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Implementing and Leading Health Care Improvement: What We’ve Learned

Yesterday, we had the chance to engage in two great online conversations about quality of care and what it takes to lead it. During a Twitter chat hosted by the Maternal and Child Survival Program, we explored what #QualityCareforAll means in the context of maternal and newborn health, and what it takes to drive improvement in low-resource settings.

High-quality health systems in the Sustainable Development Goals Era

Health care in middle and low income countries has greatly improved in the past several decades, but changing health needs, growing public expectations and new health goals are rasing the bar for health systems to produce better health outcomes.

This Lancet Global Health Commision on HIgh Quality Health System in the SDG era examined literature, analysed surveys, and did qualitative and quantitative research to evaluate the quality of care available to people in LMICs across a range of health needs included in the Sustainable Development Goals (SDGs).

Download the full commission:

 

Indian Pediatrics Special Issue: Better Healthcare Through Quality Improvement

This special issue of Indian Pediatrics (September 2018; Volume 55: Number 9) highlights mechanisms that can support health care providers in using various quality improvement (QI) approaches and showcases some of the improvement projects undertaken in India by different teams.

The USAID ASSIST Project started working in India in September 2013; initially working directly with districts and facilities to help them learn how to use QI approaches to save lives.  This work went well and the staff in these facilities were able to reduce perinatal mortality by 15% over 18 months. During this time, we met great partners from important organizations and institutions across India.

These institutions are now leading a growing movement to help more people apply QI methods to deliver care that prevents harm, improves outcomes, and meets the needs of the people receiving it through their own networks using domestic funding; continuing these lifesaving efforts after ASSIST technical support has ended.

The supplement shows important results of the ongoing QI work in these networks and shows how domestic QI networks, earlier supported by ASSIST, are now independently supporting and spreading the use of QI methods to provide better care.

ACCESS THE ISSUE HERE


This special supplement was edited by Ashok Deorari, WHO Collaborating Centre for Education & Research in Newborn Care, Department of Pediatrics, AIIMS, New Delhi, India, and Nigel Livesley, USAID Applying Science to Strengthen and Improve Health Systems (ASSIST) project, University Research Co., LLC (URC).

Improving Access to HIV Testing and Treatment Services for Vulnerable Children and their Caregivers in Uganda

In October 2015, following the PEPFAR guidance to improve integration of HIV and OVC care programs for improved outcomes for children and their caregivers, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) project set out to support OVC implementing partners (IPs) to strengthen community-facility linkages. To commence this work, ASSIST worked with 10 CSOs that were selected by the IPs in 38 villages in 6 districts.

ASSIST supported the setup of QI teams at the parish and CSO levels. ASSIST also built the capacity of these CSOs to conduct quality supervision. ASSIST used a collaborative approach where we set QI teams at the different levels: CSO and community given that they were both working on different processes of the community-facility linkages. The work started with the CSOs focusing on increasing the proportion of supported beneficiaries (vulnerable children and caregivers) with a known HIV status, then they began identifying HIV positive children in the supported communities who had not yet been reached by their programs. Subsequently, their efforts targeted closing gaps in the processes along the HIV care and treatment cascade ensuring identification, linkage, retention, and viral suppression. To increase HIV testing among OVC program beneficiaries, teams conducted targeted home visits to provide counseling on benefits of HIV testing and conducted targeted community HCT outreaches for the beneficiaries. The find new HIV positives, teams used case finding criteria to identify new HIV positive suspects by community resource persons and provided referrals for HIV testing to the nearest health facility, outreach post and home-based HCT was conducted.

Following implementation of the changes, the percentage of vulnerable children (0-14 years) with a known HIV status increased from 37% in October 2016 to 78% in July 2017 at 10 CSOs. And OVC 15+years with caregivers improved from 35% to 81%. Changes tested include: targeted home visits to provide counseling on benefits of HIV testing and targeted community HCT outreaches. Similarly, the percentage of persons eligible for HIV testing who tested HIV positive reached an average of 54% for children (0-14), adolescent 15+ years, and caregivers by July 2017. Those eligible were identified through use of a screening tool (Appendix I) with children 0-14 as an entry point to the household. On identification of eligible persons for HIV testing, 5community resource persons made referrals to the nearest health facility, outreach testing points, and, in some cases, home-based HCT. Referrals were done with the MGLSD referral form (Appendix II).

This change package illustrates how to improve processes of care for HIV-positive children (including identification, linkage to care, and viral suppression) in the community. It serves as a learning tool for organisations, CSOs, or local government Community Development Officers and any other entities working in the community that can adapt or adopt these suggested solutions to their own settings. The change package includes a “how to” section with detailed explanation of the implementation of the change ideas. Teams may select what they deem as relevant changes, adapt or adjust them as necessary, then test them on a small scale and use data to determine whether implementing those ideas has led to improvement or not. The team should continue testing or adding ideas until the desired level of performance is reached. It is important to note that the improvement teams need to understand the root cause of the challenge they are trying to address to be able to identify an effective change that will close the gaps.

