Since 2009, the United States Agency for International Development (USAID) has supported the development and strengthening of Kangaroo Mother Care (KMC) activities in ten countries through the USAID Maternal and Child Health Integrated Program (MCHIP) and the USAID Health Care Improvement Project (HCI). In order to facilitate discussion and collaboration between country programs, MCHIP, with the support of USAID and HCI, hosted the first annual regional conference on KMC programs in Santo Domingo, Dominican Republic, in December 2011. Because of the diversity of experiences in developing and implementing KMC programs and similarity of contexts, a regional conference allowed countries to make important connections with other program implementers and exchange valuable information about strategies for success. This short report details the conference goals and objectives, and discusses country advances in KMC programs.
This short report describes how the USAID Health Care Improvement Project (HCI) is working with the Ministry of Health and Sports’ National Tuberculosis (TB) Control Program in Bolivia to strengthen the quality of TB services in La Paz, Cochabama and Santa Cruz provinces. USAID began to address Bolivia’s TB epidemic in 2006 when it asked the Quality Assurance Project (QAP), HCI's predecessor project, to work with the Gestión y Calidad en Salud (GCS) bilateral project to implement a collaborative improvement project aimed at improving TB services.
This report describes an improvement activity in Cochabamba, Bolivia, to reduce the number of unusable sputum samples for TB diagnostic testing. The reduction was achieved by improving the process through which respiratory suspects provided samples and other techniques to help patients provide usable samples. The report is also available in Spanish.
This report describes an improvement activity in El Alto, Bolivia, designed to improve treatment compliance among TB patients by assuring a full dedicated treatment course. This was achieved by organizing medicines in a box reserved for each patients and by improving logistical management of medications at the health network level. This report is also available in Spanish.
Este informe corto describe una mejora ejecutada en El Alto, Bolivia, para mejorar el cumplimiento del tratamiento por tuberculosis por medio de una estrategia de asegurar la disponibilidad del curso completo de tratamiento por medio de organizarlo en cajas de medicina reservada para cada paciente y mejoramiento de la distribución de medicamentos al nivel del red de salud. El informe está disponible también en inglés.
Este informe corto describe una mejora ejecutada en Cochabamba, Bolivia, para reducir el número de muestras de saliva que son inútiles para diagnosticar la tuberculosis a través de cambios al proceso de solicitar muestras de esputo y otras técnicas para ayudar a los pacientes a producir una buena muestra de esputo. El informe está disponible también en inglés.
This paper summarizes 10 years of evidence of the effectiveness of collaborative improvement in improving health outcomes and compliance with health care standards. The collaborative improvement approach was designed by the Institute for Healthcare Improvement (IHI) in the United States to produce rapid, significant improvements in a targeted area of health care. The paper was commissioned by USAID and analyzes the results achieved by over 1,300 teams of health care providers who participated in 27 improvement collaboratives supported by USAID during 1998-2008. Data analyzed consisted of 135 time-series charts representing pooled data from groups of teams from 12 countries. All together, the data covered 81 distinct measures of compliance with standards and outcomes for maternal, newborn and child health, HIV/AIDS care, family planning, and malaria and tuberculosis diagnosis and treatment.
The study found that improvement collaboratives were able to achieve large increases in compliance with health care standards and in some cases, in health outcomes, across all care areas addressed, regardless of the baseline level of quality. Of the 135 analyzed time-series charts, 88% attained performance levels of at least 80%, and 76% reached at least 90%, even though more than half had baseline levels at 50% or below. The data provide compelling evidence that collaborative improvement can achieve large increases in performance, regardless of baseline level, and that results can be achieved relatively rapidly. Across collaboratives, time series charts showed average increases of 52%. Teams reached performance levels of 80% in about 13 months on average when baselines levels were below 50% and in about 6 months when baselines were above 50%. The analysis also suggests that moving beyond 80% performance requires different efforts (system redesign) to make high quality the routine and that deliberate spread reduces time required to raise performance of new sites.
Con el fin de identificar oportunidades y necesidades de apoyo a las redes municipales de salud para mejorar el Programa Nacional de Control de la Tuberculosis (PNCT) de Bolivia, el Proyecto Gestión y Calidad en Salud en asocio con el Proyecto de Garantía de la Calidad (Quality Assurance Project, QAP), decidieron realizar un diagnóstico rápido de la situación del PNCT en dieciséis municipios priorizados de los Departamentos de La Paz, Cochabamba y Santa Cruz. Los datos para el diagnóstico fueron recopilados entre noviembre 2006 y enero 2007. Los hallazgos sirvieron para desarrollar intervenciones de mejora que fueron implementados por medio de un colaborativo de mejoramiento iniciado en 2007 en los mismos municipios.
