Quality Improvement Pelayanan Kesehatan Anak

Bobby M. Syahrizal

1
 Kematian neonatus dilaporkan: 24% (17.490)

U5MR
Papua: 80 per 1000 KH
Kepulauan Riau: 15 per 1000 KH

Source: IDHS, 1987 - 2017 Source: Indonesia Health Sector Review 2018

Pediatric care quality improvement – UNICEF for every child

Evidence: Prevalence and Mortality
Rates by Clinical Signs

3 Pediatric care quality improvement – UNICEF for every child

Interpretation of assessment findings

4 Pediatric care quality improvement – UNICEF for every child

 5 September 2018 Are more lives lost because of non-
utilization of services or because of poor
quality services?
• For 61 conditions, compared LMICs with HICs with strong health systems:

Deaths due to Deaths due to Percentage

non-utilization of poor-quality due to poor
health services services quality
World 3.5 million 5.0 million 58%
South Asia 1 million 1.9 million 64%
 Quality a bigger issue than non-utilization

5 – UNICEF for every child

 • High-quality health system could save over 8 million lives
each year in LMICs
• People often received inadequate care
• Poor-quality care is common across conditions & countries,
with the most vulnerable population faring the worst
6 – UNICEF for every child
 Readiness of public hospital to provide comprehensive
emergency obstetric and newborn care (CEmONC)
Provinsi Maluku Utara
Indikator Persentase
Nine criteria of EmONC
Public hospital with 24 h laboratory service
• Parenteral treatment of infection
RS memiliki dokter spesialis anak
(antibiotics) 52%
Public hospital with 24 h blood service
• Parenteral treatment of pre-
RS memiliki HCU neonatal Tidak ada
eclampsia/eclampsia
Public hospital ready for obstetric operation (anticonvulsant)
in < 30 min
RS memiliki NICU • Parenteral treatment
19%of
postpartum haemorrhage
Public hospital with anesthesiologist (uterotonics)
RS memiliki ventilator• (tidak
Manualjelas 43%
vacuum aspiration of
retained
apakah ventilator anak atau product of conception
dewasa)
Public hospital with pediatrician
• Vacuum-assisted delivery
RS memiliki CPAP 29%
• Manual removal of the placenta
Public hospital with obstetrician
Source: PHO Malut, 2019 • Newborn resuscitation
Public hospital that meet the 9 criteria • Surgical capabilitly
EmONC
• Blood transfussion
0 20 40 60 80 100

Source:
7 WHO, 2012 Sumber data: RS Online 2 Januari 2020 – UNICEF for every child
Quality of care in Indonesia
• Baharuddin, et al. 2019:
90% kematian ibu di 11
RS di 6 Provinsi
seharusnya dapat dicegah

Antenatal care

Normal care delivery

Postnatal care

8 Source: WHO Quality of Care Study

– 2012
UNICEF for every child
 Quality of obstetric complication management in Hospital

9 Source: WHO Quality of Care Study 2012 – UNICEF for every child
 Quality of care management in Hospital

• Prosedur dan peralatan resusitasi tidak memadai

• IMD dan ASI eksklusif tidak dilaksanakan
sepenuhnya
• Susu formula diberikan di semua rumah sakit
• PMK tidak diselenggarakan sepenuhnya
• HB0 dan vitamin K tidak diberikan secara rutin
• Tidak ada promosi menyusui
• Diagnosis dan tatalaksana sepsis neonatal tidak
tepat
• Pemberian makan bayi muda sakit dan LBW tidak
diisi lengkap di RM
• Antibiotik lini kedua dan ketiga sangat sering
digunakan
• Tidak ada evaluasi kadar bilirubin – diagnosis icterus
hanya berdasarkan gambaran klinis

Sumber: Sidik NA, et al. 2013. Assessment of the quality of hospital care for children in Indonesia
11 – UNICEF for every child
The only way to get different results is to
change the system.

