What we learned while improving care for 180,000 babies annually in India
In India, the USAID ASSIST Project worked with over 400 facilities – delivering approximately 180,000 babies per year – to use quality improvement (QI) approaches to provide better care to women and babies before, during, and immediately after delivery. Here are some of the lessons we learned.
Over the past decade, India has greatly increased the percentage of women delivering in health care facilities—but this has not resulted in a commensurate reduction in maternal or neonatal mortality. This suggests that there is considerable room to improve the quality of care at the facility level. To address this, the USAID ASSIST Project was asked to support hospitals in 27 districts in six states in the country to improve care for mothers and newborns. These districts were among the lowest performing in each of their respective states and therefore, it was assumed, they presented the greatest opportunity for impact.
This was a large program. The facilities we supported delivered approximately 180,000 births per year – a larger delivery load than most countries. We worked in over 400 facilities in districts that were sometimes more than a day’s travel from our main office in New Delhi.
We supported staff in these facilities to form quality improvement (QI) teams, pick specific elements of routine care to improve, use simple analytical tools to understand what was leading to poor quality—and to then use this analysis to develop and test different solutions until they were able to make sure that these elements of care were being provided to everyone.
A study of this intervention, recently published in BMC Pregnancy and Childbirth, analyzed its impact on elements of routine delivery and newborn care and found that care improved for eight of the nine most common processes of care. Perinatal mortality declined from 26.7 to 22.9 deaths/1000 live births (p < 0.01) over this same period.
In addition to the great results, we learned a number of useful lessons during this work that could be applied by others implementing similarly large projects. Here are our top five:
1. Keep it simple
We started this work hiring 27 local public health practitioners to support the facilities (one staff person per district) and one person per state supporting the district staff. These individuals had very limited prior knowledge or experience in using quality improvement (QI) approaches. We provided them with short training on the fundamental elements of QI and then asked them to help facilities work on routine elements of care (those diagnostic or preventative interventions that everyone requires). Starting with simpler work allowed our staff and the teams they supported to learn QI skills and get results quickly; building motivation for more complex aims.
2. Delegate and trust
The districts ASSIST supported have a combined population of 32 million people and differ considerably from each other. There was no way that a highly regimented, centralized approach would work. Instead, we encouraged district level staff to adapt as necessary. They planned their work schedule, provided differing levels of support to different facilities as needed and helped the facilities to progress at whatever speed made the most sense.
3. Focus on results
Instead of managing the project by focusing on what activities staff were doing, we managed based on what results staff were achieving. ASSIST staff compiled data from the facilities they were supporting and sent this to the state leads each month. Each state would hold monthly meetings to discuss what was going well and what was still challenging, and adapt their approach based on this.
4. Look for successes early
QI was a new approach for our staff and in the facilities we were supporting. When people do new things, it is important that they quickly see value in them. During the first few months of our work, we focused on what was going well. We wanted to bring out the stories about successful QI projects. These stories provided learning that other teams could use for fixing similar problems, but they were also very motivating for the teams who developed these stories and for staff in similar situations to see that some of the problems they faced were solvable.
5. Focus on learning
The main goal of our work was to save lives. The secondary goal was to learn. Since this was the first time that this specific team had worked on an activity at this scale in India before, we were all learning as we went. We developed case studies as a way of learning. We also held multiple meetings to spread learning between QI teams at different facilities and among our own staff. Districts held meeting for all the involved facilities. Staff from facilities would share their work in presentation, poster or small group sessions with other facilities. Everyone would have a chance to contribute and learn.
In addition, our project staff met monthly at the state level and bimonthly as a national team to share and learn from each other. In these meetings, staff would share their progress and discuss common challenges and how different people had tried to address them. The learning meetings were designed to allow people doing similar work to learn from each other and to build motivation in both facility-level health workers and our staff by demonstrating real world success.