Adaptive Design: The Key Ingredient for Successful Large Scale Improvement Initiatives

Transcription

1 International Forum on Quality & Safety Goteburg, Sweden Adaptive Design: The Key Ingredient for Successful Large Scale Improvement Initiatives Sodzi Sodzi-Tettey MD, MPH, ISQua Salomey Akparibo MPH April 14, 2016

2 2 Objectives Case study format: Project Fives Alive! 1. What are the various design adaptations of PFA!? 2. What did these adaptations result in?

3 Project Fives Alive! AIM: Assist and accelerate Ghana s efforts to achieve COLLABORATORS : Millennium Development Goal 4 (66% reduction in Under-5 mortality to 40/1000 live births by 2015) through the application of quality improvement methods Ambitious Aims Systems View Core Metrics with Feedback Rapid Cycle Tests of local ideas Funded by the Bill & Melinda Gates Foundation

4 Independent Evaluation: UNC Adaptive 4 Development evaluation approach given different phases and national scale up Findings shared with the implementing team in an ongoing manner Evaluation strategy adapted to account for program changes (Patton 2006) The mixed methods approach; quantitative impact analysis, qualitative assessments, cost-effectiveness analysis (CEA) and the analysis of survey data

5 Implementation Scale Up Framework

6 Will Building & Set Up Alignment with Local Health Priorities National Catholic Health Service System transformation through QI was a major strategic focus Ghana Health Service Millennium Development Goals 4 & 5 prioritized Use of local data for improvement QI potential to complement existing QA structure coaching, mentoring, learning networks, rapid cycle tests

7 Scale-Up Design

8 Journey of Adaptive Designing Refocus on System Failures, from Diseases July 2008 Reliance on Routine Data July 2010 NCE-1 (PNC Policy) Hospital-Health Centre Dynamics May Referral Supplemental. May 2015, PFA! end Community Engagement Mar Cost Extension. National Scale Up. August 2015 PFA! end2012 End of Project - initial Nov NCE2. Dec PFA! end Standardized QI Capacity Building Wave 1: Launch. Nov.12 ;PFA initial end date

9 Methodology and Strategy Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Improvement Collaborative Network Health Facilities ACTIVITY PERIOD Repeated improvement cycles: ACTIVITY PERIOD Repeated improvement cycles: Act Study Plan Do Assessment and Design Period Learning Session 1 Learning Session 2 Learning Session 3 Intensive support from project staff & DHMT Source: Associates for Process Improvement months Institute for Healthcare Improvement Change package* of process improvements that had been shown to be effective in similar contexts

10 ANTENATAL PERINATAL Sub-district Change Package Care Pathway Successful Change Idea(s) Facility 1. Registration in 1 st Trimester 2. At least 4 visits before delivery 3. Skilled Delivery & Immediate Postnatal Care 1A. Community stakeholder meetings 1B. Community stakeholder meetings followed by pregnancy registration 2A. ANC offered more days at static site AND clinic process re-design 2B. ANC offered as outreach AND re-design clinic processes re-design 3A. Video show in communities on the risks of labour & delivery 3B. Male advocacy group in communities to promote skilled delivery 3C. TBA engagement on risks of unskilled delivery and provide incentives 3D. Home visits to ANC clients at 36+ weeks 3E. Domiciliary delivery if needed 3F. Create a welcoming, patient-friendly environment in health facility 3G. Create systems to ensure consistent and correct use of partographs 3H. Create systems for reliable neonatal resuscitation C H POSTNATAL 4. Care on Day 1 or 2 5. Care on Day 6 or 7 4A. If facility skilled delivery observe for 24hrs If not, facility or home visit on Day 2 4B. If domiciliary skilled delivery follow-up on Day 2 with facility or home visit. 4C. If unskilled delivery health staff notified,. Home or facility visit on Day 1 or 2 5A. Make appointment for Day 6/7 visit at facility or home. Reminder systems in place 5B. If woman lives in different area, refer to other sub-district for Day 6/7 visit. 5C. If woman lives too far away, train IMCI volunteers to provide Day 6/7 care.

