This web portal was developed by the Federal Research Institute for Health Care Organization and Information of the Ministry of Health and Social Development of the Russian Federation, in partnership with the USAID Health Care Improvement Project. It includes a library of over 400 Russian language documents and links on application of improvement methods to maternal and child health and other clinical topics. The site also features a distance learning course on improvement methods and reports on applications of quality improvement methodology in the Russian Federation.
This short report describes the results of applying collaborative improvement to strengthen human resource management and improve the quality of maternal care in Tahoua Region of Niger.
Collaborative improvement is a QI strategy to improve the quality of care and facilitate the emergence of a culture of quality in a network of participating sites, by bringing together the energy and creativity of different sites to address key quality issues in an efficient and effective manner. Little research has been done to document the extent of institutionalization achieved at the end of formal collaborative improvement activities. This evaluation examines the extent of institutionalization of quality improvement after the end of technical assistance to an essential obstetric and newborn care (EONC) improvement collaborative in Niger. This quality improvement initiative was launched by USAID’s Quality Assurance Project in 2006 and aimed to improve the quality of maternal and newborn care services according to evidence-based standards. When external technical support for the learning sessions and coaching visits ended in December 2008, this afforded an opportunity to study whether the gains achieved during the program could be sustained.
The experiences of Niger and other countries in quality improvement over the years indicate that QI cannot simply “taught” in a generic workshop setting, nor can it flourish without technical support and the integration of QI initiatives into the micro and macro aspects of the health system. Sustaining gains in quality of care and institutionalizing QI into the fabric of health care requires simultaneous efforts at both the strategic policy level and in the priority activities of the system.
The experience of Niger offers some key lessons and some key insights into the institutionalization process. The 20 sites included in the study had benefitted significantly from the EONC improvement collaborative activities, which provided both clinical and QI skills, coaching support, and opportunities to share results and effective changes. These benefits are reflected in the consistently high levels of compliance with EONC standards (verified through external chart review and direct observation of care) at these 20 sites.
While this study did not have the power to test hypotheses, the study has shed some light on certain assumptions about collaborative improvement and its contribution to institutionalization. While the collaborative itself is not a permanent activity or structure to be institutionalized, participation in collaborative activities can facilitate institutionalization of gains and sustainability of results.
A Human Resources (HR) Improvement Collaborative in Niger’s Tahoua region and its key implementer, Dr. Saidou M. Ekoye, are finalists for two WHO Global Health Workforce Alliance Awards. Award winners will be announced during the Second Global Forum on Human Resources for Health held in Bangkok, Thailand from January 25-29. The HR improvement collaborative, supported by the USAID Health Care Improvement (HCI) Project, is a finalist for an Award for Excellence. Dr. Ekoye, general secretary at the Niger Ministry of Public Health, is shortlisted for the Special Recognition Award for his leadership in directing the HR improvement work, which will be presented among 36 finalists as a case study poster at the Forum.
In 2005, the Quality Assurance Project (QAP) pilot tested in one province of Ecuador a method for improving the cultural acceptability of obstetric care in public facilities—an important barrier to increasing skilled attendance in many countries. EOC providers, representatives of health facility users’ committees, traditional midwives, and local government officials were brought together in three one-day workshops to analyze the barriers to cultural acceptability of obstetric care and then propose and monitor changes to how care is provided at local health facilities. Following the workshops, facilities began introducing changes, such as delivery in a squatting position, allowing visits by family members, and allowing birthing women to use herbal teas.
This HCI research study sought to measure the impact of these changes. The final study report in Spanish is linked below.
Tanzania, like many East, Central and Southern African Countries, is facing high maternal and newborn mortality and morbidity rates. The percentage of women delivering at health facility under care of a skilled attendant in Tanzania is estimated to be 46%.
Recognizing the value of studies of the competency of healthcare providers and their working environment, the East, Central and Southern Africa Health Community (ECSA-HC) in collaboration with Ministry of Health and Social Welfare (MOHSW) Tanzania conducted this study aiming at determining the competency levels of health providers, and enabling factors provided by the facility and the health system.
