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Central America and the Caribbean

  • Studying Spread of Best Practices for Maternal and Newborn Care from Health Centers to Health Posts in San Marcos | Guatemala | Publications

    The Promotion and Essential Obstetric and Neonatal Care strategy (ProCONE) in Guatemala uses a collaborative learning methodology to improve the quality of maternal and neonatal care in health units and includes a focus on prenatal, postpartum and newborn ambulatory care. During the demonstration phase of this strategy, 25 health units (health care centers, Permanent Health Care Centers [CAP], and one Comprehensive Maternal and Child Health Care Centers [CAIMI]) in the department of San Marcos worked together to improve care. After the demonstration phase, experiences and "best practices" were consolidated into a document and the process continued with a spread phase to 135 health posts and minimal community units.

    This cross sectional study sought to answer 1) how were health posts in the spread phase in San Marcos exposed to the ProCONE strategy, methodology, and interventions from the demonstration phase and 2) what interventions resulting from the collaborative in San Marcos were adopted or replicated by the health posts in the spread phase.
     
    Results:
    The study found that none of the personnel representative of the health posts knew of the best practices document from the demonstration phase. According to health center directors, who coordinated the health districts, health posts were not exposed to the ProCONE strategy through this document, but instead through meetings and in an informal verbal manner from the coordinators or professional nurses of the centers to auxiliary nurses of health posts. The auxiliary nurses of health posts became part of quality improvement teams of the health centers. In health center meetings, the use of medical records and the monthly measurement of indicators were explained to personnel.
     
    Accordingly, of all the changes implemented by health posts, 13% (251) were replicas (identical or similar) of the changes implemented in the demonstration phase and 87% (1699) were new changes. The intervention replicated by most health posts (52%) was training in norms, procedures and/or clinical records of care for infants and young children. The second change most frequently replicated by health posts (48%) was home visits to increase the coverage of care for postpartum women. It is possible that home visits were also implemented in the case of neonates. Most new changes implemented by health posts related to content of care and information, and education and communication (IEC) activities. IEC activities were important to increase the coverage of care.
     
    The study concludes that the expansion of the Basic ProCONE strategy from health centers to health posts in San Marcos was informal and not based on proven and documented "change packages." The study recommends future spread activities make more deliberate use of existing documentation.However, the supposition that increased and more systematic use of best practices documentation leads to better implementation and more improvement in indicators could be the subject of another study. Further, the methodology used in collecting data for this study did not allow for a thorough understanding of the process of reception, adaptation and integration of "best practices" into the daily activities of health units. A complementary case study could gain a better understanding of these processes.

     

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  • Nicaragua | Family Planning Expansion Collaborative | Collaborative Profile
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  • Nicaragua | Family Planning Demonstration Collaborative | Collaborative Profile
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  • Post Partum Family Planning Intervention for At-Risk Women in Masay and Rivas, Nicaragua | Publications

    This study examines the impact on family planning referral and follow-up of offering “Contraception Post Obstetric Event” (APEO-Anticoncepción Post Evento Obstétrico) combined with higher quality family planning services (a strengthened referral system and individual follow-up) to women aged 15-19 years or >35 years in the intervention area of Masaya, comparing the results with the control area of Rivas. Women in these age groups have an elevated risk in terms of their own morbidity and mortality as well as that of their newborn infants. However, In Nicaragua, women aged 15-19 years old or >35 years old continue to exhibit lower demand for family planning methods, especially those in rural areas and lower economic groups (ENDESA 2006/07). To examine the impact of the enhanced referral system and individual follow-up in Masaya compared to Rivas, this research study sought to 1) measure contraceptive use in women aged 15-19 years or >35 years in Masaya and Rivas who initially did not choose any method of contraception post-partum; 2) determine if higher quality of family planning services in Masaya increased the probability a women in these high-risk age cohorts would visit a health facility for contraceptives post-partum compared to Rivas, and 3) determine if higher quality of family planning services in Masaya was associated with a decreased inter-gestational period and/or a decrease in the number of high-risk pregnancies.

     
    The results of this study were unexpected. Fewer women used their family planning referral for a follow up visit to their local health facility for contraceptives in the intervention area (Masaya) compared to the control area (Rivas). Interestingly, more women in Masaya reported visiting a health facility on their own without their referral than in Rivas. However, the overall contraceptive use rate in Rivas remained higher, even after including the women who returned on their own to procure contraceptives and were still using these contraceptives. 
     
    The results of the intervention point to two interesting conclusions. First, while the number of women that used their official family planning referral to return to their local health facility was well recorded, the number of women that returned without their official family planning referral and/or visited a pharmacy was not well recorded. The type and quality of family planning service received by women that returned without their official family planning referral and/or visited a pharmacy is unknown. These women may have not received the follow up and/or additional advice on the importance of contraceptive use and adherence. Secondly, while home visits to promote the use of contraceptives may have been made to women who did not visit a health facility following their obstetric event, these visits may not have been as systematic as initially planned. 
     
