CLINICAL GOVERNANCE Fostering a culture of learning,

Transcription

1 CLINICAL GOVERNANCE Fostering a culture of learning, quality, and accountability within hospitals and health centers to ensure maternal and newborn survival TECHNICAL REPORT SEPTEMBER 2015

2 TABLE OF CONTENTS EXECUTIVE SUMMARY INTRODUCTION... 3 Clinical governance EMAS APPROACH TO STRENGTHENING CLINICAL GOVERNANCE IN HOSPITALS... 4 Mentoring to strengthen clinical governance... 7 Quality, accountability, data use, and learning in clinical governance... 7 Tools and practices to strengthen clinical governance IMPLEMENTATION: STRENGTHENING CLINICAL GOVERNANCE IN EMAS-SUPPORTED FACILITIES Performance standards Service statistics records of the evidence-based practices Clinical dashboards Maternal and neonatal death reviews and near-miss reviews Emergency drills RESULTS: DOES IMPROVED CLINICAL GOVERNANCE LEAD TO IMