Improvement in Maternal and Newborn Health Services as a Result of a PMTCT Quality Improvement Program

by: Stacie Stender1; Ouattara Kiyali1; Yao Germain Kouadio2; Virginie Ettiegne-Traor2; Serge Klanindjoue Kanhon2; Heather Harrison1; Herv Prao3; Patricia E. Fassinou4; Anthony Richard Tanoh4 and Cyprien Nioble1 1 Jhpiego, 2 PNPEC, 3ACONDA-VS and 4EGPAF

Background
With funding from the Centers for Disease Control and Prevention through the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR), Jhpiego is supporting the Government of Cte dIvoire in sustainable approaches to reduce morbidity and mortality due to HIV/AIDS. This includes scale-up of high-quality, decentralized, comprehensive HIV prevention, care and treatment services:

Domains Assessed for Quality of Care in PMTCT in Cte dIvoire

Domain 1. Information, education and communication 2. Focused antenatal care (FANC) 3. Provision of HIV counseling and testing results 4. Conducting of rapid test for HIV 5. Care during labor and delivery (L&D) 6. Postnatal care (PNC) 7. Human and material resources 8. Management systems Total Number of Standards 5 11 9 8 23 21 21 15 113

Systems Challenges and Solutions

Challenges encountered:

n Delays due to strikes resulting in staff suspension and

interruption of work

n Lack of leadership and commitment n Low staff morale due to poor working conditions
Interventions to overcome challenges:

n Pilot began in 2006 n Expanded to 25 facilities in greater Abidjan in 2008 n Collaboration with the National Program for Medical
Management of People Living with HIV (PNPEC) and USG implementing partners the Elizabeth Glaser Pediatric AIDS Foundation and ACONDA-VS

n Open communication with managers and quality

improvement teams

n Encouragement of exchange of experiences between

sites

Example: FANC Standard #7 (of 11)

n Routine monitoring and capacity building n Additional funding obtained to complete cycle

Cte dIvoire Statistics

n Population: 19.7 million n Adult HIV prevalence: 3.9% n Total fertility rate: 4.4 births/woman n Contraceptive prevalence: 13% n Antenatal care coverage: 85%/45%
(one visit/four visits)

Domain 2: Focused Antenatal Care: Baseline assessment in one project site

Performance Standard The provider explains the results of the clinical exam and comprehensively cares for the woman Verification Criteria Observe during two sessions if the provider: Explains the previous clinical results and physical exam findings to the woman Advises the woman on tetanus and administers the vaccine if warranted Advises the woman on taking iron, folic acid and multivitamins and provides prescription Supports basic prevention and treatment of anemia as needed: advises the woman to take iron sulfate 300 mg and 0.25 mg folic acid daily for 90 days Prescribes appropriate deworming treatment (from 2nd trimester) Explains and prescribes intermittent preventive therapy for malaria according to the national guidelines Advises on use and prescribes insecticide-treated nets Y/N/ NA* Comments

Action Planning: An Essential Step of SBM-R

An Example from One Facility
Sample of Problems Identified Next Steps Defined by Evaluators 1. Establish a quality improvement team and encourage teamwork 2. Work in teams to resolve simple gaps 3. Conduct internal assessments and supervision to measure progress

____ ____ ____ ____ ____ ____ ____

n Skilled attendant at birth: 57% n Maternal mortality ratio 470/100,000 live births n Infant mortality rate: 86/1,000 live births
http://data.worldbank.org/country/cote-divoire http://www.usaid.gov/our_work/global_health/aids/Countries/africa/cotedivoire.html http://www.unicef.org/infobycountry/cotedivoire_statistics.html

Domain 5: Labor & Delivery 1. Clients are not greeted with respect 2. Clients are not well-informed regarding their health (offering HIV test, counseling after delivery) 3. Clients and providers are at risk of HIV exposure and other nosocomial infections 4. Physical exams of clients are not done according to standards (partogram) Domain 6: Postnatal Care 1. Care in the immediate postpartum period is not done according to standards 2. Clients are not completely informed 3. The newborn is not appropriately examined

*Y = yes, N = no, NA = not applicable

Sample Timeline of Activities Definition of SBM-R

Standards-Based Management and Recognition (SBM-R) is a quality improvement approach, using continuous feedback to expand knowledge, attitudes and skills, for improved performance. It employs Deming's cycle of plan-do-checkact, taking both the provider and the health system into consideration. July 2010 External evaluation verification Follow-up of poorly performing sites Workshop on sustaining the approach (Module 3) Internal evaluation May 2009
Minimum standards are disseminated throughout health system management. Facility managers and clinicians are Implement empowered to Standards assess 2 performance, analyze gaps and plan for improvement. Routine internal assessment is done by local staff and management. Periodic external assessments also are done.
3 Measure Progress

Improvement in MNH Services

Average Performance Improvement in MNH Services across 20 Sites over 12 Months
100%

80%

Percentage of Standards Achieved

60%

SBM-R Process
There is consensus among stakeholders on evidencebased performance standards that delineate Set what needs Standards to be done, 1 and how.

