Improving health care Nigel Livesley MD, MPH Regional Director, South Asia USAID ASSIST Project University Research Co., LLC (URC) 1
50% of women attending an ANC clinic did not get their BP and Hb measured 100% 75% 68.50% 50% 40.80% 25% 0% BP Measured HB Measured USAID Applying Science to Strengthen and Improve Systems 2
Implementation interventions (Tuncalp et al) http://www.qualityofcarenetwork.org 1. Leadership and governance of quality 2. System re-design for implementation and scale up 3. Financial strategies to support improvement 4. Assessment and provision of resources 5. Engaging women, families, communities in their care 6. Education, training and supportive supervision for clinical and system activities 7. Data to support improvement 8. Learning communities for accelerating improvement USAID Applying Science to Strengthen and Improve Systems 3
50% reduction in maternal and newborn death USAID Applying Science to Strengthen and Improve Systems 4
50% reduction in maternal and newborn death Provider-patient interaction USAID Applying Science to Strengthen and Improve Systems 5
50% reduction in maternal and newborn death Provider-patient interaction Appropriately skilled Appropriate Appropriate and motivated processes to deliver resources healthcare workers care USAID Applying Science to Strengthen and Improve Systems 6
50% reduction in maternal and newborn death Provider-patient interaction Appropriately skilled Appropriate Appropriate and motivated processes to deliver resources healthcare workers care Leadership and governance USAID Applying Science to Strengthen and Improve Systems 7
50% reduction in maternal and newborn death Provider-patient interaction Appropriately skilled Appropriate Appropriate and motivated processes to deliver resources healthcare workers care Data to Learning Provide Financial Education and System redesign support communities resources strategies support improvement $$ Leadership and governance USAID Applying Science to Strengthen and Improve Systems 8
50% reduction in maternal and newborn death Provider-patient interaction Engaging women, families, and communities in their care Appropriately skilled Appropriate Appropriate and motivated processes to deliver resources healthcare workers care Data to Learning Provide Financial Education and System redesign support communities resources strategies support improvement $$ Leadership and governance USAID Applying Science to Strengthen and Improve Systems 9
What approach should we use to improve this problem? 100% 75% 68.50% 50% 40.80% 25% 0% BP Measured HB Measured USAID Applying Science to Strengthen and Improve Systems 10
Poll 1: What strategy would you suggest we use to improve care at this hospital? 1. Leadership and governance of quality 2. System re-design for implementation and scale up 3. Financial strategies to support improvement 4. Assessment and provision of resources 5. Engaging women, families, communities in their care 6. Education, training and supportive supervision for clinical and system activities 7. Data to support improvement 8. Learning communities for accelerating improvement 9. I don ’ t know USAID Applying Science to Strengthen and Improve Systems 11
50% reduction in maternal and newborn death Provider-patient interaction Appropriately skilled Appropriate processes Appropriate resources and motivated to deliver care healthcare workers USAID Applying Science to Strengthen and Improve Systems 12
The approach to fix this depends on the cause of the problem Resource Individual Process problem problem performance problem USAID Applying Science to Strengthen and Improve Systems 13
The approach to fix this depends on the cause of the problem Resource Individual Process problem problem performance problem Nurses lack equipment or supplies USAID Applying Science to Strengthen and Improve Systems 14
The approach to fix this depends on the cause of the problem Resource Individual Process problem problem performance problem Nurses lack equipment or supplies Approaches • Provide resources • Financing USAID Applying Science to Strengthen and Improve Systems 15
The approach to fix this depends on the cause of the problem Resource Individual Process problem problem performance problem Nurses aren ’ t doing their job Nurses lack • Lack knowledge equipment or • Lack skills supplies • Lack respect/empathy • Lack motivation Approaches • Provide resources • Financing USAID Applying Science to Strengthen and Improve Systems 16
The approach to fix this depends on the cause of the problem Resource Individual Process problem problem performance problem Nurses aren ’ t doing their job Nurses lack • Lack knowledge equipment or • Lack skills supplies • Lack respect/empathy • Lack motivation Approaches Approaches • • Provide resources Training • • Financing Involve women • Supervision • Financing • Leadership USAID Applying Science to Strengthen and Improve Systems 17
The approach to fix this depends on the cause of the problem Resource Individual Process problem problem performance problem Nurses aren ’ t doing their job The way service Nurses lack • Lack knowledge delivery is organized equipment or • Lack skills makes it hard for supplies • Lack respect/empathy nurses to do their job • Lack motivation Approaches Approaches • • Provide resources Training • • Financing Involve women • Supervision • Financing • Leadership USAID Applying Science to Strengthen and Improve Systems 18
The approach to fix this depends on the cause of the problem Resource Individual Process problem problem performance problem Nurses aren ’ t doing their job The way service Nurses lack • Lack knowledge delivery is organized equipment or • Lack skills makes it hard for supplies • Lack respect/empathy nurses to do their job • Lack motivation Approaches Approaches Approaches • • Provide resources Training • System redesign • • Financing Involve women • Use data • Supervision • Financing • Leadership USAID Applying Science to Strengthen and Improve Systems 19
What approach should we use to improve this problem? 100% 75% 68.50% 50% 40.80% 25% 0% BP Measured HB Measured USAID Applying Science to Strengthen and Improve Systems 20
Huge variation from patient to patient and week to week # high-risk identified % BP measured % Hb measured 100% 12 90% 10 80% 70% 8 60% 50% 6 40% 4 30% 20% 2 10% 0% 0 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-5 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-5 W-1 W-2 W-3 W-1 W-2 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 USAID Applying Science to Strengthen and Improve Systems 21
Poll 2: The cause of this variation is most likely to be: 1. Due to resource constraints 2. Due to staff with poor knowledge and skills 3. Due to staff with poor motivation 4. Due to inappropriate processes USAID Applying Science to Strengthen and Improve Systems 22
THIS IS A PROCESS PROBLEM # high-risk identified % BP measured % Hb measured 100% 12 90% 10 80% 70% 8 60% 50% 6 40% 4 30% 20% 2 10% 0% 0 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-5 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-5 W-1 W-2 W-3 W-1 W-2 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 USAID Applying Science to Strengthen and Improve Systems 23
Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station USAID Applying Science to Strengthen and Improve Systems 24
Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station USAID Applying Science to Strengthen and Improve Systems 25
Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station USAID Applying Science to Strengthen and Improve Systems 26
Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station USAID Applying Science to Strengthen and Improve Systems 27
Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station Nurse ’ s station USAID Applying Science to Strengthen and Improve Systems 28
Improving processes of care … # high-risk identified % BP measured % Hb measured 100% 12 90% 10 80% 70% 8 60% 50% 6 40% 4 30% 20% 2 10% 0% 0 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-5 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-1 W-2 W-3 W-4 W-5 W-1 W-2 W-3 W-1 W-2 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 USAID Applying Science to Strengthen and Improve Systems 29
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