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Standards Based Management and Recognition Approach To Quality Improvement By Prof. Emmanuel Oladipo Otolorin, FMCOG, FWACS, FICS, FRCOG Country Director,

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Presentation on theme: "Standards Based Management and Recognition Approach To Quality Improvement By Prof. Emmanuel Oladipo Otolorin, FMCOG, FWACS, FICS, FRCOG Country Director,"— Presentation transcript:

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

2 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 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 4 World Health Organizations 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 5 Different Perceptions of Quality Client Provider State/ USAID Civil Society Social-cultural Context Q

6 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 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 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 womens lives

9 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 10 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 11 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 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 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 14 The Four Steps of SBM-R

15 15 Step One: Set the Performance Standards

16 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 17 Operationalization of Standards National Guidelines (Reference standards) Assessment tool (Operational standards plus indicators)

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

19 19 Sample Performance Assessment Tool (1) Area: Pregnancy Care Perf. Standard Verification Criteria Y, N, NA Comments 1.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 20 Assessment tool areas for EMNOC: Nigerian Hospitals AREASSTANDARDS 1. Focused Antenatal Care16 2. Pregnancy Complications25 3. Labor, Delivery, Postpartum, and Newborn Care27 4. Postnatal Care for Mother and Newborn23 5. Support Services24 6. Information, Education, and Communication10 7. Human, Physical, and Material Resources26 8. Management Systems14 9. Infection Prevention34 Total199 See Page v of Nigerian Standards

21 21 Assessment tool areas for EMNOC: Nigerian PHCs AREASSTANDARDS 1. Focused Antenatal Care16 2. Pregnancy Complications20 3. Labor, Delivery, Postpartum, and Newborn Care27 4. Postnatal Care for Mother and Newborn23 5. Support Services13 6. Information, Education, and Communication10 7. Human, Physical, and Material Resources25 8. Management Systems14 9. Infection Prevention25 Total173

22 22 Step Two: Implement the Standards

23 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 24 Implementation Cycle Model Adapted from the International Society for Performance Improvement Desired performance Actual performance Gap Cause analysis Intervention identification & implementation

25 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 26 Baseline SBM-R Scores in Kano and Zamfara Hospitals: Aug. 2007

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

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

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

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

31 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 32 Pareto Graph for Reasons for Not Delivering in the Hospital (Uganda) A.Food not culturally appropriate B.Husband objects C.Rude staff D.Afraid E.Language differences F.Lack of privacy G.Lack of knowledge H.Hospital too far I.Dirty hospital J.Long waiting K.Too crowded % 50% 100% 28% 70 47% 90 60% % % % % CFHJDAEKGIB

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

34 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 There is an epidemic of workshopitis in Nigeria

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

36 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 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 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 39 Step Three: Measure Progress

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

41 41 Example: Total Results by Hospital, Honduras

42 42 Results from Seven Hospitals in Malawi

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

44 44 PROQUALI Brazil: Results from Five Pilot Clinics

45 45 Qualitative results

46 46

47 47

48 48

49 49 Step Four: Recognize and Reward Achievements

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

51 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 52 Recognition methods (as an Incentive) Feedback (verbal, written) Social recognition Material recognition

53 53

54 54 ____________________________ Secretary for Health 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

55 55 More sample awards Health care quality improvement award for Texas State, USA Ugandas Yellow Star

56 56 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

57 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 Mahatma Ghandi Mathew Luther-King Nelson Mandela

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

59 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 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 61 Thank You from


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