Implementation: address major gaps Process strengthening (Module 2) Implementation: address minor gaps Quality improvement teams identified Baseline assessments Workshop introducing process; settings standards (Module 1)

40%

July 2008

20%

0%

Process of Improving Performance

Principles:

Domain

Percentage of Standards Achieved

Upon meeting minimum standards 4 identified Recognize during the Achievements process of setting standards, facility achievements are formally recognized.

Baseline: Aug 2009

At one year: Sep 2010

n Define expectations n Improve supervision n Recognize improvement n Promote positive

competition

Average Performance Improvement in MNH Services across 5 Sites over 2 Years

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Antenatal Care Labor and Delivery Postnatal Care All 8 Domains

Fundamental Characteristics of SBM-R

n Is based on the use of operational standards and
objectives to enable providers to implement

Assess: visit facility, directly observe performance with checklist

n Emphasizes the desired level of performance and does

not focus on specific problems

Action planning and Analyze results: implement: to determine why to address standards are not gaps: training, being met and why: provider performance supervision, mentorship, (knowledge, skills, technical support, attitudes) and equipment, health systems supplies, drugs (management, equipment, supplies)

Improved performance

n Targets improving the daily process of service delivery

integrated in the functioning of the clinic

Results
Illustrative essential criteria of maternal and newborn care that were verified under standards in FANC, L&D and PNC domains:
L&D Assess for imminent signs of uterine rupture Syphilis screening Record fetal heart and maternal heart rate every hour Counseling on infant Wash hands with soap feeding choices and water before and irrespective of HIV after each vaginal exam status Physical examination Administer oxytocin imincluding vital signs mediately after delivery FANC Fetal presentation PNC Recognize signs of postnatal infection Discuss importance of family planning and birth spacing Assess vital signs of the mother every 15 minutes for the first hour Give appropriate vaccinations to the infant

Domain
Baseline: Aug 2008 At one year: Jul 2009 At two years: Jul 2010

n Promotes the development of networks for exchange of

best practices across and between sites

n Provides a source of motivation for managers and

clinicians

Conclusion
Overall conclusion: Implementing a Continuous Quality Improvement (CQI) approach (SBM-R) for PMTCT that addressed all essential health systems led to significant benefits across the spectrum of MNH including: enhanced provision of preventive services in FANC, improved infection prevention practices in labor and delivery, and increased administration of vaccines to newborns.

n Creates a platform for dynamic change n Promotes participation of clients and the community as
key contributors to the process

Methods
At defined periods in 2008 and 2010, a time series analysis of adherence to government-defined standards of performance in PMTCT was undertaken in 25 facilities. This analysis was done through facility assessment and observation of health care provider performance during clinical consultation of women in antenatal care, labor and delivery, and postpartum care:

n Best practices/Lessons learned:

n Need active involvement by clinicians and managers

n 5 facilities supported by ACONDA-VS were followed over

the course of 2 years

Baseline Assessment of Facility Performance: Examples of Insufficiencies in Health Systems

n Many providers did not meet the minimum standard
requirements for hand hygiene prior to doing a vaginal exam and/or assisting with delivery.

n 20 facilities supported by EGPAF were followed over the

course of 12 months

n Essential medicines and supplies were often not

available on day of evaluation: BCG vaccine, eye drops for the neonate, antibiotics to treat opportunistic infections, anticonvulsants, HIV rapid test kits are a few examples.

Specific Objectives of the SBM-R Program

1.
Strengthen capacity of sites to offer PMTCT services of consistent quality improvement

in CQI approach n Need concerted effort to develop and implement action plans to resolve persistent performance gaps n There were common barriers (e.g., lack of appropriate infrastructure, non-functioning referral systems, inadequate supply of essential medicines) to meeting the performance standards for MNH in many of the facilities n Ensure a forum for exchange of best practices between facilities

Recognition of Achievement of Quality

2. Establish a sustainable process of performance 3. Support the system of monitoring and supervision of
PMTCT services

Performance Improvement across 8 Domains in 25 Sites throughout SBM-R Process (Average )

100% Percentage of Total Standards Attained 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Baseline Follow-Up Follow-Up Final Verification

4. Improve performance of each sites attainment of

standards by at least 20% from baseline

84%

Although not delineated in the workplan, the health system focus of the SBM-R process considers HIV services (PMTCT) within the context of integrated maternal and neonatal health (MNH) services, and improvements in MNH care were thus documented.

62% 49% 24%

5 Sites Followed over 2 Years (ACONDA-VS) August 2008 July 2009 November 2009 July 2010 20 Sites Followed Over 12 Months (EGPAF) August 2009 February 2010 May 2010 September 2010

This poster has been supported by the Presidents Emergency Plan for AIDS Relief (PEPFAR) through the Department of Health and Human Services, Centers for Disease Control and Prevention, Division of Global HIV/AIDS under the terms of the Cooperative Agreement No. PS001463-04. Its contents are solely the responsibility of the organizing committee and do not necessarily represent the official views of CDC or PEPFAR.