Going National: Accelerating Pace, Scale & Sustainability of Improvement. Ghana College of Physicians and Surgeons February 4 th

Transcription

1 Going National: Accelerating Pace, Scale & Sustainability of Improvement Ghana College of Physicians and Surgeons February 4 th

2 AIM: COLLABORATORS: Assist and accelerate Ghana s efforts to achieve Millennium Development Goal 4 (66% reduction in Under-5 mortality to 4/1 livebirths by 215) through the application of quality improvement methods Funded by the Bill & Melinda Gates Foundation

3 Start Small, Scale up Rapidly with Change Package Total Pop n: Under 5 Pop n: 35, 6, 5 million 5, 11 million 1.7 million 11 million 1.7 million 22 million 3.3 million Nov 27 Jul 28 Sept 29 Oct 29 Aug 212 Jan 213 Start-up: months 1 8 Wave 1: months 9 22 Wave 2: months Wave 3: months Wave 1R: months *Referral project launch 41 Referral Teams Wave 4: months No of. QI Teams: >1,46

4 The Sustainability Challenge- 212 Spread Strategy Designing to Hear the Community Voice Results Across Continuum of care National Scale Up- 213

5 Ghana: brief profile Population 24 million Stable Constitutional democracy (1992- Growth rate of 13.5% in 211 Internet penetration : 1% (212) Health systems: Government, faithbased, for profit National Health Insurance from 28 Under 5 mortality 76/1 (21) Maternal Mortality 35/1, (26)

6 A P S D Breakthrough Results Wide-scale tests of Change Hunches, Theories, Best Practices A P S D Follow-up Tests Very Small Scale Test Tests under new conditions Improvement Guide, Chapter 7, p. 146

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8 1. Focus on implementation gap, not necessarily new interventions - How far is our current performance from our target or aim? 2. Emphasis on local data analysis to guide local problem-solving - What changes can we make locally? 3. Viewing data over time is critical to understanding current performance, effects of new changes, and sustainability 4. Reliability of implementation is key to closing the gap - How can we offer this service consistently? What is our contingency plan? 5. Sustainable approaches to problem-solving (e.g. equipment, HR) - How can we test or implement this change within existing resources? 6. Peer-to-peer learning fundamental to large-scale improvement - Presentations, facilitated discussions, marketplace, study tour

9 Demand accountability PFA! Sustainability Driver Diagram Capacity for continuous Deep and wide QI training QI training institute Health System Leadership QI Programme leadership QI Project Leadership QI Pre-service & in service QI training QI Institutionalized in Health System Developing a culture of continuous quality improvement SMART & comprehensive metrics Deprojectize from the start Redefine performance monitoring around system wide improvement projects Establish cross cutting feedback loops Early High level policy alignment with HS priorities Redefine existing roles as needed Establish co-funding opportunities Build protocols for best practices Unambiguous operational definitions Metrics integrated in routine reporting system Promote data transparency with learning focus Establish functional stakeholder feedback system Promote routine data quality assessment Psychological preparation for exit Design and agree on exit plan Increase visibility of HS ownership & leadership Redefine HS reporting formats and emphasis e at National /Regional/ District/Sub district review meetings Clinical Care Divisions/units aligned at all levels to drive QI Local budgets for LSs, regular site visits, cyclical improvement projects, and conference attendance QI field lessons DQI protocol Facility guide to QI Transportation management Pre-service curriculum

10 Jul'8 Oct'8 Jan'9 Apr'9 Jul'9 Oct'9 Jan'1 Apr'1 Jul'1 Oct'1 Jan'11 Apr'11 Jul'11 Oct'11 Jan'12 Apr'12 Jul'12 Number Strategic focus for Regional alignment: QI Capacity Building - Frontline Providers Multidisciplinary teams in hospitals and clinics Data-driven development and testing of changes Graphical display of data The current focus is MNCH Progress in Scale-up from Wave 1 to Wave 2 Wave 1 Wave 1+2 # of sub-district QI teams # of hospital QI teams # of districts