11 Hospital Change Package Driver Area of Clinical/ Community Care Change Concept Package # Description of Successful Change Ideas Delay in Seeking Care Care seeking behaviour Targeted health education 1A 1B Targeted health education on early care-seeking using interactive platforms Community engagement and education via durbar or place of worship Delay in Providing Care Non- Adherence to Protocols Referral Prompt Diagnosis and Treatment Adherence to Protocols Engaging primary providers Triage Fast Track Training/ Coaching/ Mentoring Task-shifting 1C Engagement with health providers (both traditional and 2A 3A 3B allopathic) Triage system for screening and emergency treatment of critically ill children Separate U5 OPD services from adult OPD service Prioritize U5 outpatient care Prioritize U5 inpatient care Training staff on protocols followed by regular coaching and mentoring which include ad hoc testing on site with immediate feedback. Training postpartum women and other care givers on hygienic cord care through demonstration, practice and immediate feedback. Midwives and nurses teach, 3C Mother-to-mother support group on food choices and frequency of feeding while on admission under mentoring of nurses. 3D Empowering nurses to start acting on standard treatment protocols before doctor arrives

12 Hospital Change Package Adoption by October 2014 Drivers of Hospital Based Deaths % of QI Teams Adopting at least one Change Idea (N=134) Comments Early Care Seeking 84.3 Three Change Ideas (H- 1A, 1B, 1C) Prompt Provision of Care 69.4 A Change bundle (H-2A) Adherence to treatment protocols 69.4 Four Change Ideas (H-3A to 3D) Change Idea H -1A H- 1B H- 1C H- 2A H- 3A H- 3B H- 3C H- 3D Proportion of teams testing this change Idea

13 Refocus on System Failures, from Diseases Results from a Journey of Adaptive Designing July 2008 Reliance on Routine Data Wave 1: Launch. Nov.12 ;PFA initial end date July 2010 NCE-1 (PNC Policy) Hospital-Health Centre Dynamics May Referral Supplemental. May 2015, PFA! end Community Engagement Mar Cost Extension. National Scale Up. August 2015 PFA! end2012 End of Project - initial Nov NCE2. Dec PFA! end Standardized QI Capacity Building

14 Tackling Root Causes of Sub-district & Hospital Processes (Program Level Time Series Analysis) 14

15 % of total deliveries conducted by skilled personnel Wave 1 Aggregated Results Skilled Delivery Coverage 100% Wave 1 Collaborative - Skilled Delivery Coverage Aim: 75% of deliveries conducted by skilled personnel NHI free for maternity & early infant care; Project launch; LS1 LS4; spread of successful change ideas Incorporation into Wave 2 80% % 40% 20% 0% Subgroup Center UCL LCL

16 % of neonates registering for PNC on Day 1 or 2 % of PNC registrants receiving care on Day 1 or 2 Wave 1 - Aggregated Results Postnatal Care in 1 st Week of Life 100% Wave 1 Collaborative - PNC on Day 1 or 2 Aim: 85% of neonates to receive PNC on Day 1 or 2 80% LS2; Testing of early PNC change ideas began LS4; spread of successful change ideas & incorporation into Wave 2 100% 80% Wave 1 Collaborative - PNC on Day 6 or 7 Aim: 80% of PNC registrants to receive follow-up care on Day 6 or 7 LS2; Testing of early PNC change ideas began LS4; spread of successful change ideas & incorporation into Wave 2 60% 60% 40% 40% 20% 20% 0% 0% Subgroup Center UCL LCL Subgroup Center UCL LCL

17 Driver Diagram: Under-5 Deaths in Hospitals Outcome Reducing Under 5 Deaths in NCHS Hospitals 1 o Drivers 2 o Drivers Delay in Seeking Care Delay in Providing Care Mobilizing Community Cultural Barriers Financial Barriers Referral from 1 o facility Attractiveness of services Knowledge of 1 o caregiver Emergency response Syst. Outpatient services Staff Issues Admission Process Process Measures Average time of 1st encounter with hospital after onset of symptoms for children U5 Average cervical dilatation of women in labour arriving at Hospital Average Time critically ill U5 identified in hospital to time first treatment is commenced Average Time spent by woman in labor from registration until assessment by midwife of doctor Reliable use of Protocols Staff Knowledge and Skills Availability of Drugs, supplies and equipment Access to Protocols Percentage adherence to selected protocols Average stock out for antimalarial, blood and oxygen

18 Wave 3: Nine Innovation Hospitals Inhibiting Factors: Weak management support Poor team dynamics High Attrition of core QI team members Challenged reporting of process measures

