Recording and materials from the 5th webinar on point of care quality improvement - Step 4: Sustaining improvement

03.07.17

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (Quality of Care Network) held a webinar on ‘Point of care quality improvement for maternal and newborn health – Step 4: Sustaining improvement’ on 29 June.

Listen to the recording of the session (starting at 00:03:05)

Nigel Livesley, Regional Director for South Asia for the USAID Applying Science to Strengthen Health Systems project implemented by University Research Co. present ideas for quality improvement teams to ‘hardwire’ a quality improvement project in order to prevent the system from slipping back to the old ways of working, ensure that the improvement is a system change not just a minor tinkering, and build more enthusiasm among health workers for quality improvement.

See his presentation here.

The Q&A that followed are available in the comment section below.

This is the 5th webinar in a series on point of care quality improvement. Read more about the series and access the materials from previous webinars here.

(Photo: Pregnant women wait for prenatal consultations at the Elmina Urban hospital in Elmina, Ghana on Tuesday November 9, 2010. ©UNICEF/Asselin)

Comments

What tips do you have to ensure that a change comes from within the clinical team, i.e. that the change is their baby?

ANSWER:

This can be challenging.  New teams often need to overcome existing hierarchies.  So teams often don’t include the clinicians or other staff doing the work.  If you are supporting a new team you often need to keep asking them to include staff on the QI team that are involved in delivering the care that you are trying to improve not just managing that unit.  When you work with them to do their fishbones and flow charts you can also use that opportunity to re-emphasize that it is hard to analyse systems if you don’t have the staff who are delivering care.  When you help them plan their PDSA you can also re-emphasize this.  If the team develops a change and then appoints a more junior person to test it that is a bad sign.  Whoever is testing it should be part of the team and should be involved in designing the change.

How do you deal with staff turn over for sustainability of change?

ANSWER:

If you are making a change in the system rather than just changing individual behaviour then the change will be sustained even when staff turnover.  In Esther’s presentation on developing and testing changes, one of the changes they made was to move the printer closer to the labour room to make it easier to get partographs. That type of change is very sustainable – it is better, easier and doesn’t require ongoing work to maintain the change.  Some changes will be susceptible to staff-turnover for example if your change is based on training then every time you need new staff you will need to train people.  So, first, you should try to make changes that will not be affected by staff turnover.  If you also need to make changes that are affected by staff turnover, then you need to put in place a system to sustain that when new staff join.

If the volume of patients gets higher with increase of quality how do you keep staff motivated not to return to the previous stage with less patients and lower quality?

ANSWER:

Every health system in the world has quite a lot of waste – things that staff do that are either not useful or are harmful (redundant record keeping is an example of this in many LMIC).  Improving care is often a function of doing less useless or harmful work and spending that time doing useful work.  So if you are getting more patients, you may want to increase your efforts on reducing waste so that you can have more time to spend with the patients.

Great Nigel. In addition to internal reward that comes from being happy with good results they start getting, how much is external recognition is important to keep the motivation of frontline workers up?

ANSWER:

Some people are not motivated by this and others are highly motivated by it.  We usually try to build in mechanisms to provide external recognition to people or facilities who are doing well.  One way to do this is to build networks to facilities who are working on similar goals and to have these facilities share their work and learn from each other.  In this way, people’s work is recognised by their peers and those groups who are doing very well stand out and can be recognized by leaders.  You have to be a bit careful with this.  Teams can do good work but not get results quickly and can be demoralized if others are getting credit and they are not.  So the general tone of these network should be very positive.

Hi Nigel. How can we validate the quality improvement data which is been recorded by the providers? Sometimes for the sake of reporting providers tends to start over reporting.

ANSWER:

If your focus is on having health workers report data to external people then data quality is often poor.  This is especially true if health workers are scolded for poor results.  In these cases people will hide bad results.  If the focus of data is for health workers and managers to use it to improve, then the data is of better quality because it is now useful to the people collecting it and using it.

You can validate data by comparing it to other sources of data (existing data sources or through additional data collection) but you have to be careful that health workers don’t see that the external validation and efforts to find data quality problems is part of the QI support.  It is hard to provide support to facilities in learning QI if they see you as a policing body and hide problems from you.

How do you get institutional support necessary to really allow frontline health workers to spend the time needed to think about process, come up with changes and monitor then (the work of these teams) and balance that with volume of work they are trying to manage?

ANSWER:

This doesn’t take much time – typically less than 10 min per day (and usually much less).  If that time is well spent – they are able to make their own work from efficient and make care better – then it is not a problem getting institutional support.  Before teams get results, some institutional leaders are sceptical but most are willing to allow a small effort to see if this new way of working is useful.  Working in a network is also helpful.  Some institutions will only start after they see that this approach is useful in contexts like theirs.

How do you proritize changes that are sustainable and high impact?

ANSWER:

You need two types of expertise for this.  The first is clinical knowledge to know if the proposed change can affect the outcome you are interested in (e.g. does drying babies immediately and keeping them warm affect mortality).  The second is context knowledge to know if a planned intervention is likely to work (is likely to be feasible and effective) in the setting you are interested in.  This second, contextual, type of knowledge is under-respected in public health.  The context of a clinic in the day shift is different than the context in the night shift so to learn if a change is going to be feasible you need to harvest knowledge from people who understand these contexts.

When the team is analysing the system and testing changes, you would like both types of knowledge on the team: clinical experts and context experts.

What role can the district play in enabling and encouraging facilities in continuing quality improvement projects? Do you have any good examples of this?

ANSWER:

Districts have two important roles to play in quality improvement projects.  The first is to set expectations that facilities need to improve care and need to use approaches to improve processes rather than just hoping that more resources and more trainings will work.  The second is to help staff in facilities improve care.  This support should include: practical hands-on support in learning whatever approach to fixing processes you want to use, supporting facilities to learn from each other about using these approaches, responding the facility requests to solve problems that are not solvable at the facility level.

The data from India that I show on slides 30-36 is an example of this.  The red sites were supported by the district government using their staff and resources.  Initially, the district clarified to the facilities that they should improve oxytocin administration and ENC but just focused on resources and training.  After September, they emphasized thinking of processes and supported the facilities to learn and use methods to fix processes.  Other countries in the network have good examples that they can share.

At SEARO we invited teams of clinicians and hospital manager as a team. It worked well for the teams to go back and practice since the manager was already oriented.

This is very important. Having managers and administrators on board is critical for getting permission to start and for solving some types of problems.

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