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Maternal, Newborn and Child Health

Region and Country: Russia

Topics: Maternal, Newborn and Child Health

Year: 
2011
Language: 
English
Description: 

A major barrier to the improvement of quality of care in Russia is the size of the country and the limited opportunities within the health care and educational systems for sharing of experience and innovation. To overcome this barrier, the Health Care Improvement Project (HCI) seeks effective ways to disseminate information and share experience among collaborating regions and health care facilities. HCI/Russia’s “Improving Care for Mothers and Babies” project has built on traditional methods to share improvement experience and innovation, such learning sessions and distribution of documents, by developing an internet portal, www.healthquality.ru, through which participating quality improvement teams can document and share their implementation of changes and the results of that implementation. This strategy presents a challenge in a country where surveys indicate that less than a third of the population says they use the internet, and health facilities have few computers. The project assisted facilities in accessing and using the portal, which if successful should lead to rapid uptake of effective changes by other participating QI teams. Sharing this learning should not be limited just within the region or implementing partner where the change originated, but should spread to other regions supported by other partners as well: the ability to build on learning both within regions and partners, and across regions and partners is important for efficient and effective achievement of better care and outcomes in maternal, child and reproductive health.

Research questions/objectives:
1)      Spread of better care practices to new areas: how well are “better care practices” (effective changes) emerging from one collaborative effort shared and used in subsequent collaborative efforts, be they within the same region, the same partner (in a new region) or new partners.
2)      Best techniques for spreading practices:  Which of the several techniques used in the project (including the internet portal) were found to be most useful and effective in spreading changes. In particular, does the internet portal provide added benefit.
3)      Quality of documentation of innovation. Conceptually, any tool can be used to spread innovation only if it adequately describes that innovation. How well are the changes teams report implementing documented on the portal.
 
Methodology:
Data for this study were collected from information on changes tested QI teams entered into “journals” on the web portal and from telephone interviews with QI team leaders. Additionally, the web portal software was programmed to automatically track logins to the system by users, allowing researchers to know who had accessed certain changes tested by other teams. These data were used to determine the number of facilities to which each change spread and the speed of that spread.

 

Author(s): 
Sandino M, Gomez I, Bowser D

Region and Country: Central America and the Caribbean, Nicaragua

Topics: Maternal, Newborn and Child Health

Partners: 
MINSA
Year: 
2011
Language: 
English
Description: 

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.

 

Author(s): 
Sandino S, Gomez I, Bowser D

Region and Country: Central America and the Caribbean, Nicaragua

Topics: Maternal, Newborn and Child Health

Partners: 
MINSA, AMOSCA
Year: 
2011
Language: 
English
Description: 

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.

 

Author(s): 
Saley Z, Boucar M, Djibrina S, Coly A, Sangare K, Broughton E, Vaid S

Region and Country: Africa, Sub Saharan, Mali, Niger

Topics: Maternal, Newborn and Child Health

Year: 
2011
Language: 
English
Description: 

The USAID Health Care Improvement has demonstrated the efficiency of the dissemination of improved care practices to new regions within a country or health care system. However, while the spread within a country has been studied, there is little or no research on transferring quality improvement processes and improved health practices from one country to another. This study aims to analyze how a list of changes was transferred from the Niger in Mali, the methods used to reproduce the improved care and costs associated with its implementation.

Research questions/objectives:
The objective of this study is to evaluate how a package of changes developed in one country may be transferred to another. Specifically, is the package of changes developed in Niger is appropriate to the context of Mali? The null hypothesis is that the package of changes from Niger had no significant effect on indicators in Mali. This study will also examine the cost-effectiveness of the implementation of Niger’s package of changes in Mali compared to maternal and newborn health care in Mali before the improvement collaborative. The specific research questions are:

1. What changes are appropriate to Mali? What are the perceptions of improvement teams and coaches about the package of changes? How have the changes been adapted by sites in Mali to their local context? What has helped or hindered the ownership of changes by the sites?
2. What improvements have there been in the indicators at sites where the package of changes was introduced?
3. Have the indicators evolved the same way in Mali and Niger?
4. What is the cost of implementing the package of changes in Mali through the collaborative?
5. What is the cost of implementing the package of changes in Mali in terms of quality indicators and clinical outcomes (incidence of bleeding avoided)?

 
Methodology:
The retrospective study will include quantitative assessment of results and qualitative assessment to better understand the process of implementation and adaptation of best practices. Key information will be obtained through in-depth interviews of improvement teams at 19 sites in Mali. Two focus group discussions with coaches from Mali will be conducted to determine their perceptions and how they were affected by the collaborative. Costs related to collaborative implementation will be extracted from HCI accounting records.

 

Author(s): 
Sabou D, Coly A, Boucar M, Saley Z, Sangare K, Broughton E, Vaid S

Region and Country: Africa, Sub Saharan, Mali

Topics: Pre-eclampsia/eclampsia, Maternal, Newborn and Child Health

Year: 
2011
Language: 
English
Description: 

An evaluation of the USAID Healthcare Improvement (HCI) Project summarizing the results of collaborative improvement in 12 countries by over 1300 teams during 1998-2008 has shown that teams were able to achieve large increases in compliance with health care standards and in some cases, in health outcomes, across all care areas addressed, regardless of the baseline level of quality (Franco 2009). Several other reports also demonstrate the cost-effectiveness of collaborative quality improvement in achieving high compliance to standards of care and in improving outcomes. However, due to operational restrictions, most assessments of quality improvement collaboratives (QICs) have been uncontrolled pretest–post-test designs that cannot rule out other plausible causes for observed improvements, such as secular trends (Mittman 2004).

This study will address this issue by comparing costs and outcomes for clinical management of eclampsia and pre-eclampsia in quality improvement collaborative facilities to facilities with no collaborative improvement intervention in the first six months. Following the initial six months, the collaborative improvement methodology will be introduced to the control sites and changes in quality performance will be monitored over that time.
 
Implementation by the HCI Project of interventions to improve maternal and newborn health services including AMSTL and essential newborn care has been ongoing in 41 facilities in two health districts (Diema and Kayes) in the Kayes region since early 2010. Most facilities are above 80% compliance in active management of the third stage labor (AMSTL) and essential and newborn care (ENC) quality indicators and are currently working on maintaining or improving performance.
 
The HCI Mali / Niger team started implementing a second QIC phase aimed at improving clinical practice with regard to pre-eclampsia and eclampsia care at the end of February, 2011. This study will determine the costs and effects of this QIC intervention and compare them to the costs and effects of a basic clinical training (BCT) in the same type of health facilities in Mali that are not part of the collaborative.
 
Research questions/objectives:
This study will determine whether a QIC intervention has an added value in improving pre-eclampsia and eclampsia care quality above basic clinical training (BCT) alone. It will also measure the relative efficiency of the two interventions. The specific research questions are:
  1. 1. Do pregnant and delivering women in QIC intervention facilities receive better care (screening/diagnostic and treatment of pre-eclampsia/eclampsia) than those in BCT-only facilities?
  2. 2. Do pregnant and delivering women in QIC intervention facilities have better clinical outcomes, in terms of eclampsia incidence than those in BCT-only facilities?
  3. 3. What is the incremental cost-effectiveness of the QIC intervention compared to the BCT-only intervention in terms of process and outcome indicators for mothers?
  4. 4. Does adherence to eclampsia/pre-eclampsia norms become higher in BCT-only sites when clinicians are trained on the QIC methodology?
  5. 5. Does adherence to eclampsia/pre-eclampsia norms in the QIC intervention facilities change in the six months following the active intervention period?
Methodology:
This longitudinal study uses a controlled pre- and post-intervention design. The QIC sites will be those participating in the QIC intervention and the control sites will receive BCT only. BCT is also part of the QIC intervention.
 