The study was conducted in 2008 in eight districts within four regions of Tanzania Mainland: Kisarawe and Bagamoyo (Coast Region), Singida Rural and Manyoni (Singida Region), Njombe and Mufindi (Iringa Region), and Muheza and Korogwe (Tanga Region). The assessment comprised of two parts to which each participant was subjected: (1) A knowledge test consisting of 50 multiple choice and true/false questions covering several topics mainly infection prevention, uncomplicated labor and delivery, prevention and management of hemorrhage, immediate care of the newborn including newborn resuscitation and prevention and management of sepsis. The test was scored using a predetermined answer key; (2) Assessment of five skill areas - (i) active management of the third stage of labor (AMTSL), (ii) manual removal of placenta, (iii) bimanual uterine compression (iv) immediate newborn care, and v) neonatal resuscitation by observing participant performance of each procedure on an anatomical model. Each participant was assessed in these five areas by trained observers.
The findings indicated that providers performed average in several areas (1) the average score for knowledge test was 56%, with the scores progressively improving with ranking of facility category from 50% for dispensaries to 58% for district hospitals and also with increasing qualifications from 45% among medical attendants to 62% among Medical Officers and AMOs. (2) The average score for skills of active management of the third stage of labor skill and manual removal of the placenta were 55.3% and 54.5% respectively. Bimanual uterine compression, immediate newborn care (36%) and neonatal resuscitation (25%) were generally poorly performed compared to the others. There were no statistically significant differences between different facility and cadre levels: Nonetheless, it was realized that providers appreciated feedback and performance was observed to improve immediately on some of infection prevention steps.
Regarding facility readiness, some key medicines such as antibiotics and haematenics were available in most health facilities. However, lives saving medicines such as oxytocin and magnesium sulphate were not in stock in more than 60% of the facilities. Organization and sustainability of referral/counter-referral systems and use of maternal and neonatal health standards were also poor.
It is concluded that gaps to provision of quality maternal and newborn services exist with regard to competency of health personnel, infrastructure and referral systems. There is also indication that minimal investment in training on specific approaches for prevention and management of life-threatening complications will significantly contribute to the reduction of maternal and neonatal mortality and morbidity. It is recommended that the MOHSW and stakeholders design and implement strategies to ensure sustained improvement of service providers’ capacity, the support systems at health facilities including infrastructure, supplies and equipment, as well as strengthening referral and counter-referral systems, to ensure safe deliveries in health facilities.
The maternal mortality ratio in Tanzania is estimated to be 578/100,000.1 A great majority of these deaths are due to obstetric complications, 90% of which can be avoided. Some obstetric complications can be predicted and most are treatable if women receive high quality care when needed.2 Care provided by a competent Skilled Birth Attendant (SBA) during labor, delivery and in the immediate postpartum period is a key component of quality obstetric care. The percentage of deliveries assisted by a SBA has become a proxy indicator for reducing maternal mortality.3
This is an evaluation of teamwork in the context of the Essential Obstetric and Newborn Care (EONC) Quality Improvement Collaborative in Niger. It focuses on what quality improvement performance looks like after the end of technical assistance for the quality improvement initiative. The quality improvement collaborative had been launched by USAID’s Quality Assurance Project in 2006 and aimed to improve the quality of maternal and newborn care services according to evidence-based standards. The external technical support for the learning sessions and coaching visits ended in December 2008, and this afforded an opportunity to study whether the gains achieved during the program could be sustained. This evaluation aims to understand the team dynamics (team stability and collaboration) that influence sustainability of quality improvement initiatives.
This study presents results of a costing and cost-effectiveness analysis conducted retrospectively of the 2006-2008 Niger Essential Obstetric and Newborn Care (EONC) Collaborative, which was implemented in 33 facilities in Niger to improve maternal and newborn care oucomes by increasing compliance with evidence-based care standards. This study used outcomes data from routine program monitoring and costs from a number of sources including Health Care Improvement Project (HCI) accounting records and surveys of clinical managers. It compares the costs of attended vaginal delivery and immediate neonatal care in the six months before the QI collaborative started with the average of the last three months of the intervention. The four measures of effectiveness used were compliance with AMTSL, rates of post-partum hemorrhage, compliance with essential neonatal care and compliance with breastfeeding within the hour following delivery. Calculating the incremental cost-effectiveness using HCI and MOH costs including development and demonstration gave low, positive incremental cost-effectiveness ratios.
This study was published in the International Journal of Health Care Quality Assurance.
