Recording and materials from the 6th webinar on point of care quality improvement: 'Approaches to support quality improvement teams to use quality improvement techniques'

 

The Quality of Care Network held a webinar on 'Approaches to support quality improvement teams to use quality improvement techniques'. Maureen Tshabalala, RNM, BBA, MPH Director of Regional Projects for Southern Africa at the Institute for Healthcare Improvement (IHI), highlighted the key drivers for quality improvement for maternal and newborn health at the facility level. She told the stories of two quality improvement collaboratives in South Africa and Malawi, which demonstrated the importance of committed leadership, staff skills and access to learning systems to drive and sustain successful quality improvement interventions.

Listen to the recording of the session here

See Maureen Tshabalala's presentation here

See details of the previous five webinars in the series here

Photo: A nurse registers pregnant women who have come for an ante-natal visit at the Princess Christian maternity hospital in Freetown, Western district, Sierra Leone in March 2011. ©UNICEF/Asselin.

 

Comments

How did this MNCH quality improvement team interacted with the hospital quality improvement team? Many hospitals have a quality improvement team or committee headed by the hospital director or the quality improvement director to cover a whole clinical area, not just MNCH.

ANSWER

We believe in not creating parallel systems but rather usage of existing structures to avoid confusion and duplication. If a facility already has a QI team, it is important to find out its composition; if they have any representation from MNCH ; that person becomes part of a smaller MNCH team that will be working on these QI projects and updates the global QI committee/team on scheduled meetings. This means you create a small team within the involved department. In both Malawi and South Africa collaboratives; we used and adapted existing structures, as well as created QI teams where there were none.

 

 

In the two examples from South Africa and Malawi, were there any specific lessons that came out on respectful care for both women and newborns?

ANSWER

Malawi used a questionnaire to identify gaps around respectful care and also had discussions with leadership to identify areas for improvement. Some solutions included provision of screens to aid privacy in labour ward ; discussions with labour ward staff to give them feedback on the survey. Other solutions included avoidance of words that were perceived disrespectful ; giving patients information to make informed decisions etc. The lessons were that patients felt more respected by being part of the decision making process etc.

Thank you for your nice presentation, my question is how to institutionalise quality improvement efforts at all levels.

ANSWER

Leadership buy-in is key to institutionalise QI at all levels within an organisation. If they are involved they create an enabling environment and all staff members get capacitated at all levels. They make efforts for every department to use the QI tools and use QI methodology in reports and meetings. It is difficult and most unsuccessful if it is a bottom up scenario.

If possible, can Maureen share the quality improvement  coach/facilitator structure for the collaboratives? I.e. who facilitated the weekly/bi-weekly meetings across 54 facilities? Did they staff the project from their organization, or rely on quality improvement team leaders from within the facilities to run regular meetings and provide support from their organization on a less frequent basis?

ANSWER

The district and facility leadership were new to QI methodology and needed support from the implementing partner to do this work. Therefore the organisation recruited QI Mentors who were assigned a number of facilities to support. The initial QI team meetings were led by the mentors and later handed over to the QI team leaders. It was important to groom MOH leadership to also mentor and coach these facilities for sustainability and institutionalisation of QI hence they also buddied (whenever they were available) during bi-weekly visits which later become monthly visits. The day to day coaching and mentoring was done by the facility leadership and QI team leaders.

We are running a collaborative in which our outcome data comes from exit interviews (there is no existing source of data). Some of our teams occasionally struggle to hit data collection targets and end up with missing data or too small sample sizes to be meaningful. Do you have any tips for data collection when the data has to be collected from scratch, rather than sourcing from existing records?

ANSWER

You are on the right track, you collect data as you move along with implementation if there is no existing data. However as you progress you could use at least eight data points as your baseline so that you can still statistically interpret data overtime. If you could share the type of data you are collecting on your collaborative then direct tips could be given.

Is there a special approach to engage first time young mothers; or unmarried, pregnant adolescents--given the inherent stigma?

ANSWER

You could provide the envisioned benefits for them once they get engaged ; as well as for other young mothers and unmarried pregnant adolescents. Provision of this information will create informed choices on their end. Most often people want to know what they will benefit before they engage on anything.

How do you address the challenge presented when the designated and trained 'champions' are rotated throughout clinics, taking with them the training? Knowledge transfer is a challenge.

ANSWER

This is a common problem for everyone who is doing QI. The important factor is to negotiate with leadership to rotate some of the trained champions so that those remaining in the department can train and mentor the new staff that have newly been rotated to their department. We had a similar challenge in the Malawi collaborative but leadership engagement was important. They stopped rotating all staff who were part of the QI team. Another idea is also to rotate assignments within the QI team e.g. letting every member lead QI team meetings, lead data collection, lead tracking of QI project (aims, change ideas, measures, PDSAs etc). This is very important as we have seen functional teams becoming unfunctional just by loosing their QI team leader due to rotations or transfers or resignations.

How can we improve coordination to ensure quality, equity and dignity? Malawi has several RMNCAH platforms which leads to a lot of duplications and a lot of time is spent in meetings - how can we have a more inclusive forum to improve quality of care?

