Results of a Study on Sustainability of Improvements in Maternal Child Care and Institutionalization of Continuous Quality Improvement in 30 Ministry of Health facilities in 10 SILAIS in Nicaragua

This study, which measures the level of sustainability of improvements in maternal child care and the Institutionalization of Continuous Quality Improvement (CQI), is being undertaken at the end of a 10 year period (2000 – 2010) of technical assistance on CQI for maternal child care (MCH) to Ministry of Health (MINSA) facilities in Nicaragua. USAID – Nicaragua, in coordination with MINSA, will use the results of the study to prioritize their continued support for CQI within specific health facilities in Nicaragua.

This study focuses on answering, above all, whether quality improvements in care processes implemented through CQI have been incorporated into and are used on a daily basis by health care workers in health units in Nicaragua. The study also focuses on determining how the support system put in place through establishing the institutionalization of CQI assists facilities in maintaining CQI within the unit’s operation and organization. Such support is reflected in the existence of basic managerial, organizational, and other conditions necessary for sustainability and institutionalization.
This study is the first one of its kind for USAID in Nicaragua. While other USAID-supported studies in Nicaragua have focused on specific aspects of institutionalization, this study is a full analysis of sustainability of quality care improvements and CQI through an examination of the many diverse components that comprise these two concepts.
This study includes both quantitative and qualitative data, with variables related to clinical and CQI training, leadership creation, acknowledgment and recognition of CQI, standardization of the care process, consensus on values for CQI, and CQI activities and institutionalization of the care processes. Measurable indicators were created for each of these variables. Data were collected from facilities in 10 out of the 17 SILIAS in Nicaragua using eight different types of instruments, including self-administered questionnaires, individual interviews and/or focus groups.
Among the study’s findings were that the trainings used to orient staff to CQI were similar in the 10 SILIAS, although there were some differences in whether trainings were offered as workshops or in the form of continuous education. Overall, 367 trainings were held between 2005 and 2010 and the average number of participants per course was 7.85. Ninety-four percent of the health centers and hospitals (28 of 30) reported that there was a CQI leader at that facility. However, 57% of the health professionals who participated in the focus group discussions were “in disagreement” that they had received respect, recognition or rewards for efforts and activities in CQI. The study found that in general health professionals had the opinion that key values related to CQI were important, including genuine interest in quality improvement, interest in improving user satisfaction, team work, and respect for ideas or input from staff. 
The study found high compliance with selected vital clinical standards, with seven of the ten SILIAS performing at levels above 80%, and 20 of the 30 health facilities studied were carrying out more than 80% of 13 key CQI activities with the correct frequency.
The ten year period of USAID-supported technical assistance though the QAP, HCI, and other projects focused on maternal and child health has coincided with a reduction in maternal mortality from 98 deaths per 100,000 live births in 2000 to 69 deaths per 100,000 in 2010. Similarly, infant mortality decreased from 50 deaths per 1,000 live births in 2000 to 29 deaths per 1,000 live births in 2010, and child mortality from 72 deaths per 1,000 live births to 35 deaths per 1,000 live births.

Based on the results of this sustainability/institutionalization study, one can see that the 30 health units from 10 SILAIS included in the sample in this study have qualities and factors that have put each of these health facilities in different pathways all with the same end goal of sustainability of best practices and institutionalization of CQI leading to improved health outcomes. The largest impact that the QAP/USAID - USAID/HCI intervention has had can be seen in the progress achieved in two aspects: the sustainability of clinical best practices and the institutionalization of the development of clinical skills and abilities and CQI. The variability seen in the different health units can help identify certain challenges and optimizing conditions, already in place or in the process of being developed, that can be used and replicated to achieve sustainability and institutionalization of CQI at the national level.


Report Author(s): 
Sandino M, Gomez I, Bowser D
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