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

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
QAP/Russia started in summer 1998 as a 2 year demonstration of the possibility of applying improvement methods in Russia. The initial scope of work included:
Consensus on & publishing a Glossary of QA Concepts & terminology
Training a core team of Russian professionals in QA
Developing demonstration projects in improving health care quality
Developing indicators of quality
Publishing a QA Guide in Russian
Given the results, it was decided to go a step further…
In summer 2000, QAP/Russia started the next phase of its work:
Developing a model for the intentional spread of successful demonstration improvements to the whole Oblast.
Oblast: An administrative region, with an independent health authority, population approx 2 million
Currently: moving into national scale spread

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)
PIH accounted for 7 of the 25 maternal deaths in There was much controversy regarding the management of PIH
NRDS accounted for 66.7% of early neonatal mortality in 1997
CVD accounted for 55% adult mortality in Uncontrolled hypertenstion was thought to be a leading factor

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 1998-2001)
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. Neonatal Transportation
Re(Designing) the System of Care for Newborns Suffering from Respiratory Disease Syndrome
Neonatal I.C.U.
Neonatal Transportation
Neonatal
Resuscitation
Neonatal
Resuscitation
Neonatal
Resuscitation

12. Key Results of (Re)Designing the System of Neonatal Care in Tver (5 hospitals 1999-2001)
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 1998-2001)
Number of patients managed at the primary care level increased by 7.6 times
BP stabilization achieved in 69.4% of patients
Hypertension related hospitalizations decreased by 85%
Hypertensive crises decreased by 60%
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 2000-2001
PIH from 3 to 42 maternity hospitals
RDS from 5 to 42 maternity hospitals
AH from 6 – 500 clinics
This has been done!

16. Results Large-Scale Implementation NRDS (42 hospitals 2000-2001)
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)
This is for the whole Oblast

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
These are the activities recently embarked on

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 system’s ability to produce care that will address the client’s health issues in an effective, responsive, and respectful manner”…
…David Nicholas
Recently, a woman in Nicaragua with bleeding caused by retained placenta in the post-partum period, was admitted to a Health Center in Bocay. She was delivered by a traditional birth attendant in her village. The attendant had been trained to recognize that if the placenta was not delivered 30 minutes after the baby was born, there was the danger of hemorrhage. She sent the brother of the woman to the road to flag down a vehicle to take him to the health center. He reported the problem, and an ambulance was sent to fetch the woman. As soon as she arrived, the health center team was ready. They inserted an IV, began an Oxytocin drip and conducted a manual removal of the placenta a few minutes after her arrival. A half hour later, and only two hours after the baby’s birth, the mother was resting comfortably in a bed nursing her infant….
Recognition of danger, decision to evacuate from the village to a health center, organized transportation, proper reception at health center, mobilization of emergency care, correct technical care, good interpersonal communication and concern, good result and follow up—this is quality health care and it happened at all points of the continuum. It is “doing the right thing right, at the right time,” and “the devil is in the details.”

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. The Framework for Clinical Quality Improvement
Content of Care
Process of Care
Evidence-based:
Standards
Protocols
Guidelines
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

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

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