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Nicaragua
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Nicaragua | Family Planning Expansion Collaborative
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Collaborative Profile
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Nicaragua | Family Planning Demonstration Collaborative
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Collaborative Profile
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Nicaragua | HIV Counseling and Testing Collaborative for People with STIs
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Collaborative Profile
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Improving outcomes of Premature and Low Birth Weight Babies through Kangaroo Mother Care
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Publications
As a component of its work to address neonatal mortality, the USAID Health Care Improvement Project (HCI) is working with Ministries of Health to implement national Kangaroo Mother Care (KMC) programs in five Latin American countries: Guatemala, El Salvador, Honduras, Nicaragua and Ecuador. This short report describes the technical assistance that HCI is providing to support the implementation and scale-up of the KMC program throughout all phases.
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Aplicación del Método Madre Canguro en Bebés Prematuros y de Bajo Peso en 4 Países de América Latina
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Publications
Volante sobre los avances del proyecto HCI en la aplicación del Método Madre Canguro en cinco países de América Latina.
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Post Partum Family Planning Intervention for At-Risk Women in Masay and Rivas, Nicaragua
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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. -
Expanding the learning: spread of innovations in MNCH to new teams | Nicaragua
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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:- How was the spread phased organized and developed to disseminate CQI and the better care practices established during the demonstration phase of the collaborative?
- 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)?
- 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. -
Evaluation of Medical and Nursing Competencies in Antenatal, Delivery, and Newborn Care in Five SILAIS in Nicaragua
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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 -
Nicaragua | Prevention and Management of Obstetric and Neonatal Complications (CONE) Collaborative
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Collaborative Profile
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Nicaragua | Antiretroviral Therapy (ART) Improvement Collaborative
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Collaborative Profile
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Community case management in Nicaragua: lessons in fostering adoption and expanding implementation
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Community Resource
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Community Health Worker Programs: A Review of Recent Literature
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Community Resource
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Evaluación de competencias del personal médico y de enfermería que brinda atención del embarazo, parto, puerperio, recién nacido y sus complicaciones en cinco SILAIS de Nicaragua | Comparativo 2005 y 2010
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Publications
En el año 2005 el Ministerio de Salud (MINSA) realizó la primera investigación de competencias del personal de salud que brinda atención durante la embarazada, parto, puerperio, recién nacido y sus complicaciones. La investigación se hizo en dos momentos, evaluación del conocimiento y habilidades en donde participaron un total de 1,358 recursos humanos de 17 SILAIS del país. En habilidades se evaluaron 580 recursos, 43% del personal evaluado en conocimiento. Los resultados de esta investigación fueron la base para que el MINSA, en conjunto con las agencias y proyectos de cooperación externa, elaboraron normas, protocolos, y guías de práctica clínica, lo que permitió estandarizar el conocimiento a nivel nacional. Así mismo se trabajó junto a las normas y protocolos, herramientas para la vigilancia y monitoreo continuo de la calidad.
Cinco años después el MINSA tenía interés en conocer ¿cuál había sido el impacto de las intervenciones para mejorar las competencias del personal de salud? Se realizó un estudio cuasi-experimental antes-después de los años 2005 y 2010 (pretest-postest) sin controles. El universo estuvo constituido por cinco de los 17 SILAIS del país. Los criterios que se utilizaran para seleccionar al personal que participó en la evaluación del 2010 fueron: que el personal estuviese laborando en el área de atención a la madre durante el embarazo, parto, puerperio, recién y además que atendiera las complicaciones que se derivan en cualquiera de estos eventos tanto de la madre como del recién nacido. A nivel de hospitales la muestra fue de 30 recursos médicos y de enfermería, que laboraran en las salas de emergencias, obstetricia y neonatología. A nivel de los municipios la muestra fue de 10 recursos médicos y de enfermería. Participaron un total de 260 recursos de salud (156 médicos y 104 enfermeras) de siete hospitales y 12 municipios.
