The HHS Afghan experience with EmONC implementation science. Wednesday, January 20, 2011 WHO- CARE Meeting Brian J.

Transcription

1 The HHS Afghan experience with EmONC implementation science Wednesday, January 20, 2011 WHO- CARE Meeting Brian J. McCarthy, MD, MSc

2 Take home messages Two Questions you have to answer Have we chosen the right things to do? Are we doing those things right? The unit of operation is the chain Process for improving the quality of life & care Quality is a local product, everyone s responsibility, and is job #1 Get the count right.or at least close

3 The creation of the MIM Storyboard Management Future Plans Problem Definition Surveillance Performance Assessment + Standardization Monitoring & Evaluation Intervention Are we doing the right things? Are we doing things right? = The MIM Storyboard

4 The EmONC Chain Developing critical Public Health & clinical systems to make the chain safe At the community level, everyone counts!...so account for mother and newborn Labor Deliver y Recove ry OR Community Surveillance CARE OMID CBE Midwifery Maternity Care Center 3 Centering Pregnancy Groups (CPG) CPG CPG CPG CPG 1 CHC CHC+ 2 ER room District Hospital X OPD Recor d Newbor n RBH focus on EmOC a critical link for chain integrity; clinical care improvements are based on QA principles and techniques consistent with PH functions and services. 4 Postpartum Child The AHI PH Strategy supports development of MoPH capacity in MCH surveillance, performance assessment analysis, intervention. monitoring and evaluation. 5 RBH The chain is as strong as its weakest link

5 What are we going to do?

6 Proposed EmOC Safety Program EmOC Safety Pre- hospital In-hospital Post Hospital Follow-up ANC Triage Decision Tree Surgical Skill PNC Follow-up Birth Planning Medical Rx Hospital Infection Prevention Program Mother Previous C-section Microbiology lab development Newborn Site Anesthesia Blood system Indicators Attendant Pharmacy Critical Care OB Contraception Transportation Nursery Infection Emergency Communication Transportation Fistula Post Partum Depression

7 Components of the EmONC System Pre-hospital In-hospital Post-hospital Hospital Infection Prevention Program Infection, fistula, contraception Pre -eclampsia APH Eclampsia Sepsis PPH Obstructed labor Chain of custody Triage Decision Tree Surgical Skill Blood System Anesthesia Pharmacology Newborn resuscitation

8 Quality Improvement Collaborative Projects Baseline Select topic decrease decision to incision times Develop Framework & Changes Participants Prework A P S D A P S D Expert Meeting LS 1 LS 2 LS 3 Planning Group The Institute for Healthcare Improvement Change Practices

9 The Team

10 Afghan EmONC Safety Program Implementation Science Team (IST) EmONC IST Senior Technical Advisor Admin MCH FETP URC liaison Public Health OB/GYN Pediatric Clinical Practice Midwifery Technical Support & Training WRA MM Surveillance Individual RBH Epidemiology 5R Table Surveillance Hospital MMCC QA/QI process Community IT

11 Assessing performance of one node in the chain

12 What is a POA? (Patient Outcome assessment) The POA is an adaptation of the CDC Patient Flow Analysis (PFA). Nine (9) facility observational posts are manned continuously 24/7 to collect data on all pregnant patients admitted to the hospital over a 28 day period. The purpose of the POA is to collect data on patient flow, clinical practices in the monitoring of labour, delivery, caesarean sections, post partum and neonatal care, in order to provide up-dated information to MOPH/RBH for decision making for improving the care of mothers and babies