 

Link: 
Author(s): 
A Ikram, E Broughton

Region and Country: Afghanistan, Asia

Topics: Documentation/data collection, Maternal, Newborn and Child Health

Partners: 
Ministry of Public Health Afghanistan
Year: 
2011
Language: 
English
Description: 

Continuous quality improvement (CQI) efforts in health care often rely on quality improvement (QI) teams performing self-assessments of compliance with standards of care. This is often the most efficient method of data collection for performance indicators and is therefore frequently used in resource-constrained settings (L Franco 2009). Some have found health provider self-assessment to be effective in improving performance in circumstances where higher level supervision is unavailable (E Kelly 2003). Information from such assessment is crucial to design the CQI intervention, identify performance gaps that require attention and allow the QI team to monitor its progress in improving the process of health care delivery (Vos 2010). It is therefore essential that these data be a valid representation of performance.

The Health Care Improvement Project (HCI) has been implementing collaborative QI interventions in hospitals in Kabul since November 2009. HCI staff started data collection and gradually delegated it to QI teams in respective facilities.
 
The MoPH is interested in determining the validity of data collected by health facility and hospital staff. There are concerns the patient medical charts and outcomes registers and do not accurately reflect the true clinical picture, possibly due to resource constraints and very heavy patient loads. If deficits are found in data collection and reporting, then the HCI project team can focus more of its improvement activities to address this in order to be able to accurately inform the intervention. 
 
No validity study of this sort has been done in Afghanistan to date. This study will help determine the validity of data collected by HCI and will provide a method that the MoPH can use to validate its HMIS data. It will help determine gaps in data collection and guide interventions to improve data quality in the future.
 
Research questions/objectives:
This study proposes to investigate the validity of data collected by QI teams in maternity facilities in Kabul. There are 3 specific research questions to be addressed:
  1. 1. To what extent are the data reported on patient charts and the register representative of what happened during childbirth?
  2. 2. What factors are associated with the validity of the self-assessment data collected from participating maternity hospitals? Factors to be tested include the cadre of the health worker, their level of experience, the type of facility and the time of day of the delivery.
  3. 3. What is the level of compliance to standards of clinical practice seen in the deliveries observed?
 
Methodology:  
We propose an observational cross-sectional study to be conducted in three maternity hospitals in Kabul. The study will consist of trained research assistants (MDs) observing deliveries taking place in participating hospitals then checking the findings from a review of charts and registers to determine if there is consistency in what was observed during the delivery and what is seen in the medical record.

 

Link: 
Author(s): 
A Ikram, I Sahak, M Anwari, E Broughton

Region and Country: Afghanistan, Asia

Topics: Active management of the third stage of labor, Birth preparedness, Essential newborn care, Essential obstetric care, Scaling up, Maternal sepsis/infection, Neonatal sepsis/infection, Newborn resuscitation/asphyxia, Post-partum care, Post-partum hemorrhage, Maternal, Newborn and Child Health

Partners: 
Ministry of Public Health Afghanistan
Year: 
2010
Language: 
English
Description: 

The collaborative model of quality improvement aims at testing and implementing Quality Improvement (QI) interventions on a small scale, synthesizing the most robust and effective changes, and spreading them at scale. Collaborative improvement not only generates improvements in the quality of care delivered in these initial sites, but also develops organizational learning. However, there still exist knowledge gaps on how to successfully spread evidence practices and ensure up-take and continuous application of these practices in resource-limited settings.

The study examines the process of spread of improvements from the demonstration phase of the MNCH Facilities Collaborative in Balkh and Kunduz to three new provinces: Parwan, Herat, and Bamiyan.  In the demonstration phase, different change ideas are tested and an intervention package composing of these change ideas and interventions that yield high outcomes will be prepared and used for scale up to the three new provinces. The aim of the spread study is to evaluate the uptake and implementation of a package of changes—which originated in the demonstration phase—in Bamyan, Parwan and Herat.