La investigación en 2010 se desarrolló en dos fases. La primera fue una fase de evaluación de conocimientos, la cual consistió en que el personal de salud llenaba un test. Además se incluyó un caso clínico pre-elaborado, a fin de que la información fuese graficada en el partograma e interpretada para la toma de acciones diagnósticas, de tratamiento y/o referencia a un mayor nivel de atención. La segunda fase consistió en la evaluación de habilidades. Se diseñaron seis escenarios donde el evaluador(a) guiaba el caso clínico y el evaluando realizaba el procedimiento a través de modelos anatómicos tanto para obstetricia como para el recién nacido.
En la evaluación de conocimientos de 2010, el personal de salud alcanzó un nivel de 72% incluyendo todos los temas abordados; hubo un incremento del 14 puntos porcentuales con respecto a los resultados del año 2005 (58% a 72%), estadísticamente estos resultados son significativos (p<0.001). Los temas que alcanzaron los mayores porcentajes fueron: sangrado durante la segunda mitad del embarazo, sepsis puerperal, hemorragia post parto, manejo activo del tercer período del parto (MATEP), vigilancia del trabajo de parto, vigilancia del puerperio inmediata y lactancia materna. Los temas que sufrieron reducción en el porcentaje con respecto a los resultados del 2005 fueron la interpretación del partograma de 59% a 51% y la anticoncepción post evento obstétrico de 75% a 74%.
En la evaluación de habilidades de 2010, el personal de salud alcanzó un nivel de 67%, incluyendo todos los escenarios que fueron evaluados, con un incremento de 8 puntos porcentuales con respecto a los resultados del año 2005 (59% a 67%). Los escenarios cuyo resultados los promedios se encuentran por encima del promedio global fueron MATEP, extracción manual de la placenta y atención inmediata del recién nacido. En cambio la compresión uterina bimanual tuvo una reducción de 3 puntos porcentuales con respecto al año 2005 (57% a 54%).
A los mejores promedios de conocimientos y habilidades alcanzados se les aplicó el Chi cuadrado de Pearson. Los resultados reflejan que son estadísticamente significativos, con excepción de la lactancia materna cuyo cumplimiento ya era alto en la investigación anterior y en la última investigación pasó de 97% a 98%. -
Continuidad de la atención en planificación familiar a puérperas con riesgo reproductivo, atendidas en dos SILAIS de Nicaragua, Julio 2008–Julio 2010
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Publications
Veintiún hospitales materno-infantiles y centros de salud con camas del Ministerio de Salud de Nicaragua (MINSA), implementan la anticoncepción post evento obstétrico (APEO) como parte de la estrategia de planificación familiar (PF) dirigida a contribuir a la maternidad segura de las nicaragüenses. La APEO se orienta a todas las puérperas y tiene entre sus propósitos disminuir la demanda insatisfecha a métodos anticonceptivos de mujeres en edad fértil que tienen dificultad para acceder a los servicios de salud.
En el año 2010, las autoridades del Sistema Local de Atención Integral en Salud (SILAIS) Masaya decidieron conocer la efectividad de una serie de actividades implementadas durante dos años en el hospital y centros de salud municipales, dirigidas a mejorar la referencia y el seguimiento local a puérperas con riesgo reproductivo por edad, garantizando continuidad de la atención en PF.
Se efectuó un estudio transversal descriptivo (post intervención), del grupo intervenido y de un grupo control, mediante el diseño de una encuesta dirigida a 120 usuarias atendidas en las unidades de salud del primero y segundo nivel de atención del SILAIS Masaya, por un evento obstétrico entre Julio y Diciembre del 2008 con el mismo número de mujeres atendidas por la misma causa y durante igual período de tiempo en un hospital control del SILAIS Rivas.
