1. Standards Based Management and Recognition Approach To Quality ImprovementBy
Prof. Emmanuel Oladipo Otolorin,
FMCOG, FWACS, FICS, FRCOG
Country Director, ACCESS/JHPIEGO

2. Learning Objectives Define Quality of Care
List a variety of quality improvement approaches
Describe the Standards Based Management and Recognition (SBM-R) model
Describe lessons learnt so far in Nigeria

3. What does “Quality of Care” mean?
Illustrative definitions:
“Doing the right things right”
“Meeting minimal standards for adequate care”
“Offering the greatest health benefits, with the least health risks, to the greatest number of people, given the available resources”

4. World Health Organization’s Definition Of “Quality Of Care”
“The proper performance, according to standards, of interventions that are known to be safe, that are affordable to the society in question, and that have the ability to produce an impact on mortality, morbidity, disability and malnutrition”

5. Different Perceptions of Quality
Client
Provider
State/
USAID
Civil
Society
Social-cultural
Context Q

6. Criteria of good quality maternal health services
Accessible and available
Acceptable to potential users/responsive to local cultural and social norms (e.g. privacy, confidentiality, quick, care by female health workers
Adequacy of essential supplies and equipment
Provides comprehensive care and linkages to other RH services
Provides for continuity of care and follow-up

7. Criteria of good quality maternal health services continued
Staffed by technically competent health care providers who rely of clear guidelines and protocols for treatment
Staffed by workers who provide respectful and non-judgmental care
Service site provides information and counseling for clients on their health and health needs
Involves clients in decision-making
Offers economic and social support to health care providers to motivate them to do the best job they can

8. Why is Quality of Care important?
Quality of care is important because good quality services:
are cost-efficient
are equitable
are effective
improve staff morale
save women’s lives

9. Factors contributing to poor quality maternal health services
Lack of compliance with defined standards leading to substandard care; with staff that:
are poorly supervised
underpaid and overworked
not adequately trained
fail to respect clients’ needs (with inconvenient operating hours, inflexible timetables and regulations)

10. Shortage of basic equipment and supplies
Factors contributing to poor quality maternal health services continued
Shortage of basic equipment and supplies
Poor Client-Provider interactions, with service providers who are:
insensitive to clients
pay little attention to clients’ concerns
treat clients rudely
judgmental

11. Delays in receiving treatment
Factors contributing to poor quality maternal health services continued
Delays in receiving treatment
Delay in problem recognition
Delay in deciding to seek care
Delay in reaching the health facility
Delay in receiving quality treatment at the health facility

12. Sample list of Quality Improvement Methods
Quality assurance
Total Quality Management
Continuous Quality Improvement
Performance Improvement
Supportive/Facilitative supervision
Standard-Based Management and Recognition (SBM-R) Approach

13. What is SBM-R?
Practical management approach for improving performance and quality of health services
Based on use of operational, observable performance standards for on-site assessment
Must be tied to reward or incentive program
Consists of four basic steps

14. The Four Steps of SBM-R

15. Step One: Set the Performance Standards

16. Steps to Setting Standards
Identify area of services to be improved
Define core support and supply processes to provide these services
Develop performance standards based on international guidelines, national policies or guidelines, and site-specific requirements
Consider providers’ input and clients’ preferences

17. “Operationalization” of Standards
National Guidelines
(“Reference” standards)
Assessment tool
(“Operational” standards plus indicators)

18. Performance Standards
The standards tell providers not only what to do but also how to do it

19. Sample Performance Assessment Tool (1)
Area: Pregnancy Care
Perf. Standard
Verification Criteria
Y, N, NA
Comments
The facility conducts a routine rapid assessment of pregnant women
Observe in the reception area or waiting room if the person who receives the pregnant woman:
Asks if she has or has had:
Vaginal bleeding
Headache or visual changes
Breathing difficulty
Severe abdominal pain
Fever
Immediately notifies the health provider if any of these conditions are present
See other examples in Nigerian Standards

20. Assessment tool areas for EMNOC: Nigerian Hospitals
STANDARDS
1. Focused Antenatal Care 16
2. Pregnancy Complications 25
3. Labor, Delivery, Postpartum, and Newborn Care 27
4. Postnatal Care for Mother and Newborn 23
5. Support Services 24
6. Information, Education, and Communication 10
7. Human, Physical, and Material Resources 26
8. Management Systems 14
9. Infection Prevention 34
Total
199
See Page v of Nigerian Standards

21. Assessment tool areas for EMNOC: Nigerian PHCs
STANDARDS
1. Focused Antenatal Care 16
2. Pregnancy Complications 20
3. Labor, Delivery, Postpartum, and Newborn Care 27
4. Postnatal Care for Mother and Newborn 23
5. Support Services 13
6. Information, Education, and Communication 10
7. Human, Physical, and Material Resources 25
8. Management Systems 14
9. Infection Prevention
Total
173

22. Step Two: Implement the Standards

23. Steps to Implement Standards
Do baseline assessment
Identify performance gaps
Identify causes of gaps and interventions to correct them
Implement interventions
Begin and support change process

24. Intervention identification & implementation
Implementation Cycle
Desired performance
Actual performance
Gap
Cause analysis
Intervention identification & implementation
Model Adapted from the International Society for Performance Improvement

25. Baseline Assessment
Determines actual level of performance using the performance assessment tool
Helps to identify performance gaps
Once gaps are identified, identifies their causes

