Sparking a national movement to improve the quality of care in health care facilities
(Local quality improvement champions reflect on ways to continue supporting and spreading the use of improvement methods to strengthen health systems in India. Photo credit: Alison Lucas, ASSIST/URC.)
Yesterday, ASSIST held a meeting in Delhi “Looking to the Future: Lessons from the USAID ASSIST Project” to celebrate all we have achieved in India during the last four years. Below, Dr. Sonali Vaid reflects on our experience.
ASSIST’s work in India is coming to end in December 2017, so our main focus over the last year was to build the skills of interested stakeholders to support the spread of improvement methods in a sustainable way.
We did this by:
- supporting individuals to become leaders in using QI methods;
- building the capacity of institutions which are invested in using and promoting QI to do so; and
- providing guidance to state governments interested in building district or state-wide QI program capacity and systems.
India is a large and diverse country, and there is likely no one best way to spread the use of quality improvement (QI) methods to improve health care and outcomes. For this reason, we took a multipronged approach, working through different types of institutions. Our goal was to build the internal capacity of a given institution to use QI methods, and then support them to work through their existing networks to help others learn about QI. In each case, we waited for different institutions to approach us and request our support. In this way, we were able to identify institutions that were proactive about learning and spreading QI.
The results that we had helped other Indian institutions to achieve and our demystified approach to teaching and explaining QI were the main reasons why different groups asked for our support. Many groups we now support had heard about QI previously, but the jargon, complexity, and rigidity of many approaches discouraged them from trying to learn more. ASSIST’s simplified, common-sense approach was more appealing.
(A treasure trove of quality improvement case studies and other materials at the ASSIST marketplace stall, "Looking to the Future: Lessons from the USAID ASSIST Project" (November 8, 2017); New Delhi, India. Photo credit: Alison Lucas, ASSIST/URC.)
The different types of institutions that we focused on were academic institutions, state governments, and professional organizations. Each of these plays a different role in the health system and exerts different types of influence:
- Academic institutions or medical colleges are well-respected, clinical practice leaders in the country and train the next generation of clinicians. The fact that some of the most respected medical colleges in India are now champions for QI leads to more people and institutions wanting to learn about QI and also leaves behind a resource and the infrastructure for supporting new people to use QI methods. AIIMS and KSCH have both become leaders in spreading QI. They have both put in place formal mechanisms for supporting QI internally (AIIMS is hiring QI nurses in certain departments and has a core team that meets biweekly; KSCH has established a QI cell) and are being asked by state governments and other organizations to spread their QI knowledge. AIIMS is also receiving funding from both WHO and UNICEF to spread QI and is now increasingly working independently from ASSIST to spread QI.
- State governments are the responsible agent for health service delivery in India. The states of Himachal Pradesh, Meghalaya, and West Bengal have started spreading the use of QI. To date, Meghalaya and West Bengal (both of which were introduced to QI in the last year by ASSIST through KSCH and AIIMS, respectively) have focused on providing initial training to staff in facilities and are just starting to think about building more sustainable, institutional mechanisms to support QI. Himachal Pradesh, which learned about QI from work with ASSIST starting in 2013, has developed a more robust system. ASSIST helped them to develop a strategy for statewide scale-up that includes training programs for facility-based staff and coaches, changes in the human resources system to allow QI coaches from the block level to visit facilities every month to help facilities apply QI skills, funding for new staff positions at the state and district levels to support QI implementation, and new management structures at facility, block, district and state level. The program is also being supported by staff from Tanda Medical College in the State and from AIIMS to provide additional QI support.
- Professional organizations in India influence their members. In FY17, we worked extensively with IAP and NNF. Some of this work through the state chapters of these organizations is promising. These organizations have regular meetings and conferences for their members and are starting to include sessions on QI to help other members learn. Professional organizations also inform governments on clinical policies and guidelines, and we hope that, in the future, they will advocate for the government to focus more on QI.
Overall, we feel that ASSIST has played a major role over the past four years in initiating and catalyzing the use of QI methods in delivering better care in India. Factors which helped in this include:
- In phase one we demonstrated that quality improvement methods improve care and outcomes. During this time, we also developed the capacity of staff in India as improvers and coaches.
- The success of phase one allowed us to share our work in various forums, which attracted the attention of local leaders in the health care space – such as AIIMS and KSCH.
- We took care to simplify the approach and avoided using jargon as much as possible. Some people actually had heard about quality improvement before hearing about it from us, but they had not tried it since it appeared too complex to them.
- We encouraged adaptation of the methodology and how we taught it to beginners based on collaboration with local academic leaders. In the beginning, we taught QI as seven steps, but over time we modified it to a four-step explanation and used more practical, interactive training approaches.
- Since the four-step approach was done jointly with AIIMS and WHO-SEARO, these organizations have a sense of ownership over the work and have, of their own initiative, developed supporting videos and started spreading the approach to other countries in the region.
- We allowed learners to design their own projects instead of having pre-determined aims. Sometimes this was messy, but overall it may have given them confidence to guide others in developing their own projects.
- We provided intensive QI coaching for key institutions, such as AIIMS and KSCH, for their initial projects so that they could experience success early on and be more likely to champion the approach.
- Some leaders in the health care space became keen on spreading quality improvement among their networks (AIIMS, KSCH, Deogiri Children’s Hospital in Aurangabad). ASSIST staff helped as faculty for the initial training sessions, but ensured that by the second such workshops the staff from more experienced facilities could teach others QI and guide people on developing their own projects.
- Exposing QI learners to different ways of learning and sharing – such as webinars, etc. This has provided them with a variety of ways to continue the quality improvement work on their own.
- To spend our resources carefully, we have focused on working with institutions who are willing to fund activity costs. We only engage with new partners if they can bear at least some of the costs. In this way, we have been able to focus on working with partners who are sincerely interested in using QI approaches and who can sustain its use in our absence.
We believe that much of this work will be sustained. Over the last year, ASSIST activity costs were very low; most travel, accommodation, and meeting costs were borne by the institutions we were supporting. Through these domestic partners, ASSIST was able to support 159 facilities providing care to over 445,000 deliveries per year. (Most countries in the world have a lower total delivery load that that! This is also larger than the delivery load of facilities supported by the USAID ASSIST Project between 2013-2015 when our funding level was four times higher.) We expect that this trend will continue.
The main loss to the QI movement in India from the closing of ASSIST is the loss of our technical knowledge, but already the institutions we supported are filling some of that gap. AIIMS and KSCH, in particular, are now independently advising governments and other groups in India (and, in the case of AIIMS, other countries in the region) and are receiving financial support from those groups to do so. We believe that the QI movement will continue to grow and are proud of the work that we did to contribute to a vibrant community interested in improving care.