Quality Improvements HBB India Experience Dr. Anju Puri HBB Review Meeting 17 th July 2012

Burden  More than 2·3 million children die annually  1.1 million occur in neonatal period  Million Death Study investigated  neonatal deaths  deaths in 1-59 months Ref: Report on causes of Death , RGI 2009  0-28 days – 3 causes (78%)  Prematurity & LBW 32%  N. Infections %  B. asphyxia & trauma 18.8%  1-59 months – 2 causes (50%)  Pneumonia 27.7%  Diarrheal diseases 22.3% 2

Our overall goal is MDG 4  ENC/R Goal: Support the MOHFW, State health departments, USAID bilateral health programs and the new National Newborn Care and Resuscitation Initiative (NSSK) to strengthen and expand access to ENC and teach basic resuscitation technique. 3

Uttar Pradesh Gonda Deoghar Jamtar a Jharkhand Giridih Simdega Chaibas a Immunization focus districts Integrated districts Geographic presence to support and influence implementation

Landscape of program inputs  Facility readiness assessment using 8 parameters was conducted in Oct 2010 using a structured questionnaire and 75 indicators generated.  KAP performance for maternal and newborn care especially neonatal resuscitation was mapped.  District mapping of the gaps generated and facility wise plan made for realistic program. Based on this implementation included provider mapping,  3- Day skill based training in essential newborn care and resuscitation skills of all district level primary providers conducted (250)  Job-aides and skill lab of key providers (28) in the demo-facilities.  Supportive supervision involving quantitative and qualitative checklists was used to provide on-going hand holding. Involving district authorities at each step was critical to success of the program.  Strengthening of health information systems by improved reporting and feedback mechanism,  Follow up of facility births of birth asphyxia newborns conducted in the community.  Facility readiness assessment using 8 parameters was conducted in Oct 2010 using a structured questionnaire and 75 indicators generated.  KAP performance for maternal and newborn care especially neonatal resuscitation was mapped.  District mapping of the gaps generated and facility wise plan made for realistic program. Based on this implementation included provider mapping,  3- Day skill based training in essential newborn care and resuscitation skills of all district level primary providers conducted (250)  Job-aides and skill lab of key providers (28) in the demo-facilities.  Supportive supervision involving quantitative and qualitative checklists was used to provide on-going hand holding. Involving district authorities at each step was critical to success of the program.  Strengthening of health information systems by improved reporting and feedback mechanism,  Follow up of facility births of birth asphyxia newborns conducted in the community.

Quality Improvement Quality Improvement (QI) approach is being used to analyse performance of the providers during training; and thereafter using systematic effort to improve the competence for the skill proficiency on neonatal resuscitation for improved outcomes.

QI areasCriteriaToolsPurposeMeasuredResults Skill acquisition Knows the steps and their sequence to perform the required skill but needs assistance Quality Assurance Checklist (QAC) Performance checklist (PC) QAC is used to document the inputs and process followed during the training Skill rating (Mega-Score) using pre-post checklist During training QAC results Pre-post test results Skill competency Knows the steps and their sequence and can perform the skill Read and Do tools (R&D) Supportive supervision (SS) Health worker with a step by step outline of the procedure for use during the practice phase of lesson. Standard checklist used during supervisory visits regular intervals During mentoring Self – Practice observations SS checklist Skill Proficiency Knows the steps and their sequence and effectively performs the required skill Cross-learning visits Knowledge attitude Practice (KAP) HIMS trends Best Practices are focused Change in behaviour & practice Survival rates During bench- marking exercises Facility Readiness

Skill Acquisition - QI Quality Assurance Checklist  Been used to assess and adhere to a minimum standard for quality of process during the training.  10 observation questions  Score less than 80, training is repeated. Pre-Post Performance checklist  Pre-post test scores are used to rate the training and provide feed-back to the providers.  Measure changes in both the knowledge and skill acquisition by the health providers as a result of the training.