Context and rationale: Most quality improvement (QI) work in developing countries relies on self-assessment of compliance with quality standards done by QI teams because it is an efficient method of monitoring program performance. While QI teams’ self-assessments foster team ownership of the improvement process, they may have the disadvantage of positive bias. Recent publications have expressed concern about the validity of findings from self-assessment in Continuous quality improvement (CQI). CQI activities conducted in Ministry of Health (MOH) hospitals in Ecuador, as part of an Essential Obstetric Care (EOC) Collaborative, offered a unique opportunity to examine the validity of self-assessment to measure quality performance.
We cannot make recommendations about implementing the intervention in other sites. However, given substantive province-wide improvements associated with the intervention, it suggests there is value in implementing it elsewhere.
The study found that there were statistically significant increases in all process indicators for quality of care and a slight decrease in the proportion of women with post-partum hemorrhage. However, given the limited funds available to the public health finance system in Afghanistan, the authors recommend implementing the intervention in other facilities in Kabul if full or partial funding from non-govermental sources can be obtained.
The failure of many health services worldwide to deliver evidence-based prevention and treatment of postpartum hemorrhage (PPH) where and when women need care is a major quality problem for maternal health. This HCI short report describes how quality improvement approaches can accelerate scale-up of a high-impact intervention to reduce PPH--active management of the third stage of labor. The report describes how quality improvement efforts in Niger and Ecuador led to remarkable gains in national coverage of this life-saving intervention.
The report is also available in French and Spanish.
Little research has been done to characterize or describe the level of institutionalization achieved at the end of formal collaborative improvement activities. Beginning in 2006, the Ministry of Health (MOH) of Niger, with support from the USAID Health Care Improvement Project (HCI) initiated efforts to reduce maternal and newborn mortality with an integrated package of evidence-based practices in essential obstetric and newborn care (EONC), introduced with a collaborative improvement strategy. These efforts led to significant gains in quality of services, and when external technical support for these activities ended in December 2008, it presented the opportunity to study whether the gains achieved during the program could be sustained.
This study describes and evaluates the strategies developed and implemented by the Ministry of Public Health in Ecuador to spread continuous quality improvement (CQI) and best care practices for essential obstetric and neonatal care (EONC) throughout the country. The first phase of this initiative began in 2003 with 14 health care facilities ranging from health centers to hospitals; new facilities were added over time. Drawing on these experiences, the Ministry of Health with technical support from HCI compiled and published conclusions on best care practices in 2007-2008 in preparation a spread phase to 51 facilities with no prior formal involvement beginning in 2009. The study compares the demonstration and spread phases; and presents data collected to monitor, evaluate and stimulate improvement. This study investigated three questions:
This summary presents the results of a study conducted to determine the effects of hospital QA interventions on compliance with clinical standards, availability of essential drugs, client satisfaction, and utilization. The study, conducted with four intervention and four control hospitals, found that after 12 months, the QA interventions produced rapid increases in compliance with clinical standards in the intervention hospitals as compared with the control group. The citation for the full report is: Hermida J and Robalino ME. 2002. Increasing compliance with maternal and child care quality standards in Ecuador. International Journal for Quality in Health Care 14 (Suppl 1): 25:34. The table of contents and article abstracts can be viewed online at: http://intqhc.oxfordjournals.org/cgi/content/abstract/14/suppl_1/25
The present document reports on an operations research study conducted by the Quality Assurance Project (QAP) to examine the process of institutionalizing a Continuous Quality Improvement (CQI) process within the context of the reforms introduced by the Law for the Provision of Free Maternity Services and Child Care. The objectives of the study were: a) Describe and document the process, methods, and results of scaling-up and institutionalizing a quality assurance mechanism within the Free Maternity Program of the Ministry of Health of Ecuador; b) Explore associations between the degree of institutionalization achieved and the presence of reforms introduced by the Law, believed to be favorable to the QA institutionalization process; and c) Synthesize lessons learned that can be adapted and applied in other Latin American countries. The main research questions of the study were: a) Is it possible to achieve expansion of CQI through a decentralized intervention involving staff from provincial offices of the MOH (CQI facilitators), who replicate training sessions and locally support and monitor the work of quality improvement teams?; b) Which are the main factors that facilitate or constrain the application of the CQI model?; c) What is the model's cost?; d) What are the results in terms of the extent of CQI expansion and quality improvement of healthcare? (excerpt)
This case study describes how quality design methodology was applied by three waves of teams to improve the quality and accessibility of obstetric care in the Comayagua and La Paz regions of Honduras. As part of the Latin American and Caribbean Regional Initiative to Reduce Maternal Mortality, the Quality Assurance Project is facilitating the design of quality obstetric care processes at hospitals and health centers in Honduras. Composed of health staff and community leaders from six Honduran municipalities, the teams applied the 10-step quality design methodology to improve a variety of hospital processes. These include reception and triage, transportation for obstetrical emergencies, referral and counter-referral, medical records, labor monitoring, normal delivery care, prenatal care, postpartum care, management of complications, and neonatal care. Overall, regional capacity to deliver quality obstetric care has been enhanced by the coordination and information sharing between quality design teams.
