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Ruma rssp qi in resource poor settings 050211
- 1. Ruma Rajbhandari, MD MPH Nick Simon’s Institute Global Health Equity Residency Brigham and Women’s Hospital Harvard Medical School Introduction to Healthcare Quality Improvement in Resource-Poor Settings
- 6. Quality gap Quality gap JAMA 284(23):2994-2995, 2000.
- 18. How to use the checklist tools: scoring
- 21. Criterion-based clinical audit cycle Step 1: Establish criteria of good practice and define cases Select topics: e.g. Management of major obstetric complications Step 5: Re-evaluate practice and give feedback Step 4: Implement changes in practice where indicated. E.g. skills up-dates, clinical guidelines Step 3: Feedback findings and set local standards Step 2: Measure current practice: -Staff questionnaire -Case-note review -Registers (Monitoring Quality of Care in Maternity Services, 2004, FHD, MoH)
- 24. Client exit interview format S.No. Questions Response 1. How did you get to this facility? Tick response [ ] Walk [ ] Bus [ ] Own transport [ ] Ambulance [ ] Carried in a doko/ dola/ stretcher [ ] Other 2. How long does it take to travel to the health facility? 30 minutes, 1 hour, 2 hours, >3 hours 3. What did clinic staff tell you about your health conditions? e.g. BP, Physical exam, Baby’s condition, Blood and urine test, Others 4. What advice did she/he give you? Did you fully understand what you were told? What were you told? 5. How long did you wait for treatment? 30 minutes, 1 hour, More than 1 hour
- 30. The model for improvement: PDSA cycle Plan Do Study Act
- 33. Fig 1 Quality improvement protocol. Kotagal M et al. BMJ 2009;339:bmj.b3488 ©2009 by British Medical Journal Publishing Group
- 35. Fig 2 Percentage of vital signs monitored. Kotagal M et al. BMJ 2009;339:bmj.b3488 ©2009 by British Medical Journal Publishing Group
- 36. Fig 3 Percentage of drugs given as prescribed. Kotagal M et al. BMJ 2009;339:bmj.b3488 ©2009 by British Medical Journal Publishing Group
- 37. Developing improvement with PDSAs PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT Accumulating information and knowledge Testing and refining ideas Implementing new procedures & systems - sustaining change Bright idea!
- 40. Doctors were not being called by the ANMs in a timely manner regarding obstructed labor and other problems during labor ANMs are not recognizing problems during labor Partograph is a useful tool to identify problems during labor. Are ANMs filling out partographs? Very few deliveries (<25%) at Bayalpata Hospital had a properly recorded partograph.
Notas do Editor
- -Introduce myself: Raised mainly in Kathmandu, after I.Sc. at xavier’s, went to the US for college and medical training. Over the last few years, I have spent a few months of the year here in Nepal, working with NSI and with Nyaya Health in Achham on issues related to health care in rural, resource-poor settings. -Just to understand what your backgrounds are: -How many of you were raised outside of Kathmandu—that is, did SLC outside of Kathmandu? -How many of you have worked at hospitals outside of Kathmandu during or after your MBBS? Where? -This main goals of this presentation are to introduce you to the concepts of quality and quality improvement in health care particularly in resource-poor settings such as that of a district hospital in rural Nepal where some of you may find yourselves after your training. Let us go to the scenario of one such hospital:
- Can I have two volunteers read out this case? What’s the firs thing that comes to your mind after having read this case? Does this surprise you, shock you? Are incidents like these things you have seen at rural hospitals you have been posted to? Are incidents like these common in Kathmandu hospitals? Where were the quality gaps in this case? No oxygen No electricity Lack of recognition by HA of how sick the child was Lack of money for transfer Quack doctors in the community Lack of resuscitation protocols No regulator for back up oxygen canister One of the arguments about quality in resource poor settings is that quality improvement requires massive resources. In this case, is it true? I want you to keep this case in the back of your head throughout this presentation.
- What is quality? What is your definition, particularly in the context of health?
- -There are many definitions of quality in health care. The health care quality improvement movement in the United States was given a jumpstart in 2001 when the Institute of Medicine released this report “Crossing the Quality Chasm: A New Health System for the 21 st Century”. The report highlighted the enormous expenditures the US made in health care, but when one looked at the facts, these enormous expenditures were not having the impact that they should have had. -There was a major gap between what we know and what we do.