    The results of this study show that while reinforcing quality standards is important to achieve certain outcomes, such as family planning referrals and advice about family planning, the reasons why women choose to use contraceptives and their adherence to these contraceptive methods remain complex and involve many different aspects of individual behavior, the community and health system.

     

    Click here for the full version of the report in Spanish.

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  • Expanding the learning: spread of innovations in MNCH to new teams | Nicaragua | Publications

    In 2003 the Nicaraguan Ministry of Health (MINSA), in collaboration with the USAID Quality Assurance Project (QAP) and its successor, the Health Care Improvement (HCI) Project, began establishing continuous quality improvement (CQI) collaborative focusing on essential obstetric and pediatric hospital care in health units. During the initial demonstration phase, a small number of facilities worked together to quickly achieve significant improvements in processes, quality, and efficiency with the intention of disseminating methods and results to other facilities within MINSA during the spread phase, which began in 2004. Both phases ended in 2007, since which HCI has supported post-collaborative CQI strengthening.

    Research questions/objectives:
    This retrospective, descriptive study sought to better understand the spread process. Specifically, it focused on the following research questions:
    1. How was the spread phased organized and developed to disseminate CQI and the better care practices established during the demonstration phase of the collaborative?
    2. What intermediate results were achieved as a result of this spread phase (e.g., efficiency of the spread, an enabling environment for improved services and CQI, and institutional support)?
    3. What results were achieved in relation to the quality of care and implementation of CQI in participating health facilities (e.g., geographic expansion, implementation of CQI and best practices in relation to duration of the spread phase)?
     
    Conclusion:
    During the implementation of the spread phase, QI teams from the demonstration phased continued working within the collaborative and supporting those health units involved in the spread phase, which allowed for immediate transmission of knowledge to spread sites. This motivated and created expectations for spread sites and illustrates that it is not necessary to wait for one phase to end before embarking on the next phase.
     
    In Nicaragua, training of health staff had a greater emphasis on capacity development in clinical processes and less emphasis on QI methodologies, but recommends that both clinical and QI capabilities should be equally emphasized in trainings to support the institutionalization of QI and ensure sustained improvements. 
     
    The regulatory framework, including protocols, guidelines, standards, quality indicators, algorithms, and checklists, was of the utmost importance for dissemination and implementation of best practices as it was closely linked to the standardization of care processes and the sustainability of improvements.
     
    Technical support provided by HCI served a dual purpose: to develop clinical skills of the QI teams at the health units; and to strengthen national and local authorities to manage and supervise the quality of care.
     
    The inter-agency work on spread was essential. MINSA aspired to achieve complete coverage of QI in maternal and child care, which was difficult to achieve as a single institution. Combining resources from several agencies allowed for coverage in 16 of Nicaragua’s 17 SILAIS.

     

     
     

     

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  • Evaluation of Medical and Nursing Competencies in Antenatal, Delivery, and Newborn Care in Five SILAIS in Nicaragua | Publications

    In 2005 the Ministry of Health (MINSA) conducted the first study of competencies of health staff who provide maternal and newborn services. Based on these results, MINSA, in conjunction with external agencies and projects, developed norms, protocols, and clinical practice guides which allowed for national-level standardization of clinical competency. In addition, MINSA and other agencies worked together to develop tools for continual monitoring of the quality of services. Five years after this initial evaluation, MINSA was interested to know whether the interventions to improve staff competencies had an impact. This led to a follow-up research question: Has the gap in knowledge and skills among health staff providing services for women during pregnancy, labor and delivery, and post-delivery and for newborns been reduced in five SILAIS (Managua, Chontales, Jinotega, RAAN and RAAS) over the course of five years? The USAID Health Care Improvement (HCI) Project conducted this follow-up evaluation to assess changes over time in knowledge and skills of health care personnel.

     
    This study found significant improvement in competencies for maternal and neonatal care between 2005 and 2010. There was an overall improvement in knowledge from 58% in 2005 to 72% in 2010 and an improvement in skills from 59% in 2005 to 67% in 2010. All of the improvements in scores achieved between 2005 and 2010 were statistically significant, with the exception of breastfeeding for which knowledge was already high (97%) in 2005. Health provider knowledge about breastfeeding, bleeding during the second stage of labor, AMTSL, post-partum surveillance, and prevention of post-partum hemorrhage and sepsis scored above the average of 72%. Knowledge of infection prevention, surveillance during delivery, interpretation of the partograph to identify risk factors, immediate care of the newborn, prevention of neonatal asphyxia, neonatal resuscitation, gestational hypertension, and management of hemorrhagic shock all received scores below the average. These are all contributing causes to maternal and neonatal mortality in Nicaragua. Based on these findings, the report provides recommendations to address these knowledge and skills gaps.
     