Pre-post test scores - trainings

Skill Competency – QI Practice exercises at skill labs

Skill Competency – QI Read and do tools

Supportive supervision  A structured guide & training methodology for supportive supervision was prepared  An “yes and no “simple checklist” is being used for regular supervision & feedback.  Each skill is only scored, if all the steps is followed for the skill.  The checklist has two copies, one for the health provider being supervised and the other for the one who supervises the activity. By this mean we assured that the provider who was supervised knows the misses and can be motivated to improve his performance.

Skill Competency QI  Questionnaire and exercise methodology developed to focus on the “preparedness” of the health facilities to deliver newborn care services as per the national guidelines.  The results framework is quantifiable in operational terms rather than health systems framework.  The analysis tool works on 75 broad indicators to generate color- codes to map the status of 8 parameters – Infrastructure, Delivery and Newborn Care services, Human resource, Essential drugs, equipment and supply, Register and client case record, Protocols and guidelines, universal precautions & infection prevention and Provider’s knowledge & competency on core skills.  A computerized SQL based analysis system has been developed to generate score based color-codes.  Implementing a planning exercise based after this exercise is found very useful and allowed us to bench mark the health facilities over a period of time.

Score-card and improvement scores

Graph showing change in knowledge on diagnosis of birth asphyxia

Graph showing change in provider’s knowledge & practice in using chronology of steps during resuscitation process

Sustaining and scaling efforts

Monthly HMIS data HMIS Data ( Focus Facility Data)Year 1Year 2Year 3* Total number of deliveries No. of Live births No. of Still births No. of Neonatal deaths 002 No. of full term deliveries NA No. of pre-term deliveries NA641 No. of neonates receiving vitamin K NA0455 No. of newborns with weight <2.5kg No. of newborns breastfed within 1hr No. of newborns requiring Bag & mask resuscitation No. of sick newborns referred to higher facility NA830

District Hospital Jamtara Year 1%Year 3*% Total number of deliveries No. of Live births No. of Still births (160 per 1000 LB) (41 per 1000 LB) No. of Neonatal deaths0 0 No. of full-term deliveriesNA 1477 No. of pre-term deliveriesNA 18 No. of neonates receiving vitamin K0 0 No. of newborns with weight <2.5kg No. of newborns breastfed within 1hr No. of newborns requiring Bag & mask resuscitationNA 86 No. of sick newborns referred to higher facilityNA 12

Consistency of reported Vs register data

Resuscitation Details District Name Facility Name Number of still borns resuscitated (X) Still borns brought back to life (BV-CU) Number of newborns with asphyxia (AJ) Number of newborns with meconium (AI) Number of newborns who had floppiness (AK) Number resuscitated by stimulation only Number resuscitated by stimulation and suction Number resuscitated by stimulation,suction and bag and mask Number resuscitated by stimulation,suction and bag and mask and oxygen Total number of newborns on whom bag and mask has been used Total number of newborns with asphyxia or meconium or floppiness (AJ+AI+AK) JAMDH JAMPabia DEO Palajori DEOMadhupur All sites total

Resuscitation indicators Non - breathing Non - breathing or meconium or floppiness % newborns with birth asphyxia Proportion of "Non - breathing" newborns resuscitated with stimulation alone Proportion of "Non - breathing " newborns resuscitated with stimulation and suction Proportion of " Non- Breathing" resuscitated with stimulation, suction and bag and mask Proportion of "Non-breathing" newborns resuscitated successfully

26 Lessons Learned  Newborn care programs have tended to be vertical, and slow to take up, have not considered or contributed to their quality.  It is feasible and beneficial to integrate ENC with Maternal Health programs and improve quality of care and have access to their concomitant resources.  The mother and baby dyad can be assessed and managed together.  The first week, especially the first three days, should be covered as a priority in the most feasible and effective manner at both facility and community levels with links between the two.