- For example, this chart shows the quality gap between where he system is performing and where it should be performing. This is from a study in the Journal of the American Medical Association looking at the differences between beta blocker prescription after an acute myocardial infarction in different types of hospitals in the US. This is Medicare data from 2000. As you can see, although teaching hospitals did better than non-teaching hospitals, the overall quality of care in the system is still low. We know that good quality care indicates that beta blocker should be given post MI. We expect this number to be close to 100%. Thus, that gap between 100% and what we actually see is the quality gap. The IOM study identified many such gaps in quality care in the United States.
- The study advocated thinking about quality in terms of six domains: 1. Safety: avoiding injuries to patients from the care that is intended to help them. 2. Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. 3. Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. 4. T imely: reducing waits and sometimes harmful delays for both those who receive and those who give care. 5. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy. 6. Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. A health care system that achieves major gains in these six areas would be far better at meeting patient needs.
- There are many different definitions of quality. This is a simple one from the Society of Hospital Medicine that I like. -Meeting the needs and exceeding the expectations of those we serve—that is, our patients. -Delivering all and only the care that the patient and family needs. That is, not giving them unnecessary care—e.g. 3 medicines when they only need one.
- -We can also use the framework of clients’ rights and staff needs to definite quality care. Within clients’ rights there is the right to information about their health condition and the treatment that is recommended. Patients’ deserve good access to care. They should be well-informed and should be given a choice of accepting or not accepting treatment. Services should be safe, private and confidential. Patients should be treated with dignity and allowed to express their opinions. Finally, patients have a right to continuous care. -when we talk about quality health care, there is also another important component to think about—the needs of health care staff—without which we cannot have quality health care. Staff need appropriate supervision and management, with clear job expectation, feedback and motivation. Similarly, they need constant training and development. There needs to be an enabling environment for staff with good organizational and environmental support so that they feel they have the tools necessary to carry out their jobs.
- -The quality improvement movement really started in developed or resource-rich settings in the 1980s. The Institute for Health Care Improvement in the US has been at the head of this movement. Much research and implementation has been and continues to be spear-headed by them. -However, in resource-poor settings like Nepal, quality improvement has not been given much attention. -Much of the attention in resource-poor settingg has focused on the quantity of services provided. For example, over the last decade, millions of dollar have gone into HIV/AIDs programs. WHO had the 3 by 5 program to have 3 million people on ARVs by 2005. -The quality of many of the resultant services has often times been low or poorly understood. -It is high time that we begin to focus on quality in resource-poor settings
- Let them read the statements and comment. Does quality mean more work? Does quality cost more money?
- In the next part of the presentation, I want to convince you that there are some basic quality improvement tools that are simple, easy to use and very effective in resource-poor settings like that of a rural district hospital in Nepal for bringing about improvement. I imagine that some of you will be working outside of kathmandu, perhaps in rural district hospitals. When you are posted there, I hope you will remember this presentation and think about some of these QI tools that I will be presenting as something that you could do to improve the quality of the district hospital. The six that I will talk about are the formation of QI committees, development of standards and checklists, clinical audits, patient exit interviews, M&M and PDSA (Plan-Do-Study-Act cycles). I will present details of programs and groups that have actually used these tools in resource-poor settings and in Nepal. ****
- The three groups/projects I will talk about are the NSMP, Nyaya Health and Partners in Health. I will present details of programs and groups that have actually used these tools in resource-poor settings and in Nepal.
- The Nepal Safe Motherhood Project was a project that supported district hospitals like Baglung in rural Nepal to improve maternity care. They used a Quality of Care approach, intially forming Infection Prevention and Maternity Teams in each hospital. They used checklists to carry out monthly assessments and conducted quarterly and semi-annual assessments and reviews.
- -Based on the experiences of other programs like NSMP and Partners in Health, we have started to develop a QI program for RSSP. -We think one of the first steps to starting quality improvement at the RSSP district hospitals will be to form a quality improvement committee at the hospital. -This committee s hould focus on quality improvement in the district hospital e.g. Infection Control, Maternity, Inpatient, OPD/ER -Different from district-wide QI committee because it is only focused on the hospital, not the whole district -Members: All hospital staff including doctors, nurses, health assistants/paramedics, support staff, store keeper, pharmacy personnel -Leaders: MDGPs, nursing-in-charge
- This was one of the early tools used by NSMP looking at accessibility and availability of BEOC/CEOC care. Their checklists consisted of simple Y/N questions that defined a standard of care. Checklists designed to ensure standardized, high quality care and team communication improve the effectiveness of clinical care in resource-limited settings [4, 14] . Checklists are a low-tech solution that can bolster managerial oversight and better utilize available human resources, improving overall effectiveness. Checklists are an important tool for standardization but their effective implementation will have to undergo rigorous site-specific testing using QI principles.