26. Baseline SBM-R Scores in Kano and Zamfara Hospitals: Aug. 2007

27. Baseline SBM-R Scores in Kano and Zamfara PHCs: Aug. 2007

28. Defining the performance gap: Example
100% of pregnant women attending the ANC deliver with a skilled birth attendant
Define the performance gap for each task (in quantitative or qualitative terms)
58% of pregnant women attending the ANC did NOT deliver with a SBA
Gap
42% of pregnant women attending the ANC deliver with a skilled birth attendant

29. In order to perform, a performer needs to:
Know how to do +
Be enabled to do +
Want to do

30. Capability (Know how to do)
Knowledge, skills, information
Opportunity (Be enabled to do)
Resources, tools, capacity
Motivation (Want to do)
Inner drive, incentives

31. Intervention Identification and Implementation
Once gaps are identified, do root cause analysis to identify corrective interventions
Interventions should match the root cause of the gap
Implement selected interventions

32. Pareto Graph for “Reasons for Not Delivering in the Hospital” (Uganda)
Food not culturally appropriate
Husband objects
Rude staff
Afraid
Language differences
Lack of privacy
Lack of knowledge
Hospital too far
Dirty hospital
Long waiting
Too crowded
160
140
120
100 80 60 40 20
150
146
148
149
144
100%
134
122
89%
107
75%
81% 90
71%
60% 70
50%
47% 42
28% 28 20
25% 17 15 12 10 2 2 1 1 C F H J D A E K G I B

33. Intervention Identification
Type of problem
Type of solution
MOTIVATION
INCENTIVES
Resources, Capacity
Strengthening of Management Systems, Provision of Resources
Knowledge, Skills, Information
Training, Information

34. “If all you have is a HAMMER… everything looks like a NAIL.”
Lack of data and
information
Lack of motivation
and incentives
Lack of tools and equipment
Lack of knowledge and skills
Training
Lack of financial
transparency
An example of why a systematic process is helpful
Training is the most popular intervention when there is a performance problem. This slide illustrates how one intervention—training—is often considered to be the right tool for different causes of performance problems.
A good root cause analysis increases the likelihood that the interventions will have a greater impact—that the right tools will be used.
There is an epidemic of “workshopitis” in Nigeria

35. Effort is NOT the same thing as Performance
Effort = Performance /
Effort is NOT the same thing as Performance

36. Change Management Strategy
Implementation of change can be difficult (business as usual mentality is rampant)
Performance standards are a tool for initiating and sustaining change
Important to focus on actions and achievement of early results to help ease the change process
Individuals can be powerful agents for or against change

37. Change Management Strategy
The standards in the tools represent easy and hard challenges
Changes start with the “low-hanging fruit”
Managers and providers should start with the easiest tasks and then move to more difficult tasks, as they develop and increase their change management skills
Observe change process to identify new developments, initiatives and behaviors

38. “Multidimensional” Supervision and Support
SBM-R process uses a variety of ways to supervise and support change process:
Self/internal assessment
Peer/benchmarking
Supportive supervision (on demand), external assessment
Client involvement and community participation (e.g. HFDC with community membership)
Bottom-up approach: based on local control, empowerment, motivation, advocacy, resource mobilization

39. Step Three: Measure Progress

40. Steps to Measure Progress
Encourage providers to self-assess
Measure progress (internal monitoring)
Bring facilities together to share challenges and successes

41. Example: Total Results by Hospital, Honduras

42. Results from Seven Hospitals in Malawi

43. PROQUALI, Brazil Compliance with standards of reproductive health care
13th Health Center-Bahia

44. PROQUALI Brazil: Results from Five Pilot Clinics

45. Qualitative results

49. Step Four: Recognize and Reward Achievements

50. Steps to Recognize Achievements
Address motivational issues
Decide upon incentives
Implement incentive programs

51. Ways to Enhance Motivation
Empowerment: Giving the tools to self-assess and implement
Challenges: Establishing a clear goal
Achievements: Easy to show results
Healthy competition: Grouping facilities encourages sharing of experiences and some competition to succeed

52. Recognition methods (as an Incentive)
Feedback (verbal, written)
Social recognition
Material recognition

54. Mzuzu Central Hospital
Conferred by the
Ministry of Health to
Mzuzu Central Hospital
in recognition of the achievement of standards
of excellence in
Infection Prevention
practices
Year 2004
____________________________
Secretary for Health

55. More sample awards Uganda’s Yellow Star
Health care quality improvement award for Texas State, USA
Uganda’s Yellow Star

56. Leadership: Enabling groups to make progress in complex conditions
Defining Leadership
Leadership: Enabling groups to make progress in complex conditions
Leadership is an activity that takes place at all levels, not a position of authority
It is not only about “the leadership” – those at the top of a hierarchy.
It is about the activity of “LEADING” – enabling groups to make progress.
Progress implies that the group or society is moving forward to a better place than it currently is.
This is not the same as using power to achieve one’s own aims.
Oftentimes those in authority need to maintain stability and order, and it is difficult for them to lead in the sense of “enabling progress.”

57. We need Leaders and Change Agents!
Leaders must be:
Visionary
Committed
Courageous
Proactive
Determined to make a difference
Humble
Role model
Persistent
Kind
Understanding
Nelson Mandela
Mahatma Ghandi
Mathew Luther-King

58. Managers should think of LEGACY after office!
Tune off the W.I.I.F.M radio station.
Think LEGACY

59. Summary
The Standard Based Management and Recognition Approach has been used in different parts of the world to improve the quality of health care services
It can be applied to a variety of technical areas including integrated RH, IMCI, EPI, Malaria, HIV/AIDS, Trauma, and Management of Chronic diseases etc.

60. Summary SBM-R is: A four-step process
Not as complicated as it may sound
Puts the power in the hands of local providers and managers
Requires multiple sources of supervision and support

61. Thank You from
ACCESS
and
JHPIEGO