La mayoría de usuarias en los dos SILAIS tenían como características similares, que eran adolescentes; recibieron consejería de PF; y llevaron una epicrisis como forma de referencia a salir del hospital después del parto. Se encontraron diferencias en el número de hijos de cada mujer, ya que en Masaya la mayoría tienen 1-3 hijos (95%) y en Rivas la mayoría no tienen hijos (87%). Había una diferencia significativa entre el tipo de método utilizado por el número de hijos que ya tenían las mujeres. Las mujeres con el número de hijos más alto fueron más propensas a usar oclusión tubárica bilateral. Las mujeres con menos hijos fueron más propensas a utilizar el condón y anticoncepción oral.Durante el proceso de la investigación fue notorio que el personal de salud en ambos niveles de atención del SILAIS Masaya conoce y asume las actividades diseñadas, pero no deja evidencia escrita de la ejecución de las mismas. También se encontró que el 21% de puérperas en el SILAIS Masaya y 25% del SILAIS Rivas no llegaron a las unidades de salud en busca de servicios de PF. La inasistencia de puérperas a servicios de PF, no generó visitas a terreno por parte del personal de salud, para dirigir esfuerzos hacia mujeres con riesgo reproductivo. -
Sostenibilidad de las Acciones y Capacidades para Impulsar el Mejoramiento Continuo de la Calidad en la Atención Materna-Infantil en AMOCSA Chinandega
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Publications
La dinámica del mejoramiento continuo de la calidad en la atención materno-infantil en Nicaragua, facilitada desde 2000 por los proyectos de USAID—Garantía de Calidad (QAP) y posteriormente, de Mejoramiento de la Atención en Salud (HCI)—abarcó las unidades de salud del Ministerio de Salud en 16 de los 17 Sistemas Locales de Atención Integral en Salud (SILAIS) en el país. En el período, la cooperación técnica en materia de mejoramiento de la atención en salud también se dirigió a Instituciones Prestadoras de Servicios de Salud (IPSS) coordinadas por el Instituto Nicaragüense de Seguridad Social (INSS) y normadas por el MINSA. La Asociación Médica de Occidente, S.A. (AMOCSA) pertenece a las IPSS incluidas en este grupo y se destacó como la que mejor aprovechó la cooperación de USAID.Al concluir la cooperación en AMOCSA (2004 – 2009), USAID decidió la realización del estudio sobre la sostenibilidad de las acciones y capacidades para impulsar el mejoramiento continuo de la calidad (MCC) en la atención materno-infantil en AMOCSA Chinandega, a fin de precisar el desarrollo alcanzado por esta IPSS, como resultado de la asistencia técnica brindada, así como, para mostrar que el MCC y las intervenciones de mejora son sostenibles, aún sin la asistencia técnica externa.El objetivo general del presente estudio es determinar los avances alcanzados por AMOCSA Chinandega, usando datos a nivel de la unidad de salud, según la muestra seleccionada, en cuanto a la sostenibilidad de las acciones y capacidades para impulsar el mejoramiento continuo de la calidad (MCC), así como de las mejoras de la calidad de la atención en el área materno-infantil, posterior a la asistencia técnica brindada por USAID (QAP y HCI).Este estudio, descriptivo-evaluativo, presenta la situación actual de AMOCSA Chinandega, en relación con la sostenibilidad del MCC y de las mejoras de la calidad de atención, a fin de evaluar su nivel de avance en este sentido. Las técnicas aplicadas fueron: consulta documental, encuesta auto-administrada y aplicación de la herramienta elaborada por HCI para medir la Documentación, Análisis, Diseminación e Institucionalización (DASI por sus siglas en inglés) de mejoras en la atención en salud a nivel de la empresa.Este estudio constituye la primera experiencia para indagar sobre la implementación del MCC en las instituciones privadas de prestación de servicios de salud en Nicaragua. Los resultados muestran que AMOCSA tiene una plataforma firme para fortalecer el MCC y sostener los niveles de calidad, así mismo, que la intervención de los proyectos de USAID ha impactado en toda la organización.El estudio ha constado que el MCC se ha establecido como un proceso de trabajo permanente en AMOCSA que se ha extendido a todas las 10 áreas de funcionamiento de AMOCSA (Consulta Externa, Enfermería, Farmacia, Laboratorio, Recepción, Riesgos, Atención al Cliente, Auditoría de Procesos, Mantenimiento e Higiene y Seguridad) y a sus tres Filiales: Corinto, El Viejo y Chichigalpa.El estudio también señaló una serie de áreas donde AMOCSA puede alcanzar mayor madurez en la implementación del MCC. Entre estas áreas se destacan: el bajo uso de la información para la toma de decisiones, el proceso de supervisión, la instancia creada para la auditoría de procesos y la necesidad de actualizar el Programa de Gestión de la Calidad mediante una metodología participativa. Las variables e indicadores utilizados en este estudio pueden ser incorporados por AMOCSA en el monitoreo de las actividades de MCC para continuar su avance en el mejoramiento continuo de la atención en salud.(El resumen ejecutivo del informe final del estudio está disponible también en inglés.)