19 National Scale-up of Hospital Change Package 202H 68H 32H 9H

20 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul Hospitals as of August 2015 (Wave 4) 35% reduction in under-5 mortality 54% reduction in postneonatal infant mortality 38% reduction in under-5 malaria case fatality UCL LCL 15.2 Under 5 Mortality Rate (Collaborative Hospitals) in 7 Regions UCL LCL 1-11 Months Mortality Rate (Collaborative Hospitals) in 7 Regions UCL LCL Malaria Case Fatality Rate (Collaborative Hospitals) in 7 Regions Subgroup Center UCL LCL Subgroup Center UCL LCL

21 Creating an Equal Health Worker- Community Platform Independent Evaluation 21

22 Referral: Deeper Community Engagement

23 Improved Access for Poor Women North-Intervention** North-Comparison+ Central-Intervention *** Central-Comparison Baseline Midline Endline Note: Significance from baseline to endline shown: p < 0.1 *p < 0.05 **p < 0.01 ***p < 0.001

24 Improving Health Worker Attitude 24 The midwife here is good and she does not scream at people in labour. As you know, going to deliver is a very painful thing and some of the midwives scream or shout at pregnant woman in labour. [Hairdresser, Central Region, 28 yrs.]

25 QI Team Dynamics 25

26 QI Team Functionality & Achievement Type of QI Team High Functioning/High Achieving High Functioning/Low Achieving Low Functioning/High Achieving Low Functioning/Low Achieving Key Quotations They work together as a unit. They all see it as a responsibility. Certain factors that are outside the facility cause them not to be able to sustain the gains. Whatever they get is because of the few who put so much into it. A team that doesn t execute. You plan, plan, plan and no execution. Pairing high functioning/high achieving teams with teams who performed less well

27 Was the QI Intervention Cost-Effective?

28 Overview of Largest Expense Categories in Wave 1 Expenditures as a Proportion of Wave 1 Budget 33.65% 25.64% 24.54% 5.97% 7.24% 2.96% Professional Training Personnel (fulltime project staff) Capital Costs Equipment Direct Project Indirect Costs Personnel (support staff) Recurrent Costs

29 Was PFA! Cost-Effective? 29 the large expenditures in the pilot phase paid off, not only in the pilot phase itself, but also in the scale-up phases as demonstrated by the reductions in under-five mortality that were significant in the Wave 2 and 4 impact analyses UNC Independent Evaluation

30 Demographic Health Survey Results (2015) The Demographic Health Survey of Ghana coincided with the start (2008) and end (2015) of the Project. Current results show: Under-5 mortality in Ghana reducing from 80 to 60 per 1,000 live births Child mortality (1-4 years) reducing from 31 to 19 per 1,000 live births Infant mortality reducing from 50 to 41 per 1,000 live births Neonatal mortality reducing from 33 to 29 per 1,000 live births

31 Wide & Deep Capacity Building Sustainability

32 ~ 400 Improvement Coaches Trained for Scale Up 10 Regional Quality Advisors ~ 3000 Site Visits ~ 4000 frontline workers trained in LSs

33 Africa based Quality Institute Formed Objectives: Centre of QI Excellence for regional support Partnership with IHI Set global standards for development and implementation of large-scale QI initiatives Deliver QI educational content, spur innovation in QI, and challenge conventional thinking Facilitate learning opportunities for organizations, professionals, and students keen to learn about QI implementation Offer basic and advanced online education learning options, and sponsor periodic benchmarking visits

34 Ghana QI Sustainability Work IHI-Ubora Collaboration to Hold the Gains Ministry of Health Objective 2: Strengthen the Ubora Institute to sustainably support the national quality improvement strategy, coordination and programming in Ghana and across the African Region Objective 1: Strengthen national-level sponsorship for a health system that mainstreams and integrates QI methodologies Funded by the Bill & Melinda Gates Foundation Nov. 15 Oct. 2018

35 Lessons Learned 1. Complement QI with QA 2. Plan project with end in mind at the beginning 3. Co-ownership, co-creation, co-design and coimplementation with health system managers are crucial for sustainability 4. Complement reliance on routine data systems with robust data quality improvement protocols 5. Communication / dissemination are part of the work 6. Need to design even more cost-effective spread strategies

36 PFA! Lessons Learned Guide Large Scale Initiatives: What Worked, Likely Pitfalls, Useful Lessons Project Design Relationships Leadership Human Resources QI Capability Measurement Communication salivelessonslearnedguide.aspx

37 Thank You Questions & Discussions 37