To make sure every mother, newborn and

underfive receives exactly the right care, 100
percent of the time

– UNICEF for every child

What is “Quality” and “Quality
Improvement”?
Mutu Pelayanan: The extent to which health services
provided to individuals and populations improve desired
health outcomes

Quality improvement: Combined and unceasing efforts of everyone

(health care professionals, patients and their families, researchers, payers,
planners and educators) to make the changes that will lead to better
patient outcomes (health), better system performance (care) and better
professional development (learning)
Paul B Batalden, Frank Davidoff, 2007

QI akan memberikan hasil maksimal apabila dilaksanakan bersamaan

dengan upaya penjaminan mutu dan pemantauan mutu pelayanan

– UNICEF for every child

 science
Dimensi Mutu
Pelayanan

No alienation

No waste No Delay

16 Not harming – UNICEF for every child

 Commission’s view…

“Health systems are complex adaptive systems that function at multiple

interconnected levels……
Fixes at the micro-level (ie, health-care provider or clinic) alone are unlikely to
alter the underlying performance of the whole system………
Achieving high-quality health systems requires expanding the space for
improvement to structural reforms that act on the foundations of the system.”

Quality improvement requires concurrent actions at different levels

MACRO MESO MICRO

17 Quality of – UNICEF for every child

 Simply ensuring coexistence of infrastructure, medical
supplies, health care providers and guidelines does not lead
to optimal health care – Add Improvement culture

Quality is always the result of intelligent efforts!

18 – UNICEF for every child
Recommendations
Four universal actions for quality

1. Govern for quality: Government should lead the way with strong national health care
quality policies and strategies  shared vision, manage, regulate, strengthen
accountability, and learn
2. Redesign service delivery: Health systems should focus on competent care and user
experience to ensure confidence in the system  Reorganize services to maximize
health outcomes
3. Transform health workforce: Health care workers should see patients as partners and
commit themselves to providing and using data to demonstrate the effectiveness and
safety of health care
4. Ignite demand for quality: Citizens should be empowered and informed to actively
engage in health care decisions and in designing new models of care to meet the
needs of their local communities  Share information on quality, develop active
patients
19 Pediatric care quality improvement – UNICEF for every child
 Committee on improving the
quality of health care globally

‘the committee vehemently rejects the idea that the

workforce is generally at fault, neglectful or uncaring.’

‘…many of these workers are ill served by being

embedded in and dependent on systems of care that
impede excellence rather than supporting it…’
20 Pediatric care quality improvement – UNICEF for every child
People involved in complex work do
better when they have:
• Purpose
• They feel that their work was useful at the end of the day
• Mastery
• They feel they are constantly getting better at their work
• Autonomy
• They have control over how they do their work
Source: Deci and Ryan, 1985; Pink, 2009

21 Pediatric care quality improvement – UNICEF for every child

How can we build health systems that
support health workers to deliver better
care?
• Resource issues
• Clinical knowledge and skill issues
• Organization, team work and process issues
• To make things easier for providers
• To make things easier for patients

22 – UNICEF for every child

 Interventions to improve quality of care
• Changing clinical practice at the front line
MICRO

• Use of continuous quality improvement methods

• Engaging and empowering patients, families and
communities
MESO

• Education for health care workers, managers and

policy-makers
• Setting standards
MACRO

• Establishing performance-based incentives (financial

and non-financial)
• Leadership, legislation and regulation
23 – UNICEF for every child
Pediatric quality of
care framework

24 Source: WHO, 2018 – UNICEF for every child

 Systematic implementation guidance

Preparing for implementation

Establish national policy, strategy and structures
Effective intervention strategies toBuild
improve QoC
a broad coalition of stakeholders
Landscape analysis and review of QOC data
Develop an operational plan and assign responsibility
National standards of care Adapt and adopt quality of care standards
Agree indicators and monitoring framework
Point of Care
Indicators and monitoring framework
Build capability for quality improvement interventions
Quality
Improvemen
Introduce QoC
implementation package t (POCQI)
Refine and adapt
Implement interventions
interventions
Implementation

Monitor progress and learn

Monitoring progress

Build national learning system

Engage communities and create demand for quality
 Quality improvement requires concurrent actions at different levels
MACRO MESO MICRO

What can we do to improve quality of

care at micro unit in health facility?