The study will include both qualitative and quantitative methods to understand:
  • How sites in new provinces react to and take up improvements coming from the demonstration phase
  • How the applicability and effectiveness of QI methodology in improving quality of health care differs in new settings
Research questions/objectives:
  • Which ‘change ideas’ were adopted, modified or rejected by health facilities in the three new provinces
  • How were the ‘change ideas’ communicated to the sites, and what were the reasons behind the uptake of each ‘change idea’?
  • Were there specific reasons that facilitated or hindered the uptake of change ideas? What were they and what are QI participants perspectives on them?
  • What were the most successful means of spreading of quality improvement changes?
Methodology:  
This is a cross-sectional study which includes both qualitative and quantitative methods. A quantitative section will record data on the number and proportion of change ideas adopted or rejected by health facilities, and reasons for those decisions. These close-ended quantitative items, as well as open-ended questions, will be administered during a structured interview. If necessary, in-depth interviews with key informants will be conducted to expand on points of interest and clarify potential gaps in results.

 

Region and Country: Russia

Topics: Active management of the third stage of labor, Antenatal care, Essential newborn care, Essential obstetric care, Newborn resuscitation/asphyxia, Pre-eclampsia/eclampsia, Maternal, Newborn and Child Health

Language: 
English
Description: 

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.

Author(s): 
Crigler L | Boucar M | Wittcoff A | Isenhower W | Wuliji T

Region and Country: Niger

Topics: Employee Engagement, Performance management, Supervision, Task definition, Maternal, Newborn and Child Health

Partners: 
Initiatives Inc.
Year: 
2011
Language: 
English
Description: 

 

Throughout Africa, the human resources crisis in the public health system has become one of the biggest challenges in attaining the Millennium Development Goals (MDGs). In the face of difficult working environments and inadequate support, health workers are often unprepared and unable to meet the high demands placed on them; they lose motivation, become disengaged, or vacate their posts altogether.   This report describes pioneering work in Niger by the USAID Health Care Improvement Project (HCI) to apply quality improvement methods to strengthen human resources management and performance at the facility- and district-management level to improve maternal care in the Tahoua Region.   
Since May 2009, 15 health facility and 11 district management quality improvement (QI) teams have worked together with the support of the Ministry of Public Health (MOPH) in Niger and the USAID HCI Project. This work uses the QI Collaborative approach to develop, test, implement, and spread feasible strategies targeting specific human resources improvement objectives to improve maternal care services. As part of this strategic human resources management process to improve maternal care, teams aligned maternal health goals and objectives from the central to facility levels, and clarified and defined tasks and competencies for clinical staff in maternity units. Regional and district health teams continue to implement system changes while facility teams focus on improving performance and providing support to engage health workers.
These improvements resulted in significant clinical, performance and efficiency gains between May 2009 and December 2010: six out of the Tahoua region’s eight districts now meet the national target for the percentage of births (i.e., greater than 25%) delivered in a health facility; postpartum hemorrhage has been reduced by half in participating sites; adherence to essential newborn care standards has increased from 72% to 98%; and the average waiting time for pre-natal consultations has been reduced by 50-98%. When the collaborative started, none of the health workers had job descriptions, whereas now, almost all health workers have specific, written job descriptions and clear roles and responsibilities outlined for their work. Results from this program demonstrate that by building the capacity of health workers and district managers in teams to solve problems that affect their ability to provide maternal care, performance, productivity, efficiency, quality of care, and clinical indicators are sustainably improved over time.

Topics: Community health workers, CHW role, Community and home-based care for PLWHA, Motivation/incentives, Performance management, Recognition/remuneration, Recruitment, Retention of health workers/reducing attrition, Supervision, Task definition, Task shifting, Training, HIV/AIDS, Maternal, Newborn and Child Health

Year: 
2011
Language: 
English

A key element of USAID’s strategic approach to maternal and child health (MCH) is to increase the number of functional community health workers serving in USAID priority countries by at least 100,000 by 2013. At the request of the USAID MCH team, the Health Care Improvement Project (HCI) developed a tool that defines a set of key elements needed for community health worker programs to function effectively and that evaluate programs on specific criteria, which were defined by recent literature reviews on CHW programs (see link below) and by suggesti