Quality Improvement Presentation (1).pptx

1. Quality of Care
The MNH Quality Improvement / Standards based management of quality
Shaimaa Ibrahim/ Health Specialist, UNICEF Iraq

2. Quality of care matters
• Due to focused efforts, facility-based deliveries are increasing globally
• Higher proportions of avoidable maternal and perinatal morbidity and mortality
occur in facilities
• Major roadblock: Quality of Care/ Experience of care
• Coverage of essential interventions is not enough

3. Why Quality of MNH care matters in Iraq
• Due to focused efforts, facility-based deliveries are
increasing
At the same time, caesarean deliveries are increasing
with dropping of essential evidence based practices such
as the early initiation of breast feeding (EIBF)
• Most of the preventable maternal & perinatal deaths
occur in health facilities and according to MOH data in
2017 :
- 70 % of Maternal Deaths occurred in Health
Facilities
- 16 % at home & 4 % on road (during referral from
home or from private clinics)
Major concern from evidences: Quality of Care
76
22
43
86
33 33
0
10
20
30
40
50
60
70
80
90
100
Institutional
Deliveries
Cesearean
Deliveries
EIBF
2011,MICS4 2018,MICS6

4. Major Gap identified from BNA-WS conducted in September 2015 for MNH care in
• Although , there are quality assurance (QA) sections at central MOH, peripheral and facility
level but these structures are not functional especially at health facility level
• No specific and functional process to assess and improve the quality of care for MNH
services
2 Main Recommendation raised from that WS:
• There is an urgent need to develop national performance standards for MNH care and to
build the capacity at all levels on use of these standards.
• The importance to pilot and scale up functional QI process to implement these standards in
facilities including training of internal assessor teams on how to develop an action plan for
improvement.

5. Maternal and Neonatal Quality Improvement Standards/ National Checklist
• The standards Adopted from UNICEF Every Mother
Every newborn (EMEN) approach /Standards for QI
• Available in English and Arabic languages
• Standard – based Management as a practical
management approach for improving performance
and quality of health services at health facility level
• They are operational, observable performance
standards for on-site assessment by internal assessors
• The process include checking records, conducting staff
& client interviews
• Can be used for external assessment
• Last update conducted by national TWG in 2019

6. Every mother and newborn receives quality care
throughout the pregnancy, childbirth and postnatal
periods
Efforts to achieve Universal Health Coverage are aimed to provide all
mothers and newborns access to the health care system
WHO vision

7. Definition of Quality of Care
Quality of care is defined as the extent to which health
services provided to individuals and populations improve
desired health outcomes.
In order to achieve this, health care needs to be

8. Specifically…
 Safe – delivering health care which minimizes risks and harm to service users,
including avoiding preventable injuries and reducing medical errors
Effective – providing services based on scientific knowledge (WHO guidelines)
Timely – reducing delays in providing/receiving health care.
Efficient – delivering health care in a manner which maximizes resource use and
avoids wastage;
Equitable – delivering health care which does not vary in quality because of
personal characteristics such as gender, race, ethnicity, geographical location, or
socioeconomic status;
People-centered – providing care which takes into account the preferences and
aspirations of individual service users and the cultures of their communities
IOM 2001. WHO 2006

9. Safe and Effective Care

10. Timely and efficient Care

11. Equitable and People centered Care

12. 7- Competent and motivated human resources
Health system
Individual and facility-level outcomes
Coverage of key practices People-centred outcomes
Health outcomes
EXPERIENCE OF CARE
4- Effective communication
5- Respect and dignity
6- Emotional support
Quality
of Care
PROVISION OF CARE
1- Evidence based practices for routine
care and management of complications
2- Actionable information systems
3- Functional referral systems
Structure
Process
Outcome
8- Essential physical resources available
- The 9 National
MNH QI Standards
address areas of
QoC at health
facility level as per
WHO Framework
with calculation of
total health facility
scoring ,with
scoring each of
each standard
performance
-An additional
module for Exit
Mother Interview
added to assess
the experience /
perception of Care
at health facility
level