26 – UNICEF for every child

Bagaimana melaksanakan QI?
Berbagai model QI: Common elements:
• Client-oriented, provider efficient services • Standards oriented
(COPE) • Organizational drivers – person, team, org
• The fully functional service delivery point
(FFSDP) • Situational analysis – identification of
problem
• HIVQUAL framework
• Specific aims
• Improvement collaborative • Identification and selection of intervention
• Improving newborn health (BASICS)
• Implementation of intervention
• Partership defined quality (PDQ)
• Monitoring and documentation of results
• Private sector quality improvement • Community involvement
package
• Quality/process improvement (Quality • Incentives and motivation
Design/Redesign) • Scale-up plan
• Standards-based management and • Sustainability plan
recognition (SBM-R)
• Point of care quality improvement (POCQI)
27 – UNICEF for every child
 Use of continuous quality improvement methods:
Point of Care Quality Improvement (POCQI)
• It’s a cyclical processes to:
1. Identify a performance using local data
4 1
(Quality gap - Problem)
2. Analyze the problem: Understand the Identify
causes - Root cause analysis Sustain
quality gap -
improvement
3. Develop and test a change: Identify problem
Solutions (Change idea)
• Plan and implement the solution
• Assess the effect of the change idea
• Failure Apply alternate change idea Develop and Analyze the
- Assess the effect Plan test a change problem
• Success Continue the changed way
4. Sustain improvement Act Do
Quality Improvement at health facilities led by
healthcare teams mostly without additional
resources
Study
3 2
28 Pediatric care quality improvement – UNICEF for every child
Penerapan POCQI di berbagai negara -
Maternal
• Meningkatkan penggunaan partograph saat persalinan di kamar bersalin
• Meningkatkan kepatuhan pelaksanaan manajemen aktif kala III di kamar bersalin
• Meningkatkan kelengkapan pencatatan riwayat kehamilan selama pelayanan ANC di poliklinik
• Meningkatkan jumlah ibu yang diperiksa tekanan darah disetiap kunjungan antenatal di poliklinik
• Meningkatkan jumlah ibu yang menjalani pemeriksaan Hb saat kunjungan ANC di poliklinik
• Meningkatkan jumlah ibu yang mendapatkan konseling gizi, persiapan persalinan, KB dan ASI
ekslusif selama kunjungan ANC di poliklinik
• Meningkatkan jumlah ibu yang mendapat paket pelayanan standar saat kunjungan ANC di poliklinik
• Meningkatkan jumlah ibu yang mendapat injeksi oksitosin intramuscular dalam 1 menit setelah
persalinan
• Meningkatkan jumlah ibu yang dipantau tanda-tanda vitalnya (TD dan nadi) selama perawatan
paska salin di RS

29 Pediatric care quality improvement – UNICEF for every child

Penerapan POCQI di berbagai negara -
Neonatal
• Meningkatkan pemberian ASI di NICU
• Meningkatkan pelaksanaan IMD di kamar bersalin – skin-to-skin contact
• Menurunkan jumlah BBLR premature dengan hipotermia saat masuk ke RS
• Meningkatkan pelaksanaan PMK di NICU untuk bayi BBLR
• Meningkatkan durasi penggunaan radiant warmer temperature probe di NICU
• Menurunkan paparan radiasi pada neonatus dan biaya pelayanan di NICU
• Meningkatkan penerapan prosedur aseptic saat memberikan terapi intravena di NICU
• Meningkatkan pelaksanaan pemantauan suhu tubuh neonatus di NICU
• Meningkatkan penerapan paket pelayanan neonatal esensial di kamar bersalin
• Meningkatkan jumlah neonatus yang mendapatkan injeksi vitamin K segera setelah lahir
• Meningkatkan jumlah neonatus yang dikeringkan segera setelah lahir untuk mencegah hipotermia
• Meningkatkan jumlah neonatus mendapat tindakan resustasi tepat waktu
• Meningkatkan jumlah neonatus mendapatkan tindakan DCC steril saat melahirkan di kamar bersalin

