Social and Behavior Change, Provider Behavior, and Quality of Care

1. Social and Behavior Change, Provider
Behavior, and Quality of Care
CORE Group Meeting
May 19, 2016
Chelsea Cooper
On Behalf of:
MCSP QualityTeam

2. 2
• Growing global body of QI approaches, but evidence still
needed (esp around effective & sustainable approaches)
• Under-focused area of SBC – need for more applications
of SBC lens, as much of QoC work has behavioral and
interpersonal dimensions
• Improve health outcomes by providing respectful and
technically sound services, delivered according to
standards known to maximize health impact.
• Client and community perceptions of quality can affect
utilization of services.
Why Quality and Provider Behavior?

3. 3
• health care delivery occurs as part of an interaction
between a health care provider and the client and
community;
• provider performance is affected and motivated by a
wide range of factors in the provider’s immediate
environment;
• the health system is responsible for providing inputs
and processes that service providers need to deliver
quality services, including infrastructure, supervision,
and management
Underlying Considerations

4. 4
Quality Aims for MCSP
High quality care is:
Effective: Adherent with evidence-based
standards
Safe: does not harm patients
Timely: care provided when needed
People centered: Respectful of patient
needs, values & preferences
Coordinated: services for a single client
are coordinated across time
and levels of care
Institute of Medicine, 2001,
Crossing the Quality Chasm

5. A Framework for Continuously Improving
Quality of Care

6. Conceptualizing Quality:
Moving beyond Inputs and building blocks….
(Source: Donabedian)
6
1. What is done
2. How it is done
• Patient health
status/outcomes
• Change in
health behavior
• Patient
perception and
experience of
care
• Human
resources
• Infrastructure
• Materials
(i.e. vaccine)
• Information
• Technology
Structure
(inputs)
Process Outcomes

7. 7
STANDARDIZATION FOCUSED
PROBLEM-
SOLVING
OPEN PROBLEM-
SOLVING
PROCESS
REDESIGN
GOVERNANCE
PURPOSE Regularity Improvement
towards target
Find solutions to
complex problems
Optimize flow of
activities
Whole organization
involvement
PROCESS SDSA PDSA PDSA Reengineering Systemic
improvement
TOOLS Process mapping,
check-lists,
assessment tools
Root-cause analysis,
team implementation
Appreciative enquiry,
collective solutions
Process-mapping,
quality function
deployment
Education, clinical
audit, risk
management,
openness, research
POTENTIAL
BEST FIT
New programs, no
best-practices in
place, multiple issues
Need to address key
specific issues
Multiple complex
issues with limited
evidence (e.g.
community)
Need for efficiency
and value-added
gains
Multi-level system
improvement
EXAMPLES SBM-R, accreditation,
certification, 5-S,
check-list
TQM/CQI (Kaizen),
Six Sigma, BSC,
Health/QUAL,
“collaboratives”
PDQ, Citizen Voice
and Action,
Community Score
Card
Lean,
reengineering
CCM, Clinical
governance, REC-
QI, RAPID
Adapted by Edgar Nocea from S. Hacker, B. Jouslin de Noray, and C. Johnston, European Quality, European Quality Publications, Ltd; London; 2001
Ilustrative Taxonomy of Quality Approaches

8. MCSP QI Principles
• Measurable clear aims focused on important health outcomes
for which high-impact interventions exist
• Prioritization of needs, values and desires of clients
• Engaging health worker hearts and minds to improve care –
Motivation; leadership, QI, clinical, management skills
• Focus on understanding and overcoming critical gaps
(bottlenecks) in local care processes and health systems
• QI team work - representatives all system functions
• Change management strategy driven by local actors
• Real-time use of data (i.e. tracking process and outcome
measures.)
• Regular shared learning to accelerate improvements at scale8

9. 9
SBC(C) and Quality of Care
In terms of….
• Provision of care
• Experience of Care

10. WHO
Quality of
Care
Framework
for Childbirth
Source: BJOG 2015

11. 11

12. Identified QI Implementation Interventions
12
The implementation interventions identified were then consolidated into 11 categories
as follows:-
1. Leadership of quality
2. Planning, designs and policies for implementation or scale-up
3. Financial strategies to support improvement
4. Assessment and provision of resources
5. Engaging women, families, communities in their care
6. Education and training for clinical and system activities
7. Supportive supervision of clinical and system activities
8. Adaptive designs for implementation or scale up
9. Data to support improvement
10. Learning communities for accelerating improvement
11. Governance of quality