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Sostenibilidad de las Mejoras en la Atención Materno-Infantil e Institucionalización del Mejoramiento Continuo de la Calidad en Nicaragua
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Publications
Desde el año 2000, la cooperación técnica entre el Ministerio de Salud de Nicaragua (MINSA) y la Agencia de los Estados Unidos para el Desarrollo Internacional (USAID) se ha concentrado en la mejora de la atención clínica en las unidades de salud y los hospitales que prestan atención materno-infantil. Este estudio mide la sostenibilidad de las mejoras en la atención materno-infantil y la institucionalización del mejoramiento continuo de la calidad (MCC) realizado entre los años 2000 y 2010 en la asociación entre MINSA y el Quality Assurance Project (QAP) y su sucesor, el Proyecto de USAID de Mejoramiento de la Atención en Salud (USAID Health Care Improvement Project, HCI). Los resultados de este estudio ayudarán a MINSA a dar prioridad a su continuo apoyo a MCC en unidades de salud específicas en Nicaragua.Este estudio se trata de las mejoras de la calidad en los procesos de atención implementadas mediante el MCC y si se han incorporado en la estructura administrativa en cada unidad. Se centra en determinar cómo este sistema de apoyo puesto en práctica durante la intervención ha ayudado en el mantenimiento de MCC en el funcionamiento y la organización de la unidad. Tal institucionalización es necesaria para la sostenibilidad de mejoras en los servicios clínicos.Este estudio, el primero en su tipo en Nicaragua, examina los diferentes componentes que comprenden la institucionalización con el fin de medir el nivel de institucionalización alcanzado por las unidades de salud en Nicaragua. El estudio utilizó métodos cuantitativos y cualitativos para recopilar datos sobre la capacitación clínica y en el MCC, creación de liderazgo, reconocimiento y estímulos del MCC, estandarización de los procesos de atención, consenso sobre los valores para el MCC, y las actividades del MCC y la institucionalización de los procesos de atención. Para la recopilación de información se aplicaron ocho tipos de instrumentos incluyendo cuestionarios auto-administrados, entrevistas y grupos focales.Dieciséis SILAIS de los 17 del país participaron en las intervenciones del MCC. Diez SILAIS fueron seleccionados en base a ciertas características y prioridades del MINSA. Dos centros de salud por cada SILAIS fueron seleccionados para una muestra de 20 de los 154 de centros de salud en el país. Todos de los 10 hospitales en los SILAIS seleccionados que ofrecen atención materno-infantil (uno hospital por cada SILAIS) también se incluyeron en la muestra. Diez SILAIS (62% de los participantes en el MCC), 20 centros de salud (2 por cada SILAIS, 13% del total de 154 del país) y 10 hospitales (1 por cada SILAIS, 100% de los que brindan atención materno-infantil de 10 SILAIS).Las 30 unidades de salud de 10 SILAIS de la muestra del estudio tienen factores que han puesto cada uno en vías distintas hacia la sostenibilidad de las mejores prácticas y la institucionalización del MCC con el objetivo de mejorar los resultados sanitarios. Cada vía ha sido influenciada por factores externos e internos y el estado del sistema nacional de salud en general.El énfasis que ha tenido la intervención de QAP/USAID - USAID/HCI se ve reflejado en el mayor avance logrado en dos aspectos: la sostenibilidad de las mejoras clínicas y la institucionalización del desarrollo de competencias clínicas y en el MCC.El estudio refleja, sobre todo, la necesidad de fortalecer las competencias para implementar el MCC con mayor dominio, sistematicidad y por ende, influya con mayor fuerza en la sostenibilidad de las mejoras en la unidad de salud. Si bien es cierto que una limitación importante es la escasez de recursos en el sistema de salud, también hay oportunidades de mejora que se pueden lograr aprovechando más el MCC.(El resumen ejecutivo del informe final está disponible también en inglés.)
