1. Integrating M&E at the
clinic level
Amy F. Stern
USAID HEALTH CARE IMPROVEMENT PROJECT (HCI)
UNIVERSITY RESEARCH CO., LLC
February 22, 2012
1

2. Data use at each level of health system.
National
Inform
National
planning
Global
Region/
Show District
Impact of Facility
Support,
Programs coach & Identify &
mentor address gaps in
care
USAID HEALTH CARE IMPROVEMENT PROJECT

3. Effective M&E integration at the clinic level:
key lessons
1. Use metrics relevant to the clinic
– Denominators reflective of clinic patients
2. Make data collection part of the daily routine
– Document in clinic data collection tools.
3. Use data to inform decisions to improve clinic
performance
– Monthly review and analysis; identify gaps in service
delivery, test changes to improve performance and close
the gap
USAID HEALTH CARE IMPROVEMENT PROJECT

4. 1. Use metrics relevant to
the clinic
4

5. Use clinic based denominator
Output Indicator 1
The # and proportion of undernourished PLHIV that
received therapeutic or supplementary food at any
point during the reporting period
Numerator: # of clinically undernourished PLHIV that
received therapeutic or supplementary food
Denominator: # of PLHIV nutritionally assesses &
found to be clinically undernourished (who visited
this facility)
USAID HEALTH CARE IMPROVEMENT PROJECT

6. Feasible quality criteria by region
Feasible Quality Criteria
100
90
80
70
60
Percent
50
National Level
40
Facility Level
30
20
10
0
East Eurasia West Southeast Southern
Africa * ++ Africa * Asia + Africa *
USAID HEALTH CARE IMPROVEMENT PROJECT

7. The value of process indicators
Process measures are more sensitive and
more useful performance indicators
than outcome measures when looking
at a narrower perspective such as a
clinic, department, hospital.1
1MantJ. 2001. Process versus outcome indicators in the assessment of quality of
healthcare. Accessed on:23 Jan. 2012. Available at:
http://intqhc.oxfordjournals.org/contents/13/6/475.full.pdf+html
USAID HEALTH CARE IMPROVEMENT PROJECT

8. 2. Make data collection part of
the daily routine
8

9. 3. Use data to make
decisions to improve clinic
performance
9

10. % of clients whose nutritional status is assessed using mid-
upper arm circumference (MUAC)
100
90
80
70
Nutrition training
60
50
%
Delivery of
40 commodities
30
20
10
0
w11
w1
w3
w5
w7
w9
w-12
w-20
w-18
w-16
w-14
w-10
w-8
w-6
w-4
w-2
w21
w13
w15
w17
w19
w23
w25
w27
USAID HEALTH CARE IMPROVEMENT PROJECT

11. % of clients whose nutritional status is assessed using mid-
upper arm circumference (MUAC)
100
90
80
70
Nutrition training
60
50
%
Delivery of
40 commodities
30
20
10
0
w11
w1
w3
w5
w7
w9
w-12
w-20
w-18
w-16
w-14
w-10
w-8
w-6
w-4
w-2
w21
w13
w15
w17
w19
w23
w25
w27
Tell everyone to do MUAC Assign a staff person to do Train expert clients to do
a non-sustained change MUAC after registration MUAC
A sustained change
USAID HEALTH CARE IMPROVEMENT PROJECT

12. Develop changes to test
• Where is the best place to assess?
• Who should assess?
• How can the findings be recorded?
• How to link clients with treatment?
USAID HEALTH CARE IMPROVEMENT PROJECT

13. Key results, Kenya: Change ideas tested to
improve nutritional assessment of HIV patients
1. Relocated place for nutritional assessment from clinician room to
registration desk
2. Re-assigned task of assessing nutritional status to expert
patients
3. Synchronized RUTF collection date with ARV follow-up dates
4. Began collecting details of clients (home address, cell phone
number, etc.) to help trace those who miss follow-up
appointments
5. Revised patient flow to enable easier movement of clients from
one service area to another and to decrease waiting time
6. Testing changes in other parts of facilities e.g. now at MNCH
7. Successful lobbying for anthropometric equipment from partner
organizations to enable nutritional assessments at the facility
USAID HEALTH CARE IMPROVEMENT PROJECT

14. Key results, Kenya: Increasing nutritional
assessments for HIV infected patients
Percentage of HIV Patients Assessed for Nutritional Status from Ambira Hospital in Kenya
September through November 2011
100
80
60
40
Percentage
20
0
BASELINE WK1 WK2 WK3 WK4 WK1
SEP SEP SEP SEP OCT OCTWK2 WK3 WK4 WK1
OCT OCT NOV NOV-WK2 WK3 WK 4
NOV NOV
# of HIV +VE clients assessed for Nutritional
Status and categorize MAM 0 49 148 109 138 214 253 162 211 202 244 270 220
SAM,Normal,Obese
Total # of HIV positive clients visiting the
health facility 0 57 169 224 161 217 254 165 212 202 247 275 257
Clients Nutritionally assesed and categorized 0 85.96 87.57 93.3 85.71 98.6 99.6 98.2 99.5 100 98.7 98.1 85.6
Numerator: # of HIV infected clients assessed for nutritional status and categorized
Denominator: Total # of HIV infected patients visiting the health facility that month
Data Source/Sampling: HIV Register
USAID HEALTH CARE IMPROVEMENT PROJECT

15. Best practices
• Integrate assessment with existing registration
or triage stations
• Have expert clients help with the additional
work load
– Train enough expert clients to accommodate for when
some are not available
– Provide supervision/mentorship for expert clients
• Document nutrition status in existing registry
rather than creating a new document
USAID HEALTH CARE IMPROVEMENT PROJECT

16. Effective M&E integration at the clinic level:
key lessons
1. Use metrics relevant to the clinic
– Denominators reflective of clinic patients
2. Make data collection part of the daily routine
– Document in clinic data collection tools.
3. Use data to inform decisions to improve clinic
performance
– Monthly review and analysis; identify gaps in service
delivery, test changes to improve performance and close
the gap
USAID HEALTH CARE IMPROVEMENT PROJECT