11 Percent Percent Percent % of districts and hospital - UER % of districts and hospitals - UWR Annual (21) Half Year (211) Annual (211) Half Year (212) Annual (21) Half Year (211) Annual (211) Half Year (212) Hospitals that include QI Districts that include QI Hospitals that include QI Districts that include QI BMCs that include QI BMCs that include QI % of districts and hospitals - NR Annual Half Year Annual Half Year (21) (211) (211) (212) Hospitals that include QI Districts that include QI BMCs that include QI

12 Jan'11 Mar'11 May'11 Jul'11 Sep'11 Nov'11 Jan'12 Mar'12 May'12 Jul'12 Sep'12 Nov'12 Percent Percent Percent 6 Logistical Support for Site Visits - UER 6 Logistical Support for Site Visits - UWR Jan'11 Mar'11 May'11 Median Jul'11 Sep'11 Nov'11 Jan'12 Mar'12 May'12 Jul'12 Sep'12 Management Support (BMC) Nov'12 Jan'11 Mar'11 May'11 Jul'11 Sep'11 Management Support (BMC) Nov'11 Jan'12 Mar'12 May'12 Jul'12 Sep'12 Nov'12 Median of logistacal support Logistical Support for Site Visits - NR Management Support Median of logistacal support

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14 How we work: taking projects to full scale in complex systems Working with - MoH, - NGOs - Funders

15 Scaling up: crucial importance of District/subdistrict as learning unit 3 o care 2 o / District Hospital/ CHC Phase 1: Testing of innovations Developing a package of changes Getting buy-in from district structures/ leadership Understanding interconnected processes between different levels of care

16 District District Hospital Sub-district Sub-district Sub-district Sub-district Sub-district Health Centre Community Community Community Community Community Community Community Community Community Community CHPS Compound Community Community Community Community Community

17 Improvement Collaborative Network ACTIVITY PERIOD Repeated improvement cycles: ACTIVITY PERIOD Repeated improvement cycles: Assessment and Design Period Learning Session 1 Learning Session 2 Intensive support from project team & DHMT Learning Session 3 18 months Institute for Healthcare Improvement

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21 Malaria Birth Asphyxia Sepsis Prematurity Direct causes Preventable under five deaths Root causes Delayed care seeking Delayed care provision Non adherence to protocols Inadequate use of data for decision making

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23 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 7% 6% 5% % OF ANC REGISTRANTS IN 1 st TRIMESTER - UER Wave 2 started 34.6% 44.8% 7% 6% 5% % OF ANC REGISTRANTS IN 1 st TRIMESTER - UWR 42.6% 51.7% 4% 4% 3% 2% 3% 2% Wave 2 started 1% 1% % % Subgroup Center UCL LCL Subgroup Center UCL LCL 7% 6% 5% 4% 3% 2% 1% % % OF ANC REGISTRANTS IN 1 st TRIMESTER - NR 28.% Wave 2 started 34.% Subgroup Center UCL LCL

24 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 1% 9% 8% 7% 6% 5% 4% 3% 2% % OF TOTAL DELIVERIES THAT ARE ATTENDED BY SKILLED HEALTH PERSONNEL - UER 71.5% 82.1% 88.5% 91.5% Wave 2 started 1% 9% 8% 7% 6% 5% 4% 3% 2% % OF TOTAL DELIVERIES THAT ARE ATTENDED BY SKILLED HEALTH PERSONNEL -UWR Wave 2 started 54.2% 64.2% 72.2% 83.8% Subgroup Center UCL LCL Subgroup Center UCL LCL 1% 9% 8% 7% 6% 5% 4% 3% 2% % OF TOTAL DELIVERIES THAT ARE ATTENDED BY SKILLED HEALTH PERSONNEL- NR 37.5% Wave 2 started 51.2% Subgroup Center UCL LCL

