: 47% </li></ul></ul><ul><ul><li>IMCI treatment: 35 </li></ul></ul><ul><ul><li>Malaria treatment: 70 </li></ul></ul><ul><ul><li>Antenatal care: 35 </li></ul></ul><ul><ul><li>Family Planning: 44 </li></ul></ul><ul><ul><li>STI 14 </li></ul></ul><ul><li>Moderate variation among districts </li></ul>
  8. 8. How do programs traditionally try to improve compliance with EBGs? <ul><li>What approaches are widely used? </li></ul><ul><li>How are these approaches working? </li></ul><ul><li>What have we learned about improving compliance? </li></ul>
  9. 9. The Basic Principles of Continuous Quality Improvement (CQI) <ul><li>The delivery of modern health services is complex and dynamic </li></ul><ul><li>It is feasible to study the process of health care and find ways to improve it </li></ul><ul><li>Our hypotheses about how to improve health care should be tested before we accept them </li></ul><ul><li>Regular health workers can do most of this work </li></ul>
  10. 10. Basic Principles, continued <ul><li>Improvement work consumes health resources, and should be accountable </li></ul><ul><ul><li>Benefits should exceed the costs </li></ul></ul><ul><ul><li>Current investments are </li></ul></ul><ul><ul><ul><li>Extremely small </li></ul></ul></ul><ul><ul><ul><li>Primarily the time of health staff </li></ul></ul></ul><ul><li>The benefits of successful improvement work grow as it is: </li></ul><ul><ul><li>Extended into the future </li></ul></ul><ul><ul><li>Spreads geographically </li></ul></ul>
  11. 11. 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? 1. 2. 3. PLAN DO STUDY ACT
  12. 12. Standards for Neonatal Resuscitation will be Applied at Each Delivery
  13. 13. Mpumalanga TB Data: Case finding per quarter (Data from 30 clinics: 10 per district) QI started
  14. 14. Salima: Improving Patient Compliance - Malaria <ul><li>Problem </li></ul><ul><ul><li>High rate of malaria “re-attendants” </li></ul></ul><ul><li>Cause Analysis </li></ul><ul><ul><li>Discarded drugs </li></ul></ul><ul><ul><li>23% of patients re-attendants (n=761) </li></ul></ul><ul><ul><li>84% of patients “forgot” instructions (n=43) </li></ul></ul><ul><li>Interventions </li></ul><ul><ul><li>DOT dose of SP </li></ul></ul><ul><ul><li>Blood smear for all re-attendants </li></ul></ul><ul><ul><li>Educate the community on importance of following treatment instructions </li></ul></ul>
  15. 15. Result: Decreased Re-attendant Malaria Patients % re-attendant malaria pat DOT implemented
  16. 16. Why isn’t everyone doing this?: Evaluation of Zambia QA Program <ul><li>Findings from a field evaluation one year after the end of USAID assistance, based on a sample of 25 clinics </li></ul><ul><li>Motivation for doing additional work: many teams stopped after first problem </li></ul><ul><li>Poor choice of problem, few clinical issues </li></ul><ul><li>Inefficiency: minimal spread of innovations among teams </li></ul><ul><li>Documentation weak </li></ul><ul><li>Slow pace of improvement </li></ul><ul><li>Training costs high relative to improvements </li></ul><ul><li>Leadership among senior MOH management lacking </li></ul><ul><li>What does the field of modern quality improvement have to offer that might address these problems? </li></ul>
  17. 17. The Improvement Collaborative Methodology <ul><li>Traditional QI teams and methods </li></ul><ul><li>Organized around a specific topic </li></ul><ul><li>Many teams </li></ul><ul><li>Technical experts provide a model of care feasible for the system, with indicators </li></ul><ul><li>High level sponsors </li></ul><ul><li>Frequent communications among teams </li></ul><ul><li>Wide experience in developed countries </li></ul>
  18. 18. Value Added of Multiple Teams Working on a Single Problem: <ul><li>More rapid progress </li></ul><ul><li>Each team learns from work of the others: don’t re-invent the wheel </li></ul><ul><li>Peer group provides motivation for QI work </li></ul><ul><li>facilitates spread of improvements--more efficient </li></ul><ul><li>Pressure for better, quantitative records </li></ul><ul><li>Can focus on priority issues </li></ul><ul><li>Framework for scaling up </li></ul>
  19. 19. Collaborative Improvement Model as Adapted by QAP Country and Province Selection Orientation of Country Leader Teams Baseline Assessment Identify Country Team CQI Teams Finalize Technical Content/ Change Package Conclusion of Collaborative Ongoing exchange of experiences: -- Website/Extranet -- Coaching visits -- Periodic meetings of teams -- Telephone calls Expert Meeting LEARNING SESSION 2 LEARNING SESSION 3 LEARNING SESSION 4 LEARNING SESSION 1 Preparatory Stage at local level 18-24 months Monthly reporting on indicators A D P S A D P S A D P S
