Quality Improvements HBB India Experience

1. Quality Improvements HBBIndia Experience Dr. Anju Puri HBB Review Meeting 17th July 2012

2. Burden • More than 2·3 million children die annually • 1.1 million occur in neonatal period • Million Death Study investigated • 10892 neonatal deaths • 12260 deaths in 1-59 months Ref: Report on causes of Death 2001-2003, RGI 2009 • 0-28 days – 3 causes (78%) • Prematurity & LBW 32% • N. Infections - 26.7% • B. asphyxia & trauma 18.8% • 1-59 months – 2 causes (50%) • Pneumonia 27.7% • Diarrheal diseases 22.3%

3. Our overall goal is MDG 4 • ENC/R Goal: Support the MOHFW, State health departments, USAID bilateral health programs and the new National Newborn Care and Resuscitation Initiative (NSSK) to strengthen and expand access to ENC and teach basic resuscitation technique.

4. Geographic presence to support and influence implementation Gonda Uttar Pradesh Deoghar Jamtara Giridih Simdega Jharkhand Chaibasa Immunization focus districts Integrated districts

5. Landscape of program inputs • Facility readiness assessment using 8 parameters was conducted in Oct 2010 using a structured questionnaire and 75 indicators generated. • KAP performance for maternal and newborn care especially neonatal resuscitation was mapped. • District mapping of the gaps generated and facility wise plan made for realistic program. Based on this implementation included provider mapping, • 3- Day skill based training in essential newborn care and resuscitation skills of all district level primary providers conducted (250) • Job-aides and skill lab of key providers (28) in the demo-facilities. • Supportive supervision involving quantitative and qualitative checklists was used to provide on-going hand holding. Involving district authorities at each step was critical to success of the program. • Strengthening of health information systems by improved reporting and feedback mechanism, • Follow up of facility births of birth asphyxia newborns conducted in the community.

6. Quality Improvement Quality Improvement (QI) approach is being used to analyse performance of the providers during training; and thereafter using systematic effort to improve the competence for the skill proficiency on neonatal resuscitation for improved outcomes.

8. Skill Acquisition - QI Quality Assurance Checklist Pre-Post Performance checklist Pre-post test scores are used to rate the training and provide feed-back to the providers. Measure changes in both the knowledge and skill acquisition by the health providers as a result of the training. • Been used to assess and adhere to a minimum standard for quality of process during the training. • 10 observation questions • Score less than 80, training is repeated.

10. Pre-post test scores - trainings

11. Skill Competency – QIPractice exercises at skill labs

12. Skill Competency – QIRead and do tools

13. Supportive supervision • A structured guide & training methodology for supportive supervision was prepared • An “yes and no “simple checklist” is being used for regular supervision & feedback. • Each skill is only scored, if all the steps is followed for the skill. • The checklist has two copies, one for the health provider being supervised and the other for the one who supervises the activity. By this mean we assured that the provider who was supervised knows the misses and can be motivated to improve his performance.

15. Skill Competency QI • Questionnaire and exercise methodology developed to focus on the “preparedness” of the health facilities to deliver newborn care services as per the national guidelines. • The results framework is quantifiable in operational terms rather than health systems framework. • The analysis tool works on 75 broad indicators to generate color- codes to map the status of 8 parameters – Infrastructure, Delivery and Newborn Care services, Human resource, Essential drugs, equipment and supply, Register and client case record, Protocols and guidelines, universal precautions & infection prevention and Provider’s knowledge & competency on core skills. • A computerized SQL based analysis system has been developed to generate score based color-codes. • Implementing a planning exercise based after this exercise is found very useful and allowed us to bench mark the health facilities over a period of time.

16. Score-card and improvement scores

17. Graph showing change in knowledge on diagnosis of birth asphyxia

18. Graph showing change in provider’s knowledge & practice in using chronology of steps during resuscitation process

19. Sustaining and scaling efforts

20. Monthly HMIS data

22. Consistency of reported Vs register data

23. Resuscitation Details

24. Resuscitation indicators

26. Lessons Learned • Newborn care programs have tended to be vertical, and slow to take up, have not considered or contributed to their quality. • It is feasible and beneficial to integrate ENC with Maternal Health programs and improve quality of care and have access to their concomitant resources. • The mother and baby dyad can be assessed and managed together. • The first week, especially the first three days, should be covered as a priority in the most feasible and effective manner at both facility and community levels with links between the two.