25 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul RATE OF STILLBIRTHS PER 1 SKILLED DELIVERIES - UER Wave 2 started RATE OF STILLBIRTHS PER 1 SKILLED DELIVERIES - UWR 27.6 Wave 2 started Subgroup Center UCL LCL Subgroup Center UCL LCL RATE OF STILLBIRTHS PER 1 SKILLED DELIVERIES - NR Wave 2 started 23.3 Subgroup Center UCL LCL

26 Jan'8 Mar'8 May'8 Jul'8 Sept'8 Nov'8 Jan'9 Mar'9 May'9 Jul'9 Sept'9 Nov'9 Jan'1 Mar'1 May'1 Jul'1 Sept'1 Nov'1 Jan'11 Mar'11 May'11 Jul'11 Jan'8 Mar'8 May'8 Jul'8 Sept'8 Nov'8 Jan'9 Mar'9 May'9 Jul'9 Sept'9 Nov'9 Jan'1 Mar'1 May'1 Jul'1 Sept'1 Nov'1 Jan'11 Mar'11 May'11 Jul'11 Jan'8 Mar'8 May'8 Jul'8 Sept'8 Nov'8 Jan'9 Mar'9 May'9 Jul'9 Sept'9 Nov'9 Jan'1 Mar'1 May'1 Jul'1 Sept'1 Nov'1 Jan'11 Mar'11 May'11 Jul'11 Sept'11 Nov'11 Jan'12 Mar'12 1% 9% 8% 7% % of Neonates who Received PNC on Day 1 or 2: UWR 6 out of 9 districts Start of Wave 1 Wave 2 began 67.62% 77.35% 1% 9% 8% 7% % of Neonates who Received PNC on Day 1 or 2: UER all 9 districts Start of Wave % 86.9% 1% 9% 8% 7% % of Neonates who Received PNC on Day 1 or 2: NR 6 out of 2 districts Start of Wave 1 6% 6% 6% 56.51% 5% 4% 3% 5% 4% 3% 2.25% Wave 2 began 5% 4% 3% 28.33% Wave 2 began 2% 1% 8.17% 2% 1% 2% 1% % % % Month Month Month

27 Jan'8 Mar'8 May'8 Jul'8 Sept'8 Nov'8 Jan'9 Mar'9 May'9 Jul'9 Sept'9 Nov'9 Jan'1 Mar'1 May'1 Jul'1 Sept'1 Nov'1 Jan'11 Mar'11 May'11 Jul'11 Jan'8 Mar'8 May'8 Jul'8 Sept'8 Nov'8 Jan'9 Mar'9 May'9 Jul'9 Sept'9 Nov'9 Jan'1 Mar'1 May'1 Jul'1 Sept'1 Nov'1 Jan'11 Mar'11 May'11 Jul'11 Jan'8 Mar'8 May'8 Jul'8 Sept'8 Nov'8 Jan'9 Mar'9 May'9 Jul'9 Sept'9 Nov'9 Jan'1 Mar'1 May'1 Jul'1 Sept'1 Nov'1 Jan'11 Mar'11 May'11 Jul'11 Sept'11 Nov'11 Jan'12 Mar'12 1% 8% 6% 4% % of PNC Registrants who Received Follow-up Care on Day 6 or 7: UWR 6 out of 9 districts Start of Wave % Wave 2 began 55.66% 1% 8% 6% 4% % of PNC Registrants who Received Follow-up Care on Day 6 or 7: UER all 9 districts Start of Wave 1 Wave 2 began 46.7% 53.46% 1% 8% 6% 4% % of PNC Registrants who Received Follow-up Care on Day 6 or 7: NR 6 out of 2 districts Start of Wave 1 Wave 2 began 34.94% 2% 2% 2% 18.59% % % % Month Month Month