30 Pediatric care quality improvement – UNICEF for every child

Quality Improvement Approaches Associated with Quality of
Childbirth Care Practices in Six Indian States –Enisha Sarin and
Nigel Livesley Results & Relevance
Study Design Compliance significantly higher in facilities where
• Compare the impact of QI staff were using QI approaches;
approaches with other health - dry & wrap infants (OR 2.6, 95% CI: 2.1, 6.6),
system factors (level of health - early breastfeeding (OR 3.6, 95% CI: 2.1, 6.2);
facility, cadre of staff conducting - post-partum vitals (OR 2.7, 95% CI: 1.7, 4.2).
the delivery, years of experience Other health system factors had mixed effects.
of staff conducting the delivery,
“improved care only seen for elements that the
and time of day)
team was specifically trying to improve”
• 12 public health facilities
Relevance: Most programs focus on setting up QI
participating in the QI program
teams and monitoring, but do not describe the need
in 6 states of India, Nov 2014.
for facility staff to focus on improving specific
• Total 461 deliveries observed elements of care
31 Pediatric care quality improvement – UNICEF for every child
List of Examples
1. To decrease use of antibiotics in newborn babies admitted in SNCU
DHAR from current baseline 45% to 25% in 6 weeks
2. To decrease the proportion of inborn babies presenting with
hypothermia at admission to SNCU from 76% to 20% in 4 weeks
3. To improve response time or emergency newborn care 79 minutes
to 30 minutes in 3 months

32 – UNICEF for every child

 .8
Antibiotic

.6
use

.4
.2

Baseline PDSA 1 PDSA 2

1
0

26nov2017 10dec2017 24dec2017 08jan2018 22jan2018

Date of admisson
 • 96 eligible inborn neonates [birth weight: 2368+622 g; 42 (43.8%) LBW

2 • PDSA 1: Improved process of drying-wrapping and measuring baby temperature before transfer
• PDSA 2: Provision of a “pink-card” to the family for rapid identification of baby at SNCU entry point.
• Hypothermia decreased progressively from 76% (19/25) in first week to 29% (9/31) in second, 19% (4/21)
in third and 10.5% (2/19) in the fourth week).

38
Reducing Hypothermia
37,5
using PDSA Pink Card made
Sensitization
Temperature in degree Celsius

37

36,5 Goal
Median

36

35,5

35

34,5

34

33,5

33

32,5
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3
 MENINGKATKAN PEMBERIAN AIR SUSU IBU SAAT PERAWATAN
DI RUMAH SAKIT UMUM DAERAH LANGSA DENGAN PENDEKATAN
POINT OF CARE QUALITY IMPROVEMENT (POCQI)
Cut Maneh1, Suwarni Abubakar1, Sulasmi Yeddi1, Dahlia Artati1, Emiralda1, Amrawati 2, Indriany E Putri3, Mira Fajarina4, Tira Aswitama5
1 Dinas Kesehatan Aceh, 2 Dinas Kesehatan Kota Langsa, 3 Rumah Sakit Umum Daerah Langsa, 4 Yayasan Darah Untuk Aceh, 5 UNICEF Aceh
Email presenter: aceh.promkes.aceh@yahoo.com

Masalah Hasil
Inisiasi Menyusu Dini (IMD) dan  IMD di ruang bersalin meningkat dari 53% menjadi
pemberian ASI saat di ruang perawatan 80%
di RSUD Langsa cakupannya masih  Pemberian ASI di ruang kebidanan meningkat dari
rendah. 35% menjadi 90%
 Di ruang NICU dari 58% menjadi 60%
Tujuan
Meningkatkan cakupan pemberian ASI
saat perawatan di RSUD Langsa dari
Inisiasi Menyusu Dini sampai pemberian
ASI di ruang perawatan hingga mencapai
80% dalam kurun waktu 6 bulan dari
April-October 2019
37 – UNICEF for every child
 IMD DAN PEMBERIAN ASI DI RSUD LANGSA
MARET-OKTOBER 2019
100
90
80
70
60
50
40
30
20
10
0
Maret April Mei Juni Juli Agustus September Oktober
Inisiasi: Langkah Langkah 3 POCQI, Perencanaan, Langkah 4
1 & 2 POCQI
IMD Kamar Bersalin
Komitmen
ASI Ruang Kebidanan ASI Ruang NICU