The USAID ASSIST Project’s approach to improving health care in low- and middle-income countries

 

The objective of the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project is to improve the quality and outcomes of health care and other services by enabling host country providers and managers to apply the science of improvement. The project seeks to build the capacity of host country service delivery organizations in USAID assisted countries to improve the effectiveness, efficiency, client centeredness, safety, accessibility, and equity of the health and family services they provide. ASSIST also seeks to institutionalize the capacity to improve through competency development at the pre and in service levels as well as engaging with host country governments at the policy level.The approach used by ASSIST has been applied to a variety of technical areas in over 30 countries.

The project uses Integrated Design as the template for improving health care outcomes, producing sustainable results, taking these results to scale, institutionalizing improvement, and generating learning for local and global purposes. This paper outlines the approach of the USAID ASSIST Project in conducting its work based on quality improvement principles and methods. It also highlights the USAID ASSIST Integrated Design Plan, outlining how each of the elements of the plan are implemented in the work of the project.

 

Read the full report to learn more:

Improving Female Involvement in Voluntary Medical Male Circumcision in Uganda

The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project in Uganda has been working collaboratively with 10 implementing partners (IPs) to carry out voluntary medical male circumcision (VMMC) for HIV prevention programs since 2013. ASSIST’s objective was to build capacity of IP, district and health facility staff to improve the quality and safety of voluntary medical male circumcision services in Uganda. Initially, 30 health facilities were involved and progressively the activity was scaled up to additional health facilities. There were 19 health facilities in the first wave and 33 in the second.

VMMC faces some challenges such as demand creation for services, adherence to six weeks abstinence after circumcision, return for post-operative review, and use of other HIV prevention methods after VMMC. Literature has shown that female involvement in VMMC can play a large role in addressing these challenges so QI teams set about to increase female partner involvement in VMMC.

The tested changes section of this change package provide guidance to health facility teams on improving female involvement in VMMC, the authors recommend that to improve female involvement in VMMC, health unit teams should implement changes under the following four aims below, which were determined based on the gaps found to affect female involvement in VMMC at the health facilities:

  • Improving the competence of health providers to provide adequate and consistent information/messages on involving women in VMMC
  • Promoting the provision of female friendly services during VMMC services
  • Focus on community sensitization and mobilization on involving women in VMMC
  • Improving data capture of female participation in VMMC

Improving Management of Adverse Events Following Voluntary Medical Male Circumcision in Uganda

The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project in Uganda has been working collaboratively with 10 implementing partners (IPs) to carry out voluntary medical male circumcision (VMMC) for HIV prevention programs since 2013. ASSIST’s objective was to build capacity of IP, district and health facility staff to improve the quality and safety of voluntary medical male circumcision services in Uganda. One of the priorities was to improve the management of adverse events following circumcision. Initially, 30 health facilities were involved and progressively the activity was scaled up to additional health facilities. There were 19 health facilities in the first wave and 33 in the second.

This change package focuses on actionable recommendations to reduce adverse events following VMMC based on the experiences of providers from the initial 30 facilities and all other waves. The change package describes the changes tested and implemented by the VMMC improvement teams to achieve the aims. It details the change ideas, the logic for their implementation and the steps taken to carry them out. The changes address the following aims:
•    Build skills of health providers in prevention, identification and treatment of adverse events
•    Improve the use of tools to capture and monitor adverse events following VMMC
•    Improve follow up of clients after VMMC
•    Improve referral of moderate and severe adverse events (as appropriate) following VMMC
•    Improve wound care practices among circumcised clients and ability to recognize danger signs early.

 

Survive & Thrive Final Report

Demonstrated that training is not enough and that quality improvement approaches are essential to sustain quality care for mothers and newborns in low-resource settings, the Survive & Thrive Final Report highlights the efforts that partners shared through developing tools and resources.

A breakthrough contribution of the Global Development Alliances (GDA) was its development of a practical approach to engage frontline health workers in improving quality of maternal and newborn care.  The GDA’s Improving Care of Mothers and Babies guide, developed by the USAID ASSIST Project and the American Academy of Pediatrics, breaks down the process of improvement in clear steps that providers can follow to plan, test, implement, continuously assess, and sustain process changes to deliver care in the best way possible for the setting. The guide, which has been translated to French and Spanish, is a critical resource to ensure care is optimized once providers have been trained.   

An equally important component of the GDA was to ensure that quality improvement (QI) is part of the implementation and long-term sustainability of maternal and newborn care. The Improving Care of Mothers and Babies: A guide for improvement teams, includes information and tools to facilitate implementation of quality improvement activities at the facility level.  The Guide outlines the process of improvement step-by-step, helping providers plan, test, implement, continuously assess and sustain interventions that enable care to be delivered in the best way possible.  Improving Care of Mothers and Babies can guide those new to improvement methodologies, as well as provide further support to those who have experience implementing and managing improvement projects.  It can be used by a leader or facilitator to help others learn about improvement in both clinical and workshop settings and can also be used as a self-study manual by improvement teams and individuals.

Download Survive & Thrive Final Report

Dando respuesta a los asuntos de género para mejorar los resultados en la atención en salud relacionada con el Zika

Este documento proporciona información sobre los problemas relacionados con el género en relación con la atención médica relacionada con el Zika.

Resalta los principales problemas:

• Roles y valores relacionados con el género
• Acceso limitado y / o control sobre educación sexual, anticonceptivos y otros servicios de salud reproductiva
• La falta de poder de las mujeres para negociar el uso de anticonceptivos (incluidos los condones)
• Estigma que lleva al abandono de la madre y el niño

Version en español

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