ANSWER

Coordination should be led by MOH leadership and funders. This ensures that implementing partners are not in competition but rather they can complement each other. Therefore, a forum to discuss partners’ activities would be helpful as teams may identify who is doing what, where ; and how they can work together in harmony and avoid duplication. Recently the Malawi Quality Management Directorate was in a process to map out all partners who do improvement work in Malawi so that they can drive these partnerships. 

Combien de personnes sont necessaire pour l' équipe de pilotage (how many people should make up the steering team?)

ANSWER

The quality improvement team composition is determined by the number of staff members. Usually it has between 6-12 people ; too few people might have problems to conduct the work as you need all categories to be represented. Too many people might have problems with decision making, focusing and making progress. Having said that, most often it becomes unavoidable to have smaller teams that comprise of three people especially when the health centre/clinic is small. In some instances, three is the composition of the entire staff at rural clinic. Whatever works is good; rule of thumb is to avoid a big group that will not do the work.

Thanks for the great presentation and the many lessons learned. You said that a functional quality improvement team is critical to quality improvement work. What criteria you have used in assessing the functionality of a quality improvement team?

ANSWER

It is a team with a passionate and highly dedicated QI leader. It must meet often e.g. weekly when the project is new, bi-weekly or monthly to make sure activities are being done. It has a clear agenda which might include review of their aim statement, identifying the key causes of their problem or gap, (can use root cause analysis tools, process map etc), review and discuss change ideas to be tested or being tested using improvement cycles (PDSAs), reviews their process and outcome measures by tracking data on their run charts. It learns through its mistakes and it’s willing to identify other new solutions or ideas to be tested (it doesn’t just give up, rather seeks help). It involves all members to participate in decision making, it plans data collection at the beginning of the project and assigns responsibilities accordingly. It gives feedback to management at a regular basis and it relies on them for resource allocation and resolving bottle necks in the system (those beyond the team). All members work as a team and they complement each other. They share responsibilities and they don’t rely on one person. They are willing to share information and are open to get ideas from other teams. These are some key areas I would look for.

I have a question on measurement. What do you measure in a small facility to show that improvement work is continuing, even if the improvement aim is changing?

ANSWER

When an improvement aim changes, it means the team has met its target on the previous aim. Measurement is an on going process ; therefore the team continues to measure and monitor the outcome measures of their aims that have been met for quality assurance purposes. They also start measuring process measures of their new aim to make sure that they are actually doing what they said they will do. If a facility has fewer patients, it if good to include a table of actual numbers below the run chart so that others can understand the story. Qualitative data is also very important in these instances.

Given all the decision making processes, planning sessions, meetings etc, - how much real time is involved in providing clinical and respectful care? I am concerned, given existing staff shortages at facility level.

ANSWER

Every facility is unique and it deserves unique ways of doing improvement. If the facility is very busy and short staffed, you have to agree on the best time to focus on these activities. Most facilities with these challenges prefer to meet first thing in the morning or late afternoon when they have no or less patients. They also try to chose days that are quieter like Fridays. We have had facilities that prefer to meet during their lunch time. It all takes the dedication of the team and accepting that they have problems/gaps and that they can still do something and improve using their existing resources including staff. They also do task sharing and task shifting (as long as it is acceptable within their scope of work).

How do you encourage sustainability of quality improvement work, so that it becomes an organisational culture, rather than 'inspection compliance'?

ANSWER

Avoid blaming individuals when you identify gaps, these are mostly systemic problems. It is important to introduce the QI concepts to leadership and make them understand that the process is not about inspection or policing but rather to celebrate areas that the team is doing well ; as well as identify areas for improvement (gaps) and find  solutions. The teams must also be told by leadership that the process is not for reprimand but for improving services to the clients. Leadership should be in a position to give positive feedback. As human beings we are driven by positive words. When gaps are identified, provide direction on how the team can start the process to improve using QI concepts. Start with smaller problems that can produce results quickly so that you can motivate the team. The team and its leadership should be involved from the beginning and this process must be led by them not an outsider. This is the best way to promote sustainability over time and promote institutionalisation of QI.

To the last question about respect for moms and babies:  Jacaranda Health is doing a quality improvement project with UCSF and a partner in India to develop a change package to improve patient-centered care that will be published in 2018. The change package will include changes that address dignity, communication, social support, hospital environment, trust, etc. We are working in family planning and maternity departments for this project. Happy to share the published results of the study with this group when the project concludes.

ANSWER

This is great news. We will be looking forward to these results.

So as you roll this out - are you using innovative approaches for trainings - such as e-learnings for the trainings-- for the sake of roll out?

ANSWER

Mostly we do face to face trainings which is formal and at a stipulated venue. We also do informal onsite trainings so that we don’t take the staff away from their facilities. However, as an organisation we have a lot of e-learning courses that can be accessed by anyone and it’s free for under-developed countries and students. The problem is most of our clients and QI teams do not have easy access to internet let alone data. Therefore, it is problematic to use webinars, Skype and other forms of e-learning. Where access is available, e-learning happens. We also have lots of QI teams and groups who now teach, learn and share information on WhatsApp groups which is currently widely used and it’s affordable.

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