Mentoring, inhouse training, Penyeliaan Fasilitatif, SK Direktur Seminar ASI Review

Peningkatan edukasi dan pendampingan bagi pasien & tentang ASI Lintas Sektor Capaian
keluarga, monitoring
– UNICEF for every child
RS Palembang Bari
• Ketepatan waktu pengiram berkas rekam medik pasien ke poliklinik
kebidanan untuk menurunkan waktu tunggu rawat jalan menjadi
kurang dari 60 menit
• Peningkatan cakupan praktik IMD
• Peningkatan ketepatan waktu penyediaan darah untuk pasien
melahirkan pervaginam dan SC

39 – UNICEF for every child

Other QI projects
Aim
Reduce use of oxygen
Reduced consumption of O2
Initiation of feeds < 24 h in
sick newborns
First hour initiation of
breastfeeding in cesareans
Use of EBM for neonates
admitted in SNCU
Increase KMC initiation and
duration
Change idea
Triage /SpO2 at admission
Use of nasal prongs instead of oxygen
Feeding SOP
Use of alternative milk source
Family counseling
Reassignment of responsibility of healthcare
provider
Family counseling and involvement
Manual expression
Counseling in delivery room/postnatal ward
SOP
 100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Baselline End of QI project
SNCU Dhar - Reducing
76,50% 10,50%
hypothermia
SNCU Sehore - Increasing
40% 100%
feed initiation
SNCU Vidisha - Reducing use
67% 39%
of oxygen
SNCU Ujjain - Reducing use
50% 19,70%
of antibiotics
SNCU Chhindwara - Reducing
43% 20,90%
use of antibiotics
SNCU Bhopal - Reducing use
47% 19%
of antibiotics
Positive Changes in Labour Rooms-Before and After Transformation Initiative
(% of delivery points showing good organization and practices in LR) N=73
“After” indicates the status seen in the most recent follow-up visit
What can we do to improve quality of
care at district level?

43 – UNICEF for every child

 Elements at district level to support improvement
• What you want to improve
QUALITY
• Where you want to improve
IMPROVEMENT PLAN
• What methods should be used to improve
FACILITY QI TEAMS
ONGOING QI
COACHING
PEER-TO-PEER
SHARING AND
LEARNING
QI PROGRAM
MANAGEMENT
SYSTEM ALIGNED TO
SUPPORT THE QI
PROGRAM
LEADERSHIP SUPPORT
 Elements at district level to support improvement
• What you want to improve
QUALITY
• Where you want to improve
IMPROVEMENT PLAN • What methods should be used to improve

• Ensure existing and functioning of QI team at health facility

• Facilitate capacity development of health facility in quality improvement
FACILITY QI TEAMS
• Facilitate establishement of supporting environment at health facility for QI
implementation
ONGOING QI
COACHING
PEER-TO-PEER
SHARING AND
LEARNING
QI PROGRAM
MANAGEMENT
SYSTEM ALIGNED TO
SUPPORT THE QI
PROGRAM
LEADERSHIP SUPPORT
 Elements at district level to support improvement
QUALITY • What you want to improve
• Where you want to improve
IMPROVEMENT PLAN • What methods should be used to improve
• Pick specific aims
• Identify barriers to good care
FACILITY QI TEAMS • Develop change ideas (fix resource, clinical skill or organizational issues)
• Test and adapt change ideas