28 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul RATE OF INSTITUTIONAL NEONATAL MORTALITY UER Wave 2 started RATE OF INSTITUTIONAL NEONATAL MORTALITY - UWR Wave 2 started Subgroup Center UCL LCL Subgroup Center UCL LCL RATE OF INSTITUTIONAL NEONATAL MORTALITY - NR 1.7 Wave 2 started Subgroup Center UCL LCL

29 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 RATE OF INSTITUTIONAL U5 DEATHS PER 1 ADMISSIONS - UER RATE OF INSTITUTIONAL U5 DEATHS PER 1 ADMISSIONS - UWR Wave 2 started Wave 2 started 18.1 Subgroup Center UCL LCL Subgroup Center UCL LCL RATE OF INSTITUTIONAL U5 DEATHS PER 1 ADMISSIONS - NR Wave 2 started Subgroup Center UCL LCL

30 Deaths per 1 Admissions 1/3 3/3 5/3 7/3 9/3 11/ 1/3 3/3 5/3 7/3 9/3 11/ 1/3 3/3 5/3 7/3 9/3 11/ 1/3 3/3 5/3 7/3 9/3 11/ 1/3 3/3 5/3 7/3 9/3 11/ Deaths per 1 Admissions Jan Mar Jul-8 Se No Jan Mar Jul-9 Se No Jan Mar Jul-1 Se No Jan Mar Se No Jan Mar Jul-12 Se No Deaths per 1 Admission Jan Mar Jul-8 Sep Nov Jan Mar Jul-9 Sep Nov Jan Mar Jul-1 Sep Nov Jan Mar Sep Nov Jan Mar Jul-12 Sep Nov Ja M M Ju S N Ja M M Ju S N Ja M M Ju S N Ja M M Ju S N Ja M M Ju S N Ja M M Jul Se No Ja M M Jul Se No Ja M M Jul Se No Ja M M Jul Se No Ja M M Jul Se No Ja Jul Se No Ja Jul Se No Ja Jul Se No Ja Jul Se No Ja Jul Se No Deaths per 1 Admissions Deaths per 1 Admissions Deaths per 1 Admissions Rate Under 5 Deaths per 1 Admissions in Our Lady of Grace Hospital, Breman Asikuma, (Jan 28 - Dec 212), U-Chart UCL 22.3 LCL 7.8 Rate Under 5 Deaths per 1 Admissions in Margaret Marquart Hospital, Kpando, (Jan 28 - Dec 212), U-Chart UCL LCL Rate Under 5 Deaths per 1 Admissions in St. Martins de Porres Hospital, Eikwe, (Jan 28 - Dec 212), U-Chart UCL 25.8 LCL 17.5 Rate Under 5 Deaths per 1 Admissions in Mathias Hospital, Yeji, (Jan 28 - Dec 212), U- Chart UCL 23.3 LCL 13.5 Rate Under 5 Deaths per 1 Admissions in St. Francis Xavier Hospital, Assin Foso, (Jan 28-Dec 212), U-Chart UCL 17.4 LCL 8.8 Rate Under 5 Deaths per 1 Amdissions in Catholic Hospital, Battor, (Jan 28 - Dec 212), U-Chart UCL 25.8 LCL

31 Jan-8 Mar-8 May-8 Jul-8 Sep-8 Nov-8 Jan-9 Mar-9 May-9 Jul-9 Sep-9 Nov-9 Jan-1 Mar-1 May-1 Jul-1 Sep-1 Nov-1 Jan-11 Mar-11 May-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Deaths per 1 Admissions 4 Rate 35 3 UCL LCL Launch: Wave 3 Innovation Wave 3 Scale-up Launch

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33 Three + Change Packages Sub District, Hospital & Referral Data Quality Improvement Protocol Improvement Coach Curriculum Designed Need to redefine GHS QI Structure DDCC (facility), DDPH (Community) Strategizing with GHS to reduce Neonatal Mortality Collaboration with RHIOs in seven regions to select Phase One Districts Project Officers positioned for National Scale Up

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