13 POA III at RBH Outcome results for 28 POA III days 1244 women delivered 1273 newborns (25 twins, 2 triplet) 2 maternal deaths 77 total perinatal deaths 58 deaths in newborns 2500+g Perinatal Mortality Rate (PMR) Total (68.3/1000), real (~110/1000) (26.5/1000) Very high risk population 16.3% LBWR C-section rate 6.6% Vaginal delivery = 20.6/1000 C-section PMR = 75/1000 Multiple gestations 17% of all perinatal mortality Labor room 43% no BP or FHR monitored 63.8% no BP 56.2 no FHR Average patient to MW ratio is 10:1 Can be as high as 22:1 Delivery room 78.4 no BP or FHR monitored 85.8 no BP 89.8 no FHR Average patient to MW ratio is 8:1 Can be as high as 18:1 High risk births identified in the OPD Appropriate monitoring (PMR = 31/1000) Inappropriate monitoring (PMR = 120/1000) 55% of high risk delivered by Midwives C-section Decision to Incision (DI) time 12% in < 30 minutes 26% > 2 hours When decision made in the OPD, no DI < 1 hr

14 POA III (October, 2008) vs POA IV (February, 2010) 28% reduction in MMR associated with EmOC system Reversal of General Anesthesia to spinal anesthesia (95% to 5%, then 5% to 95%) DIT less than 30 min from 12% to 23% No change in the rates of monitoring in Labor and delivery room No reduction in BWSMR

15 The Chain takeaway messages The Chain is essential for achieving the maternal and newborn goals of MDG 4 & 5 Success is about planning, implementing, and evaluating the chain using the MIM Storyboard. The Chain is a system solution that is best described by 5 Rights, x 2, plus 1 Is best developed as a whole, and NOT in segments develop the infrastructure of the chain for coverage, matching skill with need, defining the referral pattern, altering risk factors through prevention. The Chain must be ethically guided No surveillance without service, no service without surveillance Do no harm Promote ethical equivalency in patient care along the Chain The Chain must: Get the count right...account for every mother and child Match skill with need Eliminate the 4 delays through its referral pattern Alter risk factors...have a prevention focus BE SAFE! Avoid outcome displacement Account for all mothers and newborns Link outcome indicators with process indicators. Assure & Assess EmOC package safety... Quality Improvement Process (QIP) helps assure the package is life saving, rather than life threatening. Safely, within 30, 24/7. The Chain s quality is a local product, is everyone s responsibility, and is job 1! Process for establishing a quality culture in the chain Process for developing the Local Indicator Matrix (LIM) LIM Scaled up using the IHI model for quality improvement collaborative (QIC) Quality services will require data being translated into information for local action at service faculties by empowered local staff.

16 END

17 What is the best way for HHS to serve MOPH? WHO s 5 C s with all our partners (Collaborate, coordinate, cooperate, communicate, to build community) MOPH USAID H4+, JICA Short term (6 months) Strengthen EmONC safety program at RBH Assure RBH chain integrity Initiate development of the MCH FETP Implementation Science team Intermediate (6 18 months) Fully developed RBH EmONC safety program Initiate Kabul EmOC Safety program Initiate MCH FETP Long term ( 12 months to 36 months) Country wide EmONC safety program Established MCH FETP Competency based EmONC certification OB/GYN residency program Hospital accreditation process for EmOC services JCI collaboration

18 How can Dr Dalil help HHS serve the people of Afghanistan? Budget CR contingencies RBH staff switched to PRR Drug supplement transparency RBH Tashkil increase Midwives Residency consistency IT Adm personnel IST Identify MOPH counterpart for IST categories Move quickly to establish FETP MCH FETP in-country Midwives Consider using Global funds for MCH FETP and programs related to it Maternal health EmOC safety program Collaborate South-to-south EMR collaboration Integrated EMR

19 Objectives Afghan Health Initiative (AHI) Review The MIM Storyboard Future focus Community and EmOC and their linkage ( the chain ) South to south collaboration (Ethiopia) MOPH Implementation Science Team (IST) MCH FETP Afghan EmOC safety program scale up Surveillance EMR Patient Outcome Assessment (POA) adaptation on EmOC QuIP protocols RBH Storyboard Peer review publication & conferences National conferences

20 Recent AHI reviews MOPH EmONC safety USAID Demonstration project QA/QI process in RBH chain Chain quality & integrity CDC Director USAID has the health lead, support USAID Collaborate, Compliment & coordinate EmOC Chain safety Transition to wider role to build MOPH system RBH as demonstration project for chain operation and safety More linkage within chain Develop MOPH public health functions and essential services APHI development Implementation Science Team (IST) MCH FETP Work closely with USG, H4+, JCI, JICA, USAID (URC), & NGO partners