Coaches with:
• Experience in using QI methods
ONGOING QI • Time, permission and resources to visit facilities monthly
COACHING A coaching management system to:
• Assign coaches to facilities
• Ensure coaching is happening and learn if care is improving
PEER-TO-PEER
SHARING AND
LEARNING
QI PROGRAM
MANAGEMENT
SYSTEMS ALIGNED TO
SUPPORT THE
PROGRAM
 Elements at district level to support improvement
QUALITY • What you want to improve
• Where you want to improve
IMPROVEMENT PLAN • What methods should be used to improve
• Pick specific aims
• Identify barriers to good care
FACILITY QI TEAMS • Develop change ideas (fix resource, clinical skill or organizational issues)
• Test and adapt change ideas
Coaches with:
• Experience in using QI methods
ONGOING QI • Time, permission and resources to visit facilities monthly
A coaching management system to:
COACHING • Assign coaches to facilities
• Ensure coaching is happening and learn if care is improving
PEER-TO-PEER
Opportunities for staff from different units or health facilities to learn from and
SHARING AND
motivate each other
LEARNING
QI PROGRAM
MANAGEMENT
SYSTEM ALIGNED TO
SUPPORT THE QI
PROGRAM
LEADERSHIP SUPPORT
 Elements at district level to support improvement
QUALITY • What you want to improve
• Where you want to improve
IMPROVEMENT PLAN • What methods should be used to improve
• Pick specific aims
• Identify barriers to good care
FACILITY QI TEAMS • Develop change ideas (fix resource, clinical skill or organizational issues)
• Test and adapt change ideas
Coaches with:
• Experience in using QI methods
ONGOING QI • Time, permission and resources to visit facilities monthly
A coaching management system to:
COACHING • Assign coaches to facilities
• Ensure coaching is happening and learn if care is improving
PEER-TO-PEER
SHARING AND Opportunities for staff from different facilities to learn from and motivate each other

LEARNING
Management structures have specific roles in managing QI program activities (e.g.
QI PROGRAM
training and forming teams, coaching, peer to peer learning, fixing problems not
MANAGEMENT
fixable at facility level)
SYSTEM ALIGNED TO
SUPPORT THE QI
PROGRAM
LEADERSHIP SUPPORT
 Elements at district level to support improvement
QUALITY • What you want to improve
• Where you want to improve
IMPROVEMENT PLAN • What methods should be used to improve
• Pick specific aims
• Identify barriers to good care
FACILITY QI TEAMS • Develop change ideas (fix resource, clinical skill or organizational issues)
• Test and adapt change ideas
Coaches with:
• Experience in using QI methods
ONGOING QI • Time, permission and resources to visit facilities monthly
A coaching management system to:
COACHING • Assign coaches to facilities
• Ensure coaching is happening and learn if care is improving
PEER-TO-PEER
SHARING AND Opportunities for staff from different facilities to learn from and motivate each other

LEARNING
QI PROGRAM Management structures have specific roles in managing QI program activities (e.g. training and forming teams, coaching, peer to peer
learning, fixing problems not fixable at facility level)
MANAGEMENT
e.g.
SYSTEM ALIGNED TO
1) financial systems (e.g. to support coaching visits)
SUPPORT THE QI
2) human resources (e.g. to encourage staff to improve care)
PROGRAM
3) data systems (e.g. to ensure that management fixes problems)
LEADERSHIP SUPPORT
 Elements at district level to support improvement
QUALITY • What you want to improve
• Where you want to improve
IMPROVEMENT PLAN • What methods should be used to improve
• Pick specific aims
• Identify barriers to good care
FACILITY QI TEAMS • Develop change ideas (fix resource, clinical skill or organizational issues)
• Test and adapt change ideas
Coaches with:
• Experience in using QI methods
ONGOING QI • Time, permission and resources to visit facilities monthly
A coaching management system to:
COACHING • Assign coaches to facilities
• Ensure coaching is happening and learn if care is improving
PEER-TO-PEER
SHARING AND Opportunities for staff from different facilities to learn from and motivate each other

LEARNING
QI PROGRAM Management structures have specific roles in managing QI program activities (e.g. training and forming teams, coaching, peer to peer
learning, fixing problems not fixable at facility level)
MANAGEMENT
SYSTEM ALIGNED TO e.g.
1) financial systems (e.g. to support coaching visits)
SUPPORT THE QI 2) human resources (e.g. to encourage staff to improve care)
PROGRAM 3) data systems (e.g. to ensure that management fixes problems)

• Enable all of the above

LEADERSHIP SUPPORT
• Build a culture of trust and improvement
Thank You
How will you make
changes that improve

© UNICEF/UN035993/Page
quality in your workplace,
health facility?
Pediatric care quality improvement – UNICEF for every child