    Below is summary report in English. The full Spanish-language version of this report is available here: http://www.hciproject.org/node/2890

     

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  • Nicaragua | Prevention and Management of Obstetric and Neonatal Complications (CONE) Collaborative | Collaborative Profile
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  • Nicaragua | Antiretroviral Therapy (ART) Improvement Collaborative | Collaborative Profile
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  • Evaluation of the Institutionalization of Improving the Quality of Maternal-Neonatal Health Care Services in Guatemala | Publications

    The ProCONE Maternal and Neonatal Health Care Improvement Collaborative was developed by the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) and focuses improving prenatal, delivery, postpartum, and neonatal care. From March 2007 to September 2008, ProCONE (Promoción y Cuidados Obstétricos Neonatales Esenciales) was implemented using a collaborative improvement approach in 22 health centers, 1 Centro de Atencion Inmediata Materno-Infantil (CAIMI), and 2 hospitals in the San Pedro District of San Marcos Department, in western Guatemala. After this successful demonstration phase, ProCONE best practices and quality improvement processes (documentation of changes implemented, monitoring of key quality of care indicators, and periodic sharing of QI team learning) were spread to 122 additional health facilities in seven high-priority regions of Guatemala, starting in January 2009. The success of this spread phase led to plans to spread these best practices and QI process to new regions of Guatemala and to lower levels of the health system (health posts) in active regions.

    While the initial effectiveness of the ProCONE process has been evaluated and reported through the preparatory, demonstration and initial spread phases, the maintaining of the QI process as an integral, sustained part of the health system and continuing improvement of maternal and neonatal health care since the completion of each phase has not been assessed. Thus, the ProCONE process provides an opportunity to evaluate its institutionalization across the national, health area, district and health center levels of care. By evaluating the institutionalization of the ProCONE process across levels of health care, this study will also contribute to information to identify and improve deficiencies (including updating norms and practice based on new evidence) and lapses in QI or systems performance as well as particularly successful processes that merit previously unanticipated action.
     
    Primary research questions/objectives:
    1. 1.      Have the ProCONE demonstration and initial spread phases maintained the quality of care (QOC) gains for clients over time (between the end of the active collaborative phase and 6 months after the end of the initial spread phase)?
    2. 2.      To what extent are key QI activities still being implemented at the point of service delivery? What QI activities facilitated, impeded or altered the QOC gains? Is there a culture of quality at the site/facility that supports QI implementation and evolution? What activities after the collaborative phase facilitated, impeded or altered this culture over time?
    Secondary research questions/objectives:
    1. 3.      To what extent are key maternal-neonatal QI activities being implemented at the supportive (district, health area, central) levels of the health system? What is the status of the 8 elements of institutionalization in relation to QI? For example, are policies created that encourage a culture of quality, leadership, basic values, allocation of resources, evaluation and strengthening of infrastructure, communications and information, recognition at the district, health area and central levels of the health system? Are regular support and QI coaching, essential inputs, accountability, recognition for QOC and for monitoring of indicators being provided? What factors do or do not facilitate providing this support? Has the QI process been applied to clinical domains and services (other than maternal-neonatal health care)? How and why, or why not?
     
    Use study results on the levels of institutionalization achieved through the collaborative’s implementation processes to define a future focused institutionalization strategy that the MPHSA can implement.
     
    Methodology:

    Various complementary quantitative and qualitative methodologies will be used to evaluate the research questions using a controlled pre-post (quasi-experimental) design. The sample frame includes all of the ProCONE demonstration and initial spread phase facilities and facilities that were unexposed to the ProCONE interventions with similar socio-demographic characteristics for which health service statistics data are available for the same time period.

     

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  • Evaluation of a Collaborative Approach and of ISO Certification to Improve Quality of Maternal-Neonatal Health Care Services in Guatemala: A Comparative Cost Analysis | Guatemala | Publications

    The USAID Health Care Improvement project (HCI) has supported two initiatives in Guatemala focused on improving the quality of health care. The ProCONE Maternal and Neonatal Health Care Improvement Collaborative was developed by the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) and focuses improving prenatal, delivery, postpartum, and neonatal care. The approach of ProCONE (Promoción y Cuidados Obstétricos Neonatales Esenciales) was to engage health center staff in quality improvement (QI) teams to monitor compliance with clinical norms and records and improve care through training and coaching, providing Information Education and Communication (IEC) materials and job aids, proving opportunities for shared learning through Collaborative sessions, introducing health improvement activities, and documentation and review of best practices that proved effective in improving process indicators. The demonstration phase was implemented between March 2007 through September 2008 in the department of San Marcos in western Guatemala. In this study, facilities participating in the ProCONE collaborative are referred to as ProCONE alone facilities.