13. Lessons from MCHIP
Guinea SBM-R
• Three urban health
facilities already
implementing SBM-R for
MNH/FP.
• Six months
• 34 performance standards.
Zimbabwe SBM-R
• Adapted one year after SBM-R
was introduced for MNH
• Implemented in 21 health
facilities
• Three years 2011 to 2013
• 38 standards
13
 Evidence of immediate positive influence on provider’s adherence
to agreed performance standards.
 No firm conclusions on SBM-R’s scalability and sustainability

14. Case Study:
Respectful Maternity Care in Ethiopia
14

15. The Maternal Child Health Integrated
Program in Ethiopia
• Service delivery interventions: Integrated Maternal & Newborn health
(MNH) in 4 regions = 119 facilities (104 Health Centers, 12 hospitals)
from 2011 – 2013
• Package of interventions centered on Quality Improvement Approach –
Standards-Based Management and Recognition™ (SBM-R):
 Verifiable, objective standards to measure performance (RMC practices
integrated into quality standards)
 Providers & managers measure actual performance against standards &
identify gap filling to reach desired performance
 Competency-based skills training to ensure essential package of MNH
services
 Development of job aids, posters
 District health offices provided with small grants to support &
facilitate SBM-R
 Integrated into existing training, supervisory support 15

16. Findings & Recommendations
• Quality Improvement i.e. SBM-R intervention facilities
performed better in provision of RMC practice from
observation (e.g. respectful reception, explaining every step,
encouraging questions, woman allowed to give birth in position
of choice, woman never left alone during labor, privacy ensured)
• No difference found between study groups on disrespect and
abuse experienced
Recommendations:
• Quality improvement approaches should look at integrating
RMC as part of MNH care
• RMC needs to take clients’ views into consideration when
designing and promoting care; more attention to “experience”
of care 16

17. Low Dose, High FrequencyTraining in Ghana
(Jhpiego)
Traditional Approach
• Off-site group-based training
• 12-day BEmONC package
• Limited number from each
facility
LDHF
• “On-the-Job, on-site training”
• Shorter training, repetition
(high frequency)
• Local ownership, whole team
participation
• Simulation and training with
low-cost models
• Supportive use of technology
• Mentorship, master mentors
• On-site peer support and
practice post training

18. Reinforcement and reminders: mMentoring
• Text messages and quiz questions sent
to all training participants
• Option to “opt out”
• Messages are sent Monday – Friday
• 16 thematic areas over 6 month period
• PPCs receive mentoring phone calls
from Master Mentors
• Master Mentors receive mentoring
phone calls from Jhpiego team

19. Performance of Master Mentors,
3 Regions, September 2014 – September 2015
79%
56%
91% 91%
95% 95%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Knowledge Assessment OSCE
Pre-training Post-training 1 year post intervention

20. Performance of Service Providers:
10 facilities, September 2014 – September 2015
84%
47%
94%
90%
93%
71%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Knowledge Assessment OSCE
Pre-training Post-training 1 year post intervention

21. Coming Soon:Age and Stage in Nigeria
• Health workers will be supported with age- and
stage-specific counseling tools for each type of
contact in a health facility with young people.
• Health workers will be oriented on adolescent
development, best practices, and age-specific
counseling skills to address adolescents’ needs.
• Young people will be actively engaged in quality
improvement process through Partnership
Defined Quality forYouth (PDQ-Y). Girls and
boys will define and support a quality improvement
process in collaboration with community leaders
and health workers.
21

22. Takeaways
• Quality improvement is a behavior change intervention!
• SBC(C) and QoC in terms of provision of care and experience
of care [further efforts needed around experience of care]
• Need for further cross-fertilization between SBC and QoC
practitioners; apply SBC evidence, principles, processes
• Need for more focus on SBC(C) at point of service delivery
• Consider respectful, client centered care approaches beyond
RMC
• Explore opportunities to strengthen “change agency” role of
health workers
• Pair QI efforts with HSS
22

23. For more information, please visit
www.mcsprogram.org
This presentation was made possible by the generous support of the American people through the
United States Agency for International Development (USAID), under the terms of the Cooperative
Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not
necessarily reflect the views of USAID or the United States Government.
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