21 Afghan Conceptual Framework Evolution HHS MOPH Public Health Activities Hospital Man ment Activities Professional Education Clinical Practice Activities RBH APHI Community RBH Minisystem RBH Institute for Health Sciences (IHS) Med Sch & Med Res RBH Minisystem RBH

22 Afghan EmONC Safety Program Implementation Science Team (IST) EmONC IST Senior Technical Advisor Admin Public Health OB/GYN Pediatric Clinical Practice Midwifery Technical Support/Training

23 Backup slides

24 The local indicator matrix Outcome Impact Intervention Impact Indicator Process Output The 5 A s Input

25 Chain Integrity AHI Focus Public Health Practice Community Surveillance CARE surveillance Home based record Reproductive age women 5 R Tables QA/QI KAP Block MMCC Surveillance Medical record QA/QI Partograph RBH Surveillance 5 R Tables POA IV Analysis Partograph EMR QA/QI QuIPs (Consent, ID, Triage, etc) Clinical Practice Community AMTSL Referral MMCC AMTSL Partograph Referral RBH Clincal Decision tree Surgical Skill Systems Infection control Anesthesia Blood Pharmacy

26 POA III at RBH Outcome results for 28 POA III days 1244 women delivered 1273 newborns (25 twins, 2 triplet) 2 maternal deaths 77 total perinatal deaths 58 deaths in newborns 2500+g Perinatal Mortality Rate (PMR) Total (68.3/1000), real (~110/1000) (26.5/1000) Very high risk population 16.3% LBWR C-section rate 6.6% Vaginal delivery = 20.6/1000 C-section PMR = 75/1000 Multiple gestations 17% of all perinatal mortality

27 POA III at RBH Surveillance indicators to detect problem Labor room 43% no BP or FHR monitored 63.8% no BP 56.2 no FHR Average patient to MW ratio is 10:1 Can be as high as 22:1 Delivery room 78.4 no BP or FHR monitored 85.8 no BP 89.8 no FHR Average patient to MW ratio is 8:1 Can be as high as 18:1 High risk births identified in the OPD Appropriate monitoring (PMR = 31/1000) Inappropriate monitoring (PMR = 120/1000) 55% of high risk delivered by Midwives C-section Decision to Incision (DI) time 12% in < 30 minutes 26% > 2 hours When decision made in the OPD, no DI < 1 hr

28 Patient Count by Block

29 Block 411 drill down in POA III 100 women 57 without any risk factors after OPD assessment No low birth weight newborns No C-sections No deaths 2 perinatal deaths One 2500+

30 Block 411 drill down in POA IV

31 Building the LIM using BABIES to identify priority intervention packages g g g Total 5 9 AP IP PreD PostD yr Total Pre-pregnancy health Family Planning Nutrition "ART" for complications Substance Abuse Anticipatory Guidance NICU Care for < 1500 gms FP acceptor rate Anemia rate Referral rate Smoking rate 1 st trimester ANC rate Pre-pregnancy health Family Planning Nutrition FP Acceptor Rate Anemia Rate Out - 1 A - 1 A - 2 A - 3 A - 4 A - 5 In - 1 Out - 1 A - 1 A - 2 A - 3 A - 4 A - 5 In - 1 Out - 1 A - 1 A - 2 A - 3 A - 4 A - 5 In - 1 Out - 1 A - 1 A - 2 A - 3 A - 4 A - 5 In - 1 ART Referral Rate Out - 1 A - 1 A - 2 A - 3 A - 4 A - 5 In - 1 Out - 1 A - 1 A - 2 A - 3 A - 4 A - 5 In - 1 Substance Abuse Smoking Rate Out - 1 A - 1 A - 2 A - 3 A - 4 A - 5 In - 1 Out - 1 A - 1 A - 2 A - 3 A - 4 A - 5 In - 1