    The International Organization for Standards (ISO) is a non-governmental organization that develops and continually updates standards for quality management systems called ISO 9000. These standards are used by objective ISO auditors to audit and certify that formalized processes conform with up-to-date standards. With support from HCI, the MOH committed to the ISO certification process to evaluate health care QI at Permanent Attention Center San Pedro Sacatepequez (San Pedro CAP), which also participated in the ProCONE demonstration collaborative. Activities to prepare for ISO certification were introduced in October 2009 and continued through July 2010. The audit was conducted and certification provided in October 2010. The audit identified 5 minor areas requiring improvement. The MOH and URC are taking actions to fully comply with the established standards and the CAP is scheduled for re-audit in October, 2011. In this study, the San Pedro CAP is referred to as the ISO+ProCONE facility.
    This study compares the cost-effectiveness of the ISO and ProCONE strategies on essential maternal and neonatal health care best practices and their mediating factors to determine how the Ministry of Health can best leverage each of these strategies in improving and maintaining quality of care.
     
    Research questions/objectives:
    The primary objective of the study is to elaborate how the ProCONE and ISO approaches affect process (mediating) variables, including purchasing, availability of supplies, equipment maintenance, staff competence and training, record keeping and planning, the coverage of care (numbers of patients), compliance with MNH best practices, patient satisfaction and the incremental cost-effectiveness. This information will help to determine whether and where the integration of these two strategies is beneficial. To meet the study objectives, the study will answer the following specific research questions:
    1. 1. What are the current differences in processes (mediating variables) that theoretically affect outcome (coverage, effectiveness and cost-effectiveness)?
    2. 2. What are the relative differences between ISO+ProCONE and ProCONE alone in MNH patient coverage?
    3. 3. What are the differences between ISO+ProCONE and ProCONE alone in MNH best practices?
    4. 4. What is the incremental cost-effectiveness (ICE) of ISO+ ProCONE compared with ProCONE alone; and
    5. 5. What drivers (mediating variables) affect the success of each method?
    Methodology:

    A quasi-experimental research design will be used because the ISO+ProCONE and ProCONE alone study groups were not randomly allocated. The quasi-experimental design takes advantage of the data equally available from both study groups. Data collected in May 2011 in an all-facilities endline cross sectional survey of process variables, patient satisfaction, and patient-provider observation and associated clinical records review. These will be compared with data previously collected in 2009 and 2007.

     

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  • Institutionalization of Improved Quality of Care and Continuous Quality Improvement (CQI) in Demonstration and Replication Regions| Honduras | Publications

     

    This study investigates whether the improvements in quality of care achieved during implementation of Continuous Quality Improvement (CQI) activities in Honduras were maintained over time. CQI was implemented in Honduras in two phases using different strategies. The first, demonstration phase was implemented by the USAID/HCI project in five health regions from 2004 to 2006. A second replication phase in 2007 to 2009 expanded CQI to six additional regions, reproducing the approach used in the demonstration phase, but implemented by the Honduran Secretariat of Health through its Department of Quality Assurance (DGC). Given these two different implementation strategies for introducing CQI in Honduras, this research study sought to:
    1. 1.  Analyze differences in the process and results between the demonstration and replication phases for the purpose of learning strengths and weaknesses of each phase to guide spread activities.
    2. 2.    Document the level of QI institutionalization and/or activities maintained upon finalization of the implementation phase to determine what needs to be strengthened.
    3. 3.     Document the changes implemented that have been successful in achieving improvements in EONC care for the purpose of spreading these effective changes to other regions.
    Methodology: Two research studies were conducted: 1) a retrospective study to compare QI implementation during the demonstration and replication phases and 2) a cross-sectional analysis to evidence the level of institutionalization achieved after the implementation phases ended. From the 224 health units that participated in the EONC QI project (119 from the demonstration phase and 105 from the replication phase), we selected a representative sample of 31 health units, 17 from the demonstration phase and 14 from the replication phase within the 11 health regions targeted.
     
    Results: The study examined several elements of institutionalization of QI, including measures of developmental/preparatory activities that impact CQI implementation (such as training and coaching, sharing experiences, and rewards and incentives), the establishment of a supportive environment for institutionalization (including leadership, team work, values that support CQI, support from higher authorities, and continuous coaching/supervision), and evidence of institutionalization (such as use of clinical and CQI norms and standards, consistent performance of CQI activities), and impact on outcome indicators. Overall, results were similar in the demonstration and replication phases, although differences did emerge in areas such as coaching/supervision, mean number of trainings attended, and QI team opportunities for sharing experiences and lessons learned with one another. Overall, compliance with indicators of obstetric care (prenatal, delivery, postpartum and obstetric complications) increased from 80% to 90% in demonstration sites while in replication increased from values around 50% to almost reach 80%.
     