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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
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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
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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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Cost-effectiveness analysis of the Pediatric Hospital Improvement Initiative in Nicaragua
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Publications
The Pediatric Hospital Initiative was launched by Nicargua's Ministrio de Salud (MINSA) in partnership with UNICEF and USAID though the Quality Assurance Project (QAP) and its successor the Health Care Improvement Project (HCI). The initiative worked to improve the quality of care provided in hospital pediatric wards to children with common infectious diseases. The initiative involved 14 hospitals, which were organized into an improvement collaborative, and focused on children affected by diarrhea and pneumonia.
This study used a longitudinal pre/post design using data from medical records of inpatient admissions to examine the cost effectiveness of PHI initiatives, as measured by the impact on days of hospitalization, disability adjusted life years (DALYs), and deaths attributed to diarrhea or pneumonia from seven of the collaborative hospitals, which were selected based on a minimum criteria of two years of surveillance data for the indicators of interest and where QI teams were actively engaged in monitoring and evaluation of the program and implementing improvement cycles. A total of 2,799 records were examined: 647 records from the year prior to the collaborative and 750 after the collaborative for diarrhea and 647 records before and 755 after for pneumonia.Costs were calculated retrospectively. Those paid by HCI and its partners were determined by the project's accounting records. Hospitalization costs were calculated from a mix of available data from the public sector such as published salary rates and price lists of basic medicines, and from equivalent private sector costs for items such as laboratory blood tests and chest radiographs for pneumonia patients because public hospitals do not account for clinical line items such as these.The study shows that implementation of the quality improvement collaborative decreased patients' length of stay and the number of deaths and did not increase the cost of hospitalization for diarrhea and pneumonia cases, meaning that the QI collaborative improved health outcomes while decreasing costs to the hospital system.This study was accepted by the Pan American Journal of Public Health and is awaiting publication.
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Economic analysis of a pediatric ventilator-associated pneumonia prevention initiative in Nicaragua
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Publications
This economic analysis of an improvement intervention to decrease ventilator-associated pneumonia (VAP) prevalence in pediatric intensive care units (ICUs) in two hospitals in Nicaragua to was done to determine the cost-effectiveness of a simple intervention involving utilization of additional sterile hospital supplies and providing training to PICU / NICU staff on practices to decrease the risk of pneumonia among ventilated patients. The study asks: 1) how much the improvement intervention costs to implement?; 2) how effective must it be to be cost-neutral?; and 3) what are the most important variables in the model? Assuming the results are indicative of cost-effectiveness, the ultimate purpose of the study is to present the final results to decision-makers in the Ministry of Health (MINSA) to encourage support for the intervention.
This study has been accepted for publication by the International Journal of Pediatrics, and will be available when published.