More than 500,000 women worldwide die each year from complications related to childbirth. With good quality obstetric care, approximately 90% of these deaths could be averted. The assistance of a skilled birth attendant during labor, delivery, and the immediate postpartum period is one important component of quality obstetric (OB) care. Other key factors are an enabling environment for skilled attendance at delivery and prompt attention at a medical facility for women arriving with an OB complication. However, little is known about the competence of skilled birth attendants (SBAs), the elements that contribute to an enabling environment, and the causes of what is commonly known as the "third delay": the delay in receiving medical attention after a woman with an OB complication arrives at a healthcare facility. Through its Safe Motherhood Research Program, the Quality Assurance Project implemented three studies to explore these issues in countries with high maternal mortality ratios. The first study examined the competency of SBAs. The second measured SBA performance and the relative contribution to performance of different enabling factors in the work environment. The last examined causes of inhospital delays in providing OB care. All three occurred between September 2001 and July 2002 in Benin, Rwanda, Ecuador, and Jamaica. This report presents the results from Jamaica. The Competency Study measured knowledge with a 55-question test covering six subject areas. It also tested skills in several key areas, including neonatal resuscitation, manual removal of placenta, bimanual uterine compression, and insertion of an intravenous needle. Third, it asked participants to assess their own ability to carry out common obstetric procedures. The knowledge and skills tests were completed by providers from the four hospitals in the study plus a representative sample of community-based midwives. Results yielded a mean score of only 58% correct for the knowledge test and 46% on the skills test. Hospital-based provider scores were higher than the community-based providers in both tests, and in all topics except asepsis in the knowledge test and mouth-to-mouth and resuscitation in the skills test, which were slightly higher in the community-based group. Knowledge scores related to pregnancy-induced hypertension were higher for both hospital-based and community-based providers than for any other topic. Community-based providers' knowledge about sepsis and active management of third stage labor was low. In the skills test, manual removal of placenta and bimanual uterine compression mean scores were low for all types of providers--only about 38% for hospital-based and 14% for community-based providers. There was little correlation between providers' self-assessment and their competency as measured by the knowledge and skills tests. The Enabling Environment Study addressed the contribution of enabling factors and essential elements to health worker performance. We used an observation checklist to evaluate performance during labor, delivery, and the immediate postpartum period and reviewed medical records to evaluate performance in managing OB complications. We also surveyed providers in each facility about supervision, training, and motivation, and, finally, we inventoried the availability of essential drugs, equipment, and supplies in each study hospital. Labor monitoring, including checking fetal heart rate and the mother's blood pressure, was inadequate in most observed cases. Key tasks for intrapartum and postpartum care for the mother were performed adequately in most observed cases, although use of sterile drapes and clothing was done in far less than half the cases. Most administered oxytocin to the mother after delivery. However, some key tasks for postpartum care for the newborn in the first two hours after birth were frequently not done, including suctioning, putting the baby into skin-to-skin contact with the mother, checking baby's temperature, checking the umbilical cord, and keeping baby under constant supervision The Third Delay Study used direct observation to analyze patient flow in all four study hospitals. In addition, three physicians reviewed medical records to identify any delays at different points in patient care: Most of the delays they found occurred during diagnosis, especially for obstructed labor. For women who were not in labor, waiting times after arrival at the OB department to initial exam averaged 19 minutes, and to exam by a professional averaged 43 minutes, although these times differed substantially by hospital. Waits were significantly longer on weekdays than weekends at all hospitals, but whether wait times were different during the day or night differed by hospital. Delays in treatment were documented for all types of emergencies, with many resulting from delays in C-sections, which average 102 minutes from order to beginning of surgery. Sepsis was the emergency with the longest time from order to its administration: 205 minutes on average. (author's)