13. Quality Improvement Process

15. Stages Of Change Model

16. Standard Definition
Statement of acceptable performance
against which measurement and/or
judgement takes place
16

17. Performance Components
• Structure/Inputs: Resources
• Process: Activities
• Outcomes: Results
17

18. Hospital Systems
18
Inputs
Building
Adequate trained
personnel
Policies, procedures,
protocols
Equipment/supplies
Processes
Admission
Assessment
Treatment/care
Tests & procedures
Medication
management
Inventory
management
Sterilization
Outcomes
Improved health
status
Efficient services
Accurate test results
Patient satisfaction

19. Organization of Standards
• Domains: groups of related standards for certain functions eg MNH-
Clinical care
• Standards: statement of expectation
• Criteria: judgement of quality (quality statements, measurable
elements, measures, assessment criteria)
• Indicators: measure extent to which a set target is achieved;
expressed in numbers.

20. Clinical Example
Domain: Clinical Care
Standard: Evidence-based safe care is provided during labor and
childbirth.
Intent: Quality care at the time of labor and childbirth can have the
highest impact on reducing maternal and neonatal deaths and
stillbirths, as most of these deaths are concentrated in this time
period.
Criteria: The pregnant woman’s general condition (labor and stage
confirmed) and emergency signs are assessed immediately upon
arrival and documented.

21. Core and Critical
Core
Evidence-based (where possible),
which have the most impact on:
• Maternal and newborn health
outcomes – mortality and
morbidity
• Access to services
• Safety of the mother and her
newborn
Critical
Commonly include:
• required by national laws and
regulations
• if not met, may cause death or
serious harm to patients,
visitors, or staff

22. Internal vs External Approach/ Mixed
Internal Assessment External Assessment
1. Use of checklists
• Inventory of drugs, supplies, equipment
• Review of medical records
• Review of training records
• Monitoring of processes (protocols or
procedures)
1. Use of collaborative analysis
• Assess process for ordering and maintaining
drugs, supplies & equipment
• Review of medical records
• Review of training records
• Review of facility quality monitoring (self-
assessment )
2. Verifying compliance with a set of pre-defined
processes
2. Judge the efficiency and effectiveness of a working
system.
3. Validation of internal quality control 3. Examine quality and implementation
Both analyze data objectively based on defined standards, policies, procedures and protocols
Mutually supportive

23. Maternal and Newborn quality Improvement Standards
• Standard 1. Evidence-based safe care is provided during labour and childbirth
• Standard 2. Evidence-based safe postpartum care is provided for all mothers and the
new-borns.
• Standard 3. Human rights are observed, and the experience of care is dignified and
respectful for every woman and new-born.
• Standard 4. A governance system is in place to support the provision of quality
maternal and newborn care.
• Standard 5. The physical environment of the health facility is safe for providing
maternal and newborn care.

24. Maternal and Newborn quality Improvement Standards
• Standard 6. Qualified and competent staff are available in adequate
numbers to provide safe, consistent and quality maternal and new-
born care.
• Standard 7. Essential medications, supplies and functional
equipment and diagnostic services are consistently available for
maternal and newborn care.
• Standard 8. Health information systems are in place to manage
patient clinical records and service data.
• Standard 9. Services are available to ensure continuity of care for
all pregnant women, mothers and newborns
Questions for Mothers’ Interview

25. Every Mother Every Newborn Standards
• Evidence-based labor & delivery
• Evidence-based postnatal care
for mother & baby
Clinical
• Human rights observed; experience of care
dignified & respectful
Patient Rights
• Governance system
• Safe physical environment
• Qualified & competent staff
• Essential drugs, supplies, equipment &
diagnostics
• Health information systems
• Continuity of care
Cross-cutting

26. Thanks for your attention
26