  20. 20. Rwanda Malaria Collaborative Overview <ul><li>Geographical Scope </li></ul><ul><ul><li>4 districts ( Gisenyi, Kibungo, Muhima, Ruhengeri ) </li></ul></ul><ul><ul><li>23 teams and sites </li></ul></ul><ul><ul><ul><li>19 health centers </li></ul></ul></ul><ul><ul><ul><li>4 district hospitals </li></ul></ul></ul><ul><ul><li>Progress </li></ul></ul><ul><ul><li>baseline study in 2 districts completed Nov 2002 </li></ul></ul><ul><ul><li>quality improvement (QI) changes and indicators proposed by level of care </li></ul></ul><ul><ul><li>70% of sites used flowcharts to analyze their problems </li></ul></ul><ul><ul><li>QI changes made and results monitored </li></ul></ul><ul><ul><li>Mortality impact in both simple and severe malaria </li></ul></ul>
  21. 21. Exampless of Findings from Initial Assessment (2 district sample) <ul><li>no children were (case) managed according to norms </li></ul><ul><li>only 29% of children treated according to norms </li></ul><ul><li>mothers wait an average of 3 days before going to health centre </li></ul><ul><li>31% of health centres have had stock-outs during the 30 days before assessment </li></ul>
  22. 22. Key Changes <ul><li>For malaria in children 0-4 years </li></ul><ul><li>Decision to seek care within 24 hours </li></ul><ul><li>Diagnosis and treatment at health centers and hospital according to national standards </li></ul><ul><li>No stockouts of drugs or supplies at district </li></ul><ul><li>Appropriate and successful referral of serious cases </li></ul>
  23. 23. Measures <ul><li>Numbers of children treated in health centers </li></ul><ul><li>Numbers of severe cases treated in district hospital </li></ul><ul><li>Number of deaths due to malaria in hospital </li></ul><ul><li>Hospital case fatality rate for child malaria cases </li></ul><ul><li>Percent of children treated according to national norms in HC and hospital </li></ul><ul><li>Error rate of lab tests on quality control exercises </li></ul><ul><li>Stockouts of drugs or supplies at HC/hosp </li></ul>
  25. 25. Changes tested by the teams <ul><li>CHWs motivated and included in teams </li></ul><ul><li>CHWs organized their own meetings </li></ul><ul><li>Bonus for CHW performance </li></ul><ul><li>Educational materials distributed in community churches </li></ul><ul><li>Presentations at community meetings </li></ul><ul><li>Discount on clinic fee for bringing child within 24 hours </li></ul>
  27. 27. Changes tested by the teams <ul><li>CM training during weekly staff meetings </li></ul><ul><li>Regular review of medical records </li></ul><ul><li>Flow charts, other provider job aids </li></ul><ul><li>Improved patient registration </li></ul><ul><li>Reorganization of services </li></ul><ul><li>Started triage </li></ul><ul><li>Extended lab availability </li></ul>
  28. 28. Niger Pediatric Hospital Improvement Collaborative
  29. 29. Equipe de PMTCT de Kicukiro
  30. 30. KICUKIRO Health Facility: Percentage of partners tested Changes tested: -Home visits and meetings by couples involved in the PMTCT program -Home visits by health providers -IEC on responsible paternity LS1 LS2
  31. 31. Gihundwe Health Facility: % of partners tested Send invitation letters to partners Reinforce counselling
  32. 32. Rwanda PMTCT—Data Exported from Extranet Percentage of partners of prenatal care women who were tested for HIV
  33. 33. Evolution of the Collaborative <ul><li>Expected duration of 9-18 months </li></ul><ul><li>Leaders schedule final meeting based on results: teams using a package of improvements </li></ul><ul><li>Expansion (or Spread) Collaborative: </li></ul><ul><ul><li>high performers can each lead a new effort </li></ul></ul><ul><ul><li>change package requires minor adaptation </li></ul></ul><ul><ul><li>Rogers’ Diffusion of Innovations </li></ul></ul><ul><li>Potential for multinational sharing of best practices </li></ul>
  34. 34. Successful Collaboration-Identify and Make Use of the “Early Adopters” Late Majority Early Majority Early Adopters Tradition-alists Innovators 2% 13% 35% 35% 15%
  35. 35. Active Management of the Third Stage of Labor
  36. 36. Some issues for discussion <ul><li>How to maximize learning from this experience (17 USAID supported collaboratives to date) </li></ul><ul><ul><li>Documenting and analyzing implementation </li></ul></ul><ul><ul><li>What’s working and what needs to be fixed </li></ul></ul><ul><ul><li>How to make this approach more cost-effective and simpler </li></ul></ul><ul><li>Connecting collaboratives to the institutionalization of improvement </li></ul><ul><li>Leadership: countries, donors, others </li></ul><ul><li>Obstacles to wider use </li></ul>