Thank you for such clear presentations. Could you speak to how you balance the importance of addressing a problem with high impact value with the importance of addressing something easy to fix?

ANSWER

It is best to choose easy to fix issues first, as often, high impact value measurements may not be occurring frequently. Working on infrequent events means the learning is too slow for a new team to learn quality improvement well. By working on easy to fix problems, you bring efficiency in the system, thereby saving time and resources. In addition, early success motivates the team.

As is often the case, the staff is overloaded in facilities in Bihar and Jhakhand, and they tend to think of quality improvement team meetings as just another meeting.

ANSWER

The teams need to meet more frequently, not just once, to share the progress and the learnings. Depending on the project, this can be weekly or every two weeks.

Despite being shown improvements in the highest platform they (staff in facilities in Bihar and Jhakhand) still seems to be disinterested.

ANSWER

Here comes the role of motivation and sharing the gains of the quality improvement work.

What is the place of the WHO standards and assessment based on standards in generating data to prioritize problems and set aims?

ANSWER

WHO standards provide information on what should be done, like doing skin-to-skin or implementing early breast feeding. And if these are not getting implemented, quality improvement can fix the problem, if adequate professionals are present in the health facility. It is better to start on common problems that can be addressed quickly and that staff in the facility feels are an issue. Doing a big assessment to generate data to prioritize problems could happen after the obvious problems have been addressed. It is not necessary at the beginning.

Thank you for good presentations! What interventions did you take to change the behaviour on skin-to-skin contact?

ANSWER

We worked to educate professionals, convince mothers and provide an enabling environment.

(I) would like to explore ways to motivate them (staff in facilities) for this meeting.

ANSWER

We will cover that topic in the next webinars.

Besides Kangaroo Mother Care, what are other examples (of interventions) in your facility?

ANSWER

Improving counselling, reducing hypothermia at admission to NICU, increasing mothers milk intake in sick and premature babies, decreasing alarms in NICU, reducing breakages of warmer probes etc. In addition, multiple departments other than NICU have completed various quality improvement projects.

Why did you combine affordability in terms of time and resources? Combining would make it difficult for service providers to give an objective score, since these are two separate issues. Could you consider separating them as you did in your definition of PICER?

ANSWER

I agree that resources in terms of extra money/support and time may confuse members. But as a leader, you have the opportunity to clarify that, based on what the processes involved are, while collating the prioritization matrix (PICER) scores .

What tips do you have for motivating participation?

ANSWER

A few techniques include picking problems that staff wants to solve, appreciating the frontline workers, rewarding by giving certificates or identifying ‘jewel of month’ staff members, bringing to notice of senior faculty and nursing managers, giving opportunity to share success stories.

Thanks! How do you approach patients or communities for participating in (quality) improvement and how long do you keep them in the process of quality improvement?

ANSWER

And also (I) would like to ask: can’t we incorporate quality improvement team meetings in the terms of reference for BPMs and HMs and monitor its efficacy using some measurable checklists?

ANSWER

These are contextual issues, depending on how much importance one gives to quality imrpovement work. One thing to keep in mind however, is that two of the key points of quality improvement are to focus on the patient outcome and to trust the frontline workers. Externally monitoring whether quality improvement teams are meeting and what happens in those meetings takes away from both of those points and would probably be very demotivating. The external support, instead should be on what progress the team is making on their aims and what help they need.

How long do you have to implement a change idea in the cycle, after you have done the prioritisation using PICER?

ANSWER

We will learn about this in the next webinar.

I feel using quality improvement projects to optimise work reduces the burden on the available staff.

ANSWER

I agree: in the long run, it reduces the work burden on staff and brings efficiency and early discharges.

Do you have reliable data to identify the priority problems?

ANSWER

We will learn about data/ measurement in the next step.

You mentioned projects should be short. Do you have more specific recommended time lines?

ANSWER

By short we mean projects which can give results quickly over 4 to 8 weeks, where the change is tested on few patients and the results are positive. Once you master this in a few quality improvement projects, you can take projects which are longer such as collaboratives, which can last several months and up to a year.

How do you select enthusiastic people?

ANSWER

When the teams meet, look for those team members who contribute actively to discussions and are suggesting how to fix problems. It is best to assign those team members tasks or pick those who volunteer to take responsibility.

Ashok is a very motivated champion for quality improvement. However, in other settings, there are managers that see quality improvement as an extra activity that takes people away from their ‘key functions’. Any ideas on how to address this perception and reality?

ANSWER

You won’t find motivated individuals everywhere. They need support to bloom and lead the teams to do good work.

Bihar is struggling with systemic issues which can improve and provide an enabling environment to service providers to generate more motivation and interest among service providers. I need help on how to sustain interest and motivation after successfully making an aim statement, running a PDSA cycle for quality of care improvement, and achieving the aims!

ANSWER

Best wishes for your endeavors. Look for local professionals who are ready. Ownership by the community is crucial to do and sustain quality improvement. We will talk about sustaining improvement in two webinars from now.

Do you think there is a role for defining the number of patients (e.g. thye next 10) rather than time?

ANSWER

This will come when we talk about PDSA. How many patients to be tested and how much baseline data is to be collected? But we must have quick wins for quality improvemeng projects over 4 to 8 weeks.

Exactly what was the change tested and which became a best practice?

ANSWER

We will cover this in the next step.

In AIIMS, are you practicing ENBC? And have you taken any change idea in labour room practices like the use of a partograph?

ANSWER

Yes, we practice ENBC. We use a partograph in obstetrics.

How do you incorporate a quality iprovement team in other existing teams in a facility?

ANSWER

Ideally, the frontline workers themselves should be able to incorporate quality improvement, with external support for some time. We engage frontline workers to decide among themselves whether to take forward the quality improvement work, under the leadership of an identified/selected leader.

Most of the time I have seen that quality improvement teams are primarily based at health facility level. Is there any example where senior programme managers were engaged in quality improvement processes for maternal and newborn health? I firmly believe that even senior programme managers should be part of quality improvement processes.

ANSWER

Yes, programme managers need to be educated, as system support is often needed to sustain quality improvement gains. We noticed this in the state of West Bengal, where we engaged the programme managers from the beginning, and they were constantly informed about the quality improvement projects lead by various teams. As a result, the scaling up of activities in the entire state, scheduled to happen soon, is becoming easy, and frontline professionals got more enthusiastic to carry forward the quality improvement work.

When there is a cluster of poor practices, such as in relation to essential newborn care, what is the role of training to address these as a package and to follow this up with careful monitoring and quality improvement approaches to sustain high performance?

ANSWER

We need education in ENC first and than support them with quality improvement skills.

Do you have tips for sharing success with the administration to promote “recognition (future assistance?) and similar processes in other areas?

ANSWER

Yes sharing with senior management is crucial. We draft a policy for successful quality improvement and share with administrators MS/Chief Nursing Officers. It is then signed by the Head of Department as a policy.

You can identify local champions who have tested change and achieved success, and make them your ambassorders for other facilities.

ANSWER

I agree.

Could you please let people know how nurses were “trained”? Did you have a day to learn quality improvement, or was learning “on-the-job”?

ANSWER

It was a mix of both short training workshops and on-the-job learning.

I would also like to add that involving patients in the quality improvement team meetings should be started and documented. I have started to do this recently and have had a mixed experience, but in my opinion this is because grievance redressal mechanisms are non existent, at least in the state of Jharkhand. Quality improvement team meetings can be a great platform for the patients.

ANSWER

I fully agree, patients can be important stakeholders in quality improvement projects.