1. Introducing QI Tools and Approaches COPE ® APPENDIX F Session B Facilitative Supervision for Quality Improvement Curriculum 2008

2. Goals of Quality Improvement Actual practice Best practice Quality services that meet clients’ needs Improved performance of staff and institutions Better health

3. The QI Process Information gathering and analysis Action plan development and prioritization Implementation Follow-up/ evaluation

4. EngenderHealth’s QI Package QI Approaches Facilitative supervision Whole-site training (including Inreach) QI Tools COPE ® Community COPE Quality Measuring Tool Cost Analysis Tool Medical Monitoring

5. INFO Community assessment Client interview CFA Observation of services Data review Facility audit Record/ case review INFO Staff interview COPE ® Information Gathering Identify gap between actual practice and best practice Quality Measuring Tool Cost analysis PNA

6. Underlying Principles A customer mindset Staff involvement and ownership Focus on systems and processes Cost-consciousness and efficiency Continuous quality improvement Staff development and capacity building

7. Clients’ Rights Information Access to services Informed choice Safe services Privacy and confidentiality Dignity, comfort, and expression of opinion Continuity of care

8. Staff Needs Facilitative supervision and management Information, training, and development Supplies, equipment, and infrastructure

9. COPE ® : Client- COPE is a continuous, participatory process with tools to improve the quality of care through self-assessment. There tools are used by all levels of staff and supervisors to collectively identify and solve problems. COPE is based on a framework of clients’ rights and staff needs. Oriented, Provider- Efficient services

10. Who Are Our Customers? External customers? Internal customers?

11. COPE Tools Self-assessment guides, including record-review checklist Client interviews Client-flow analysis (CFA) Action plan

12. COPE for Reproductive Health Services: Topics Antenatal care Labor and delivery Postpartum and newborn care Family planning Postabortion care RTIs/STIs/HIV Gynecologic disorders Disorders of the male reproductive system Sexuality Infertility Harmful practices

13. The Self-Assessment Guides Self-assessment: the heart of COPE By staff, for staff: To encourage staff and supervisors to recognize what they are doing well and to identify and solve the problems they face. The guides are not a test. Trigger questions relate to common issues at most service sites.

14. How to Use the Self-Assessment Guides (1) Staff might split into teams, each working on one or more guides. If something does not apply to the site, skip it. If something important is not listed, add it! “No” means a possible problem; try to find out more.

15. How to Use the Self-Assessment Guides (2) Be honest about problems Get input from coworkers who are not on your team Be specific and concrete

16. Client Record-Review Checklist The checklist is a part of the self-assessment guide on safety. Ten client records are selected at random. Records are assessed to learn whether key information is being recorded accurately and completely.

17. Client Interviews Why conduct client interviews? To learn what clients think about services. To get suggestions from clients about how to improve services. Because we do not know what clients say unless we ask them. To show that we care about their needs.

18. Client-Flow Analysis (CFA) CFA is a process for measuring the time each client spends waiting for services and the time that staff spend in direct contact with each client.

19. Client Register Form (for CFA) Client № _______ Type of visit: Male Female Contraceptive method____ Revisit First visitTime of client’s arrival in clinic:

20. Client-Flow Analysis 9:00:15:30:4510:00:15:30:4511:00 1 2 3 4 5 6 7

21. Developing the Action Plan Involve all levels of staff in the discussion Review problems identified Analyze root causes of problems Recommend solutions Be specific Prioritize

22. Developing a Clear Problem Statement (1) Problem: The difference between the actual and desired situation Must agree that this is a problem “Count the problem” (state measurable indicators). But do not try to measure everything!

23. Developing a Clear Problem Statement (2) Focus on processes and systems. Do not blame individuals for mistakes. Define problems and processes that are manageable.

24. Analyze the Root Cause of the Problem: Multiple Why’s Why? Are there any other causes?

25. Action Plan Format

26. Schedule for the First COPE Exercise Day 1 Morning: Introducing COPE Conduct tour of facility/meet management and participants Hold COPE introductory meeting with staff (approximately three hours) Afternoon: Client interviews and self-assessment (All Activities are carried out during routine work hours at staff’s convenience) Conduct client interviews Use self-assessment guides, including client-record review

27. Schedule for the First COPE Exercise (2) Day 2 Morning and afternoon: Client interviews and self-assessment (All activities are carried out during routine work hours, at staff’s convenience.) Conduct client interviews and prepare an action plan Use self-assessment guides and prepare an action plan

28. Schedule for the 1 st COPE Exercise (3) Day 3 Morning: Action plan Action plan meeting Select QI Committee members Schedule the follow-up meetings and next COPE exercise

29. Action Plan Meeting Presentation of action plans Prioritization of problems and consolidation into one action plan for the site Discussion of site strengths Establishment of QI Committee Setting of date for follow-up with QI Committee

30. Tasks for QI Committee Make the action plan accessible for all staff to see it. Follow up the site’s action plan. Support staff responsible for implementing solutions. Schedule subsequent COPE exercises. Help monitor results.

31. Implement solutions Analyze root causes Second and later exercises Review status of action plan Conduct self-assessment, client interviews Apply other tools as needed Follow up: By staff, by off-site supervisors, by COPE ® Committee Develop an action plan First COPE ® Identify needs: Self-assessment, client interviews Ongoing COPE ® process

32. The COPE Toolbox COPE Handbook COPE Toolbooks: –Family planning –Reproductive health –Child health –Maternal health –Community involvement –Adolescent reproductive health –Emergency obstetric care –PMTCT services –Cervical cancer –HIV treatment and care –HIV testing and counseling

33. Benefits of COPE Develops a customer focus among staff Empowers staff at all levels and builds teamwork Provides tools for local problem identification and problem solving Helps to communicate standards and improve performance Presents concrete and immediate opportunities for action Responds to local needs in decentralized health systems

34. Implement Interventions Clarify roles and expectations Supervision and follow-up Whole-site training Reorganization of work Resource development (job aids, etc.) Supplies and equipment

35. Evaluation Reassess What worked? Why did it work? What did not work? Why not? Revise action plan

36. Using the Action Plan for Evaluation

37. The QI Process Information gathering and analysis Action plan development and prioritization Implementation Follow-up/ evaluation