In early 2007, QAP and the Gestión y Calidad en Salud (GCS) Project managed by John Snow, Inc. (JSI) initiated, with USAID support, an improvement collaborative with the National Tuberculosis Control Program of Bolivia and 16 municipal health networks, aimed at expanding the coverage and quality of DOTS and increasing TB cure rates. To identify opportunities for improvement and needs of the specific municipal health networks, QAP and GCS/JSI staff conducted a rapid assessment of the current TB program in the municipal health networks, located in the Departments of La Paz, Cochabamba, and Santa Cruz. Data for the rapid assessment were collected through site visits to the 16 municipalities between November 2006 and January 2007 and drawn from the National Health Information System and epidemiological reports. The assessment found wide variations in program quality among the 16 municipalities and widespread problems with low case detection, lack of follow-up of contacts, limited use of DOTS follow, and low cure rates. These findings were used to develop the interventions implemented through the improvement collaborative.
In an attempt to address high maternal mortality and morbidity in Latin America and the Caribbean, the United States Agency for International Development (USAID) began the Latin America and Caribbean Regional Initiative to Reduce Maternal Mortality (LAMM) in 1996. Recognizing that existing USAID-supported programs already address family planning, prenatal care, and clean delivery strategies to reduce maternal mortality, LAMM targets essential obstetric care at the first level of referral facilities. Bolivia, Ecuador, and Honduras were sites for the development and pilot testing of essential obstetric care (EOC) interventions. Under LAMM, the Quality Assurance Project (QAP) is responsible for supporting process redesign and quality improvement teams as they address weak components in the EOC system. QAP conducted a baseline assessment of the quality of care and compliance with EOC standards at the facility level in a selected area of each country in 1998. The QAP LAMM team developed a set of 21 indicators to measure quality of care and how each system was functioning. Data on the indicators were collected through the review of patient medical records and other facility records, structured observation of deliveries, and a questionnaire completed by healthcare professionals. The assessments indicate that adequate infrastructure to provide EOC exists in all three study areas. However, deficits were documented in the capacity of these facilities to deliver quality EOC services. Inadequate supplies and equipment, lack of trained personnel, and failure to comply with quality standards all limit the functional access to EOC. The assessments also suggest that low utilization of the study facilities is an important barrier to the delivery of EOC in all three countries. Over a third of the staff surveyed reported never having been trained in the management of obstetrical emergencies. With respect to the performance of clinical EOC tasks, the assessments found that time intervals between recordings of fetal heart rate failed to meet international standards. Asepsis was routinely practiced during delivery in all three countries, while the administration of hemoglobin tests to patients whose admitting diagnosis suggested the possibility of hemorrhage varied widely among the three countries. The assessments also examined whether basic tasks were recorded in patients' medical records, and many tasks appeared unrecorded. The assessment results suggest that a variety of interventions will be required to increase awareness of and compliance with performance standards. Such interventions could include effectively disseminating and communicating standards, in-service training, job aids, increased supervision and monitoring, and assuring availability of supplies and equipment through process redesign and quality improvement. The LAMM initiative contemplates repeating assessments in 2001 to evaluate the effectiveness of its efforts. The adequacy of the 21 indicators to reliably measure the initiative's achievements should be reviewed, and efforts should be made to better standardize data collection instruments and sampling methods. Some of the original indicators may be hard to interpret as gauges of progress, and there may be other indicators that should be introduced. A new set of nine indicators, including five of the original ones, has been introduced by LAMM for routine quality monitoring. These indicators should be considered for future facility assessments. (excerpt)
The Case Study series presents real applications of quality assurance (QA) methods in developing countries at various health system levels, from national to community. The series focuses on QA applications in child survival, maternal and reproductive health, and infectious diseases. Each case study focuses on a major QA activity area, such as quality design, quality improvement, communication and development of standards, or quality assessment. In some cases, more than one QA activity is presented. Quality improvement is a systematic process of addressing the gaps between current practices and desired standards. Effective approaches to quality improvement include individual problem solving, rapid team problem solving, systematic team problem solving, and process improvement. These methods vary in the time and resources required and the number of people who participate. Regardless of the rigor and intensity of the method used, quality improvement approaches usually share four basic steps: identification of opportunity for quality improvement, analysis of improvement area, development of possible interventions to address a need for improvement, and testing and implementing interventions. Sometimes, when the potential solutions to a problem are clearly defined, a shorter quality improvement activity focused on testing the alternatives is used. This case study illustrates how the quality improvement methodology--specifically rapid team problem solving--can be used to target areas for improvement and produce rapid, yet dramatic, improvements. (author's)