- -Here is an example of a simple checklist of performance standards for infection prevention in a clinic: -The rule for these performance standards is that you need to meet each aspect of it in order to meet the standard. That is, you must have a Yes for all of the points. Even one No means that you have not met the standard. Need to emphasize that one should go through all of the lists within each “performance standard”. If any of the answers are “No”, then you don’t get a point for the standard. Everything must be a “Yes” to get a point.
- -At the end of each tool, is a scoring sheet where one can calculate one’s score on the tool. E.g. 5 out of 10 standards achieved will give a score of 50%. Again, these tools are standards that should be aimed for. Such tools can be used periodically, e.g. once a year to assess where a site is and how it can improve. It can be used by health care staff to learn what standards for their own knowledge and improvement.
- -It’s not enough though to go through a checklist and identify gaps. One has to figure out what to do about the gaps. -This is where Action Plans come in. -After discussing with relevant staff, it is important to go through each of the gaps and figure out what actions should be taken, who is responsible for the action, what support is needed and what the deadline is for such action. -I think such documentation is crucial to keep people on track.
- -Clinical audits were another tool used by NSMP in its pilot districts. -An audit is a systematic and critical analysis of the quality of medical care. -Too often we assume that best practices are followed. However, despite the desires/knowledge of the clinician to do the best he/she can for the patient, there may be many systems issues that prevent best practices from being followed
- A basic audit cycle consists of the following cycle of steps. The first is the selection of topics for audit. In the case of the Nepal Safe Motherhood Program in Nepal, management of obstetric complications was chosen as the topic because improving quality in this area would result in lives saved of both mothers and babies. It was an area where improvement was clearly needed in NSMP districts. -Once the topic is established, the first step is to establish criteria for good practice and define cases. Criteria for good practice can be found in the medical literature..for e.g. management of post-partum hemorrhage. Sometimes criteria for good practice may have to be modified based on the resources available in a local setting or the cultural beliefs of that settings. -Step 2: Involves measuring current practice. That is, how are cases of PPH currently managed/ This can be done via case record review, looking through maternity/delivery registers and through staff questionnaires. -Step 3: Involves setting local standards and giving feedback about the current practice. Identifying gaps in good practice and how these can be improved. -Step 4: Involves actually implementing changes in practice where it is indicated via skills up-dates, posting guidelines on the wall, etc. -Step 5: Involves re-evaluating the practice and giving feedback. -As the circle in the middle shows, this is a continuous process. It is not something that happens overnight. One must constantly go through the process, picking different topics until we are sure that we are carryng out good/quality practice in each area of clinical care.
- In the Nepal Safe Motherhood Program, one of the topics chosen for audit was management of PPH. They first defined PPH. -Then standards and criteria for best practice were locally set and taught to all clinicians and practitioners. -Cases of PPH in the past 1-2 years were looked through to see if they had met local standards. After the establishment of the standards and criteria, the cases of PPH in the next year were looked through to see how many met the standards. If local standards were not met, the reasons for not meeting the standards were explored. Standards were modified as necessary. *** What are some barriers to such audits in Nepal?
- Patient exit interviews were another tool used by NSMP for quality improvement in its districts. Exit interviews are simple tools to help identify patient’s perceptions of quality of care at the hospital. -They help to identify problem areas that may have been overlooked by hospital staff. -Its important to choose outsiders to conduct these interviews as patients may not be candid with staff from the hospital or health facility.
- Exit interviews can be very simple and short. These are some questions from an exit interview used by the Nepal Safe Motherhood Program. These questions address issues of access to health, information given to patients and their understanding of them, timeliness of treatment.
