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The State Of The Art In The Field Of Quality Improvement Jim Heiby, MD, MPH, Medical Officer, USAID Washington, CTO QA/WD Krishnapada Chakraborty, CTO,

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Presentation on theme: "The State Of The Art In The Field Of Quality Improvement Jim Heiby, MD, MPH, Medical Officer, USAID Washington, CTO QA/WD Krishnapada Chakraborty, CTO,"— Presentation transcript:

1 The State Of The Art In The Field Of Quality Improvement Jim Heiby, MD, MPH, Medical Officer, USAID Washington, CTO QA/WD Krishnapada Chakraborty, CTO, USAID/Dhaka, Bangladesh Kerry Pelzman, MPH, Chief of Health Division, USAID/Russia Rashad Massoud, MD, MPH, Associate Director, QA/WD, URC-CHS, Bethesda, MD Elena Gurvich, MD, PhD, DSc, CTO QA/WD, USAID/Russia

2 Standards/Guidelines SYNERGY OF INTERVENTIONS Creating A Norm of Access and Quality Organization of Work Community Engagement Provider Rewards/Engagement Client Engagement Leadership/Management Training Job Aids Supplies/Logistics/Environment Supportive Supervision Evaluation/Certification Problem Solving & Tools

3 Why should I care about Quality Improvement? A well-developed, distinct field –addresses both quality and waste in health care –carried out by regular staff –adapted to different settings –short term results –long term cumulative impact –dynamic

4 Why care about QI, continued An important strategic option –acceptance of evidence-based guidelines –health care becoming more demanding –complements technical training and T/A –can focus on priority services –low cost –USAID comparative advantage

5 Improving Health Care Quality in the Russian Federation Kerry Pelzman, MPH Chief of Health Division, USAID Moscow

6 Three Phases of the QAP/Russia : Demonstration Improvements in Facilities : Oblast-wide implementation 2002: National Scale-Up

7 Phase I: QA Demonstration Projects Maternal and Child Health (Tver Oblast) –Improving care for women suffering from Pregnancy-Induced Hypertension (PIH) –Improving care for neonates suffering from Respiratory Distress Syndrome (NRDS) Primary Care (Tula Oblast) –Improving care for patients suffering from Arterial Hypertension (AH)

8 Key Changes Made in the Care for Women with PIH in Tver Classification ICD - 10 Early and induced delivery Fewer number of women hospitalized Poly-therapy mono-therapy MgSO4 Promotion of the role of the midwife

9 Key Results in the Care for Women with PIH in Tver (3 hospitals ) No cases of maternal deaths since intervention No cases of progression to eclampsia 77% reduction in hospitalizations due to PIH Economic Effect: 87% reduction in the cost of care for women with PIH

10 Key Changes Made to the System of Care for Neonates with RDS in Tver Evidence-Based Clinical Guidelines Developed & Implemented Central Referral NICU Created Neonatal Transport System Set Up Neonatal Resuscitation Instituted New Directives Prikaz Issued Resources Re-allocated

11 Re(Designing) the System of Care for Newborns Suffering from Respiratory Disease Syndrome Neonatal Resuscitation Neonatal Transportation Neonatal I.C.U. Neonatal Resuscitation Neonatal Resuscitation

12 Key Results of (Re)Designing the System of Neonatal Care in Tver (5 hospitals ) 95% 7-day survival rate after initial resuscitation 99% increase in neonates transported to NICU with normal body temperature 64% reduction in neonatal mortality due to RDS

13 Key Changes Made to the System of Care for Patients with AH in Tula Evidence-Based Clinical Guidelines Developed & Implemented Screening Program Instituted Health Promotion Program Instituted Hypertension Chart Developed & Instituted New Directives Prikaz Issued

14 Key Results in Improving the System of Hypertension Care in Tula (5 clinics ) Number of patients managed at the primary care level increased by 7.6 times Number of patients managed at the primary care level increased by 7.6 times BP stabilization achieved in 69.4% of patients BP stabilization achieved in 69.4% of patients Hypertension related hospitalizations decreased by 85% Hypertension related hospitalizations decreased by 85% Hypertensive crises decreased by 60% Hypertensive crises decreased by 60% Economic analysis: Economic analysis: –Cost of hospital care reduced by 41% –Cost of care at the primary care level increased by 39% –Overall reduction in the cost of care of 23%

15 Phase II: Oblast-wide Implementation PIH from 3 to 42 maternity hospitals RDS from 5 to 42 maternity hospitals AH from 6 – 500 clinics

16 Results Large-Scale Implementation NRDS (42 hospitals ) 87% 7-day survival rate after initial resuscitation 99% increase in neonates transported to NICU with normal body temperature 62% reduction in neonatal mortality due to RDS 49.6% reduction in early neonatal mortality (from 10.8/1,000 in 1998 to 5.3/1,000 in 2001)

17 Phase III: National Scale-Up Begin with 19 new Oblasts to Spread the QA Methodology –Implement Improvements Accomplished –Develop New Improvements –Implement Oblast-Wide Improvements QA in Medical School Curricula Federal Center for QA MOH Appointed QA Official MOH Working Group for QA MOH Directive on QA Staff in each Oblast

18 Improving the Quality of Health Care:- Principles and Frameworks M. Rashad Massoud, MD, MPH Associate Director, QA/WD, Bethesda, MD

19 What Do We Mean By Quality Health Care? … Quality health care is what happens at all the points of service along the continuum of care. High quality care is a function of the systems ability to produce care that will address the clients health issues in an effective, responsive, and respectful manner… …David Nicholas

20 How Does Quality Improve? Scientific Discovery Mastery Trial & Error Coincidence Improvement Methodology

21 The Fundamental Concept of Improvement Every System is Perfectly Designed to Achieve Exactly the Results it Achieves … Don Berwick

22 Principles of Improvement 1- Understanding health care delivery in terms of systems and processes

23 The System of Care for Patients Suffering from Hypertension in Tula Oblast Clinical Content Screening Organization of care Health Promotion Policy/ Regulation Resource Allocation

24 Principles of Improvement 2- Working in Teams

25 Principles of Improvement 3- Customer Focus 4- Scientific Method

26 Intervention Started

27 The Quality Improvement Methodology

28 Content of Care Evidence-based: Standards Protocols Guidelines Process of Care Quality Improvement Methodology + Traditional Quality Improvement Continuous Quality Improvement Adapted from: Paul Balalden, Patricia Stoltz A Framework for Continual Improvement in Healthcare The Joint Commission Journal on Quality Improvement October 1997 The Framework for Clinical Quality Improvement

29 The Cost of Poor Quality patients Death THE TIP OF THE ICEBERG THE REST OF ICEBERG illness patients drugs/antibiotics treatment materials time infectiousness productivity services Frustrated workers managers community

30 Concluding Remarks on Quality Improvement Tackling health care priorities Evidence-based practices Re-organizing health care delivery Developing the Interventions Motivation/ Teamwork/ Leadership Significant Improvements Health Systems Strengthening Rationalizing Health Care Cultural Transformation

31 QAP – Russian Perspectives Elena Gurvich, MD, PhD, DSc, CTO QA/WD, USAID Moscow

32 QAP – Russian Perspectives Powerful Methodology for Health Reform Two Key Success Factors: –Motivated Health workers –Committed Health leadership Bottom Up Health Care Reform National Demand for Dissemination


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