    The study provides recommendations on training, coaching, motivation/incentives, reporting, coordination/supervision, and community support to guide institutionalization of QI and improved quality of care and to strengthen current implementation in both demonstration and replication regions.   

     

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  • Results of a Study on Sustainability of Improvements in Maternal Child Care and Institutionalization of Continuous Quality Improvement in 30 Ministry of Health facilities in 10 SILAIS in Nicaragua | Publications

    This study, which measures the level of sustainability of improvements in maternal child care and the Institutionalization of Continuous Quality Improvement (CQI), is being undertaken at the end of a 10 year period (2000 – 2010) of technical assistance on CQI for maternal child care (MCH) to Ministry of Health (MINSA) facilities in Nicaragua. USAID – Nicaragua, in coordination with MINSA, will use the results of the study to prioritize their continued support for CQI within specific health facilities in Nicaragua.

    This study focuses on answering, above all, whether quality improvements in care processes implemented through CQI have been incorporated into and are used on a daily basis by health care workers in health units in Nicaragua. The study also focuses on determining how the support system put in place through establishing the institutionalization of CQI assists facilities in maintaining CQI within the unit’s operation and organization. Such support is reflected in the existence of basic managerial, organizational, and other conditions necessary for sustainability and institutionalization.
     
    This study is the first one of its kind for USAID in Nicaragua. While other USAID-supported studies in Nicaragua have focused on specific aspects of institutionalization, this study is a full analysis of sustainability of quality care improvements and CQI through an examination of the many diverse components that comprise these two concepts.
     
    Methodology:
    This study includes both quantitative and qualitative data, with variables related to clinical and CQI training, leadership creation, acknowledgment and recognition of CQI, standardization of the care process, consensus on values for CQI, and CQI activities and institutionalization of the care processes. Measurable indicators were created for each of these variables. Data were collected from facilities in 10 out of the 17 SILIAS in Nicaragua using eight different types of instruments, including self-administered questionnaires, individual interviews and/or focus groups.
     
    Results:
    Among the study’s findings were that the trainings used to orient staff to CQI were similar in the 10 SILIAS, although there were some differences in whether trainings were offered as workshops or in the form of continuous education. Overall, 367 trainings were held between 2005 and 2010 and the average number of participants per course was 7.85. Ninety-four percent of the health centers and hospitals (28 of 30) reported that there was a CQI leader at that facility. However, 57% of the health professionals who participated in the focus group discussions were “in disagreement” that they had received respect, recognition or rewards for efforts and activities in CQI. The study found that in general health professionals had the opinion that key values related to CQI were important, including genuine interest in quality improvement, interest in improving user satisfaction, team work, and respect for ideas or input from staff. 
     
    The study found high compliance with selected vital clinical standards, with seven of the ten SILIAS performing at levels above 80%, and 20 of the 30 health facilities studied were carrying out more than 80% of 13 key CQI activities with the correct frequency.
     
    The ten year period of USAID-supported technical assistance though the QAP, HCI, and other projects focused on maternal and child health has coincided with a reduction in maternal mortality from 98 deaths per 100,000 live births in 2000 to 69 deaths per 100,000 in 2010. Similarly, infant mortality decreased from 50 deaths per 1,000 live births in 2000 to 29 deaths per 1,000 live births in 2010, and child mortality from 72 deaths per 1,000 live births to 35 deaths per 1,000 live births.
     
    Conclusions:

    Based on the results of this sustainability/institutionalization study, one can see that the 30 health units from 10 SILAIS included in the sample in this study have qualities and factors that have put each of these health facilities in different pathways all with the same end goal of sustainability of best practices and institutionalization of CQI leading to improved health outcomes. The largest impact that the QAP/USAID - USAID/HCI intervention has had can be seen in the progress achieved in two aspects: the sustainability of clinical best practices and the institutionalization of the development of clinical skills and abilities and CQI. The variability seen in the different health units can help identify certain challenges and optimizing conditions, already in place or in the process of being developed, that can be used and replicated to achieve sustainability and institutionalization of CQI at the national level.

     

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  • Process and Level of Institutionalization Achieved in AMOCSA, a Private Health Care Entity in Chinandega, Nicaragua | Publications

    USAID has supported the introduction and implementation of Continuous Quality Improvement (CQI) activities in Nicaragua since the year 2000, first through the Quality Improvement Project (QAP) and most recently through the Health Care Improvement (HCI) Project. These quality improvement activities focused primarily on Ministry of Health (MINSA) facilities. However, private health care facilities were invited to participate. The Medical Association of the West (La Asociacion Medica de Occidente, S.A.) (AMOCSA) was one of these private health care facilities and has participated in CQI activities since 2004. AMOCSA, through this collaboration with QAP/HCI/USAID, participated in a series of improvement activities in order to improve the quality of services offered to clients with a specific focus on maternal and infant health, family planning, and prevention of infections. Assistance was provided for: standardization of the care process, monitoring the compliance with care standards using relevant indicators, guaranteeing the right to proper care for newborns including breast feeding, strengthening the team approach, and measuring the satisfaction of patients in the facilities. In 2007, through technical assistance from HCI/USAID, a Quality Management Program was developed for AMOCSA in order to ensure sustainability of continued quality improvement activities into the future.

