MaNHEP – Testing changes at the community level
In previous blog posts I mentioned that when I began working on the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), I had to shift my thinking from facility-level improvement to the community level. To begin with, we set up community-level quality improvement teams and trained them. Then, it was time to get to the business of improving care.
Unlike the finite world of the facility, with limited staff members and limited scope of work, a community system may encompass thousands of people. At a facility level, the number of people who may perform a given step is limited. If the team involves a nurse representative, (s)he is able to inform all other nurses in her department of changes in a step or process. In a community care system, the person performing any given step in a process – such as identifying a pregnant woman and informing the community health worker (CHW)– may be any number of community members. The entire community may be involved in this process at some point.
The first complication was convincing teams to test changes on a small scale or testing one change at a time. For instance, when trying to develop a process for identifying pregnant women the religious leaders had one idea, the women’s groups another and kebele (community) leaders a third. All of these ideas would be valid for addressing a specific barrier and would reach different groups in the community. One change might address husbands’ reluctance to allow women to seek care, another may encourage the woman to reveal her pregnancy, and a third would address the concerns of an influential mother-in-law. Usually they did not want to wait to test their ideas.
We did our best to convince teams – and new district coaches – that limited tests were the best way to begin. We explained the need to test what worked and what didn’t, the benefit of differentiating between the influence of different tests, and the caution of not wasting many community members’ time by having them engage in untested and unproven activities. Our results were mixed. One MaNHEP staff member found teams had started five or six different changes to identify pregnant women simultaneously. He recommended a table which showed each change and the number of women identified through that change, which allowed them to see which changes resulted in the most identified women.
Some changes that teams tested were effective, but not efficient. For instance, having a CHW go house-to-house to uncover pregnancies was effective at finding all currently pregnant women. However, they cannot sustain this level of activity monthly, or even yearly.
In the end, the critical part is convincing the team to keep track of what changes they are testing and to analyze which change(s) lead to improvement. We tracked the changes tried, guided teams in ranking exercises and summarized across sites during coaching visits, learning sessions and at a workshop focused on harvesting and synthesizing information around all of the changes tested. We were able to compile the learning in a Change Package.
Should we push teams to strictly follow the PDSA model and small tests of change when working in the fluid environment of a community? These teams were: 1. making a change; 2. measuring and reviewing the effect of the change on a regular basis; and 3. making corrections when they weren’t achieving their goal. They probably were not strictly following a PDSA model or testing changes on a small scale. These teams were following the spirit of improvement, if not the law, and perhaps that’s enough. I am still not sure…
To learn more about the MaNHEP project, see this special issue of the Journal of Midwifery and Women’s Health.