- -This next tool—the Morbidity and Mortality conference is a simple effective practice in hospitals throughout the world. -I am sure that during your medical training, you have been to and participated in many of these before. -M&Ms are a great tool for identifying key problems in clinical care and in helping to improve the quality of the hospital and its departments. -I want to present the M&M program of a Bayalpata Hospital in Achham in the far-West of Nepal. It is a hospital run in a public-private partnership between Nyaya Health, an NGO, and the government of Nepal. -The unique aspects of Nyaya Health’s M&M is that is a hospital-wide QI program. All the hospital staff, including non-clinical staff participate. It is carried out weekly. Morbidity and mortality (M&M) case conferences can ensure both ongoing clinical education and regular, inclusive, team-based process evaluation [15] . This has been our experience in rural Nepal, where health personnel typically have few opportunities for continuing medical education or team-based reflection. M&Ms in other locations have also been transformed into QI meetings where district/subdistrict process and outcome data are shared with a community of clinics and hospitals to assist with data feedback.
- Discussion takes place along the seven domains of causal analysis. These are clinical operations, supply chains, equipment, personnel, outreach, societal and structural issues.
- This is an example of an M&M that occurred at the hospital.
- Here is another chart showing you a summary of some of the other M&M conferences that have occurred at the hospital with recommendations that came about from the discussions.
- Staff overall are very positive about the M&M program. Many of the non-clinical staff find it useful to get involved because they learn about clinical care and the services offered at the hospital. Involving all of the staff, doctors, nurses, ambulance driver, non-clinical staff adds to the knowledge of the case and brings in points that would not otherwise have been brought up.
- The PDSA cycle is the last of the tools that we will talk about. - The Plan-Do-Study-Act (PDSA) model is a component of the well-tested Model for Improvement. -The model for improvement is based on three important questions. What are we trying to accomplish? What is our aim? How are we going to get to that aim? What are we going to do? How will we know that a change is an improvement? What changes can we make that will result in improvement? A PDSA (Plan-Do-Study-Act) cycle is a way of determining if a change leads to an improvement. It is a method for rapidly testing a change - by planning it, trying it, observing the results, and acting on what is learned
- Many of you will have seen cycles like this one already. This particular one is called the PDSA cycle and is designed to test improvements. It was used widely in the NHS in the late 1990s as part of a change management program in UK healthcare. The idea is to start small, even one patient and see what happens. Not like a clinical trial. Emphasis is on ‘DO’ Take along the NHS improvement guide for PDSA
- It will be easy to see how this PDSA cycle works through an example. -This example is from the African country of Rwanda. Partners in Health is an international NGO that has partnered with the Rwandan government to provide quality health care to Rwandans. This particular project was from a district hospital with 50 beds in rural Rwanda -One of the recurrent problems at the hospital that doctors and other staff found was that that vital signs and medications given in the inpatient ward were not being done and recorded regularly (only 50% of the time). When doctors came on morning rounds, they found that some patients did not have any vital signs recorded over night. Some patients had not been given their medications. Labs ordered two days before had still not been recording in the patient’s chart. -So they established a QI project whose aim was to have vital signs recorded and medications given recorded in the inpatient wards 100% of the time for 5 days. The tracked their progress every day, drawing simple graphs. -They identified barriers to their goal—e.g. nurses were too busy in the mornings to finish recording vitals and meds given on everyone. So, they taught one of the nursing assistants/health aides to do vital signs so the nurse could focus on giving medications and recording this. -Team work was required to get around barriers. -Eventually, they stopped checking every day and went to monthly spot checks and found that vitals signs/meds given were still being recorded >90% of the time.
- Fig 1 Quality improvement protocol. Adapted from Langley et al15
- These are pictures of the staff at the hospital and of the simple graphs they made to track their progress.
- Fig 2 Percentage of vital signs monitored. Baseline median was calculated from 14 days of baseline data before interventions were implemented; new median was calculated for new system according to run chart rules (consistent improvement for eight straight data points)
- Fig 3 Percentage of drugs given as prescribed. Baseline median was calculated from 14 days of baseline data before interventions were implemented; new median was calculated for new system according to run chart rules (consistent improvement for eight straight data points)
- What would your aim statement be for a partograph project at Bayalpata?
- We’ve now finished talking about the 6 tools that are useful in resource poor settings for QI work. Let’s now step back and look at that case from the beginning. You identified many of the quality gaps in the case. Can you think of ways in which we can use the 6 tools we have just learned to bring about quality improvement at the hospital so that such deaths do not happen again.
- Going back to this initial case, what are some QI tools that you would use to improve care at this X hospital? How would you use them?