    While there have been a number of studies examining the process and impact of institutionalization in Ministry of Health facilities in Nicaragua, there have been few studies examining the process and impact of institutionalization in private facilities. This study examines the process and impact of institutionalization in AMOCSA facilities: the development process related to clinical and QI training, the enabling environment for QI, and the evidence for institutionalization and sustainability of CQI.
     
    Research questions/objectives: 
    In order to examine the process and level of institutionalization of CQI in AMOCSA, this research study seeks to: 
    1.      Identify how CQI activities are organized and implemented in AMOCSA facilities and the leadership that is received from higher authorities with respect to the development process for CQI, including initial training of personnel in key quality improvement activities, additional training (continuing education, workshops, and on the job technical assistance), and training for new personnel. 
    2.      Examine which aspects of the supporting environment for CQI contribute to the CQI institutionalization process including leadership, values for CQI, rewards and incentives, CQI team stability, and support from higher authorities.
    3.      Analyze the evidence for institutionalization within AMOCSA including how CQI activities have become part of the daily routine, how clinical procedures and norms have become standardized, examples of QI activities that have been incorporated into clinical standards, as well as quantitative results showing the appropriate practice of CQI activities, knowledge and ability with respect to CQI activities, compliance with clinical norms and standards.
    4.      Compare AMOCSA facilities and MINSA facilities in Chinandega with respect to several CQI institutionalization indicators.
     
    Methodology: 

    This study is a qualitative cross sectional study where a sample of heath care professionals working in AMOCSA facilities in Chinandega are surveyed on their exposure to different aspects of continuous quality improvement (CQI). Most of the survey questions refer to CQI activities that are currently being implemented in AMOCSA, while some survey questions refer to activities that may have happened over a longer period of time. Responses from the study participants are used to measure the level of institutionalization achieved in AMOCSA facilities. A convenience sample of 27 study participants was selected. Each of the participants answered a self-administered questionnaire that included questions on the development process for CQI, the enabling environment for CQI, evidence of institutionalization of CQI and other external factors.

     

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  • Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems | Community Resource

    This report aims to identify CHW programs with positive impacts on Millennium Development Goals (MDGs), related to health or otherwise, through a global systematic review undertaken of such interventions, as well as eight in-depth country case studies in SubSaharan Africa (Ethiopia Mozambique and Uganda), South East Asia (Bangladesh, Pakistan and Thailand) and Latin America (Brazil and Haiti).

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  • Strengthening QI Team Performance Through Shared Learning and Coaching | Guatemala | Publications
    In collaborative improvement, participant facilities organize QI teams that meet periodically to measure and monitor indicators, plan changes oriented to improve gaps identified, test and evaluate the effects of changes to determine which changes were successful in improving quality. Accordingly, QI team performance is essential to effective collaborative improvement and teams that perform well can be expected to improve the quality of care provided.
     
    This study assessed team performance of teams that participated in the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) program, ProCONE (Promoción y Cuidados Obstétricos Neonatales Esenciales). ProCONE used a collaborative improvement approach to improve essential obstetric and newborn care.  The demonstration phase was implemented from April 2007 through September 2008 in 28 health centers in the San Marcos region of Guatemala, and in November 2008 a spread phase was implemented to include 130 health units in 7 additional regions. QI teams in each health facility received coaching from the central and area-level technical teams and teams shared relevant information such as difficulties encountered and best practices implemented to overcome performance gaps with other QI teams. This cross-sectional study assessed team performance in 38 of the 130 health facilities that participated in the spread phase both in terms of implementation of QI activities and the sharing processes and mechanisms teams utilized. 
     
    This study had several objectives:
    • 1) To assess performance of QI teams at several levels in the health system: national, health area, and  health facilities
    • 2) To document the QI activities teams performed, including documenting best practices and changes, monitoring and analyzing data, and sharing successful experiences between teams in the collaborative
    • 3) Provide information on results achieved by QI teams in the indicators reported during 17 consecutive months measured as absolute improvement in indicators, speed of the improvement and maintenance of the improvement over time.
    The study found good team performance at the health area and health facility levels, but that the central level was not functional. Facility-level teams performed well on use of QI tools, data analysis and monitoring, and most teams shared their results with other teams. Overall, most indicators tracked by the teams improved by 60-80% over the 17 months of data analyzed by the study. Giving insight into how effective teams should function, QI teams that didn’t share information within their units were delayed by an average of 1.8 months in reaching a performance level of 80% in the ambulatory indicators. Teams with four or more members sharing the responsibilities for QI activities maintained gains over 80% in the ambulatory indicator value an average of 2.2 months longer than teams that had functions more distributed among their participants.
     
    The study concludes with recommendations for strengthening QI team performance at the central, area, and facility levels.

     

     

     

     

     

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  • Analysis of Effectiveness and Cost Effectiveness of Adding Quality Improvement Collaborative to a Conditional Cash Transfer Program in Guatemala | Publications
    The "Mi Familia Progresa" conditional cash transfer program (CCTP) in Guatemala promotes demand for public health and education services by providing subsidies to families with children under 16 and to pregnant women as long as families meet certain conditions, such as visiting health care centers or ensuring that their children regularly attend school. While evidence suggests that conditional cash transfer programs in low-income countries are effective in increasing access to and use of health services, if the quality of care provided at health facilities is poor, then CCTP programs may have limited impact on health outcomes.
     
    The USAID Health Care Improvement Project (HCI) supports a quality improvement (QI) initiative in specific low-income regions of Guatemala participating in the "Mi Familia Progresa" program. This study compares service quality at CCTP facilities in that were part of the QI intervention with services in comparable CCTP-supported facilities receiving no such intervention. It examines the intervention’s costs and cost-effectiveness.
     
    Methods This cross-sectional study directly observed prenatal and child health care visits to evaluate service quality in 38 CCTP-supported facilities involved in the QI intervention and 12 CCTP facilities that were not part of the intervention. Costs were collected from the QI intervention implementing partners. Multiple logistic regression determined odds ratios of full compliance with quality standards in the intervention compared to the non-intervention groups, controlling for confounders. Using this data, the study estimates the costs per additional service delivered to quality standards in the intervention sites.
     
    Results Full compliance with quality standards was 18 times more likely for both prenatal and child health services. in facilities participating in the QI intervention. During the study period, there were about 95,000 prenatal and 280,000 child health visits in these facilities. For a $293,385 total ($0.78 per service provided) for the QI intervention, there were 60,102 additional prenatal care consultations and 122,900 additional child health consultations done to full compliance with clinical norms. This is an additional cost per prenatal visit delivered in full compliance of $1.25 and an additional cost of $1.78 per child health visit in full compliance.
     
    Conclusion The intervention was associated with improved quality of care for a low additional cost per service delivered to compliance with norms. With a small additional investment, the Guatemala MOH could implement a QI intervention to increase health service quality in all areas where CCTP is operating to increase the quality of and demand for CCTP-supported services.

     

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  • Diseño de servicios obstétricos para reducir la mortalidad materna en Guatemala | Publications

    In 1999, the Guatemala Ministry of Health and the Quality Assurance Project undertook a joint initiative, which applied quality design methodology at seven hospitals in the highlands of Guatemala. The goal of the quality design effort was to create client-driven obstetric care services that would improve quality of maternal care, with the longer-term vision of decreasing maternal mortality. This case study describes the quality design experience of seven hospitals in Guatemala, using the Solola Hospital to illustrate some of the specific steps in the process. It is noted that quality design teams were formed and trained in each hospital. Each team identified a particular area of concern for its facility, such as the reception and triage of patients in labor, postpartum care, or regional surgical care. Overall, facilitators were able to guide the teams over several months to redesign and implement improved processes of obstetrical care.

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  • Iniciativa de Unidades de Salud Amigas de la Niñez y la Madre en Nicaragua: Factores influyentes para el éxito y sostenibilidad | Publications

    La Iniciativa de Hospitales Amigos de la Niñez fue lanzada por el Fondo de las Naciones Unidas para la Infancia (UNICEF) y la Organización Mundial de la Salud (OMS) en 1993 y ha llegado a ser el programa de acreditación más grande a nivel mundial, con aproximadamente 19,000 hospitales certificados en 150 países al haber cumplido con los “Diez de Pasos de una Lactancia Exitosa”. A pesar de este éxito, la Iniciativa ha venido presentando problemas con la sostenibilidad de la misma. Muy frecuentemente, personal bien capacitado se traslada a otro centro laboral y el hospital pierde su compromiso o entusiasmo inicial y, el establecimiento de salud que una vez fue certificado no continúa con la aplicación exitosa de los Pasos. Sin embargo, la Iniciativa de Unidades de Salud Amigas de la Niñez y la Madre en Nicaragua--un Programa liderado por el Ministerio de Salud con la cooperación de UNICEF--aparece ser la excepción. En seguimiento a un estudio de 1999 que documentó su crecimiento progresivo e impacto, el presente estudio del Proyecto de Garantía de Calidad/USAID y UNICEF/ Nicaragua buscó responder a las siguientes preguntas: ¿Las tendencias positivas documentadas en 1999 se han mantenido? ¿Ha continuado el programa creciendo a centros y puestos de salud y municipios? ¿Qué factores han contribuido al éxito de la Iniciativa? Para llevar a cabo el estudio se realizaron entrevistas semiestructuradas a informantes claves, grupos focales y entrevistas grupales, siendo la muestra obtenida de forma aleatoria y estratificada de hospitales, centros y puestos de salud, y equipos administrativos de los SILAIS del país. El estudio encontró que después de un proceso inicial de institucionalización, la Iniciativa ha continuado su crecimiento y ha tenido un impacto positivo sobre las prácticas de lactancia materna Varios factores ayudaron a que la Iniciativa tuviese un inicio rápido lo que fue crucial para el éxito continuado del programa. Estos incluyen: las leyes nacionales que apoyaron la lactancia, el tal fuerte compromiso y liderazgo del Ministerio de Salud, el crecimiento en el número de profesionales de la salud desde diversas organizaciones y regiones convencidos de los principios de la Iniciativa que han luchado por su supervivencia y éxito, la expansión más allá de los hospitales hacia todas las unidades de salud, especialmente en el Primer Nivel de Atención, y una permanente publicidad local y nacional así como actividades educativas.

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  • Evaluación de competencias en la atención del embarazo, parto, posparto, recién nacido y sus complicaciones | Publications

    En Nicaragua no se contaba con mucha información sobre los conocimientos y habilidades que tenía el personal de salud que se considera calificado para la atención del embarazo, parto y posparto: igualmente se conocía muy poco sobre la capacidad del personal para tratar las complicaciones más comunes del parto, que ponen en peligro la vida, tales como la hemorragia, la hipertensión inducida por el embarazo, la sepsis y la labor de parto obstruido. Ante esta realidad el Ministerio de Salud, convocó a las Agencias de: UNICEF, OPS/OMS y USAID a través de sus Proyecto Garantía de Calidad (Quality Assurance Project, QAP) y CARE y, propone realizar una investigación a nivel nacional sobre competencias que tiene el personal de salud calificado en la atención del embarazo, parto, posparto, recién nacido y sus complicaciones, con la finalidad de identificar los conocimientos científicos y las habilidades, orientar la asistencia técnica para la adecuación de los planes de mejora, además de poder contar con una herramienta que permita evaluar el desempeño del personal de salud (médicos y de enfermería) de forma permanente. Para ello se seleccionó una muestra representativa: 20 hospitales que brinda atención a la madre y al niño/a de 22 existentes a nivel nacional, 44 unidades del Primer Nivel de Atención, de un total de 175, siendo evaluados un total de 1,358 personas. La investigación tuvo dos momentos: el primero fue la aplicación de una evaluación en forma escrita del conocimiento conteniendo cincuenta y ocho preguntas, distribuidas en diez temas; siendo aplicadas al dos tercio del personal de salud que brinda atención directa a la mujer y al recién nacido. El segundo momento fue evaluar las habilidades en la atención de las principales complicaciones del parto y atención del recién nacido. Para este proceso se utilizaron modelos pélvicos anatómicos y maniquíes del recién nacido. Un total de veinte personas participaron por cada hospital y seis personas por cada Centro de Salud del Primer Nivel de Atención. La aplicación de esta metodología de evaluación demostró ser fácil y sostenible, además de brindar tanto una visión global como a nivel de detalles de los conocimientos y habilidades que tiene el personal de salud.

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  • Evaluación de competencias en la atención del embarazo, parto, posparto, recién nacido y sus complicaciones, Junio – Septiembre 2005 | Publications

    In 2005, QAP assisted the Ministry of Health of Nicaragua to carry out a national competency assessment of skilled birth attendants to identify gaps and weaknesses that would be addressed through in-service training and supervision. The assessment included Ministry of Health hospitals (20) and health centers (44) drawn from each of the country's 17 health areas. A total of 1,358 physicians and nurses who attend deliveries were evaluated through a written knowledge test. From this group, 580 providers participated in skills tests related to the prevention and management of obstetric and neonatal complications. Anatomical models were used for the skill assessment. While the assessment found moderate to high levels of knowledge in several functional areas, clinical skills were generally weaker. The skill assessment found that only 51% of the personnel assessed were able to adequately fill out a partogram; 46% correctly performed active management of third stage of labor; 51%, manual extraction of the placenta; 46%, bimanual uterine compression; 71% immediate newborn care; and 55%, neonatal resuscitation. The report was published in 2006 by the Ministry of Health of Nicaragua, QAP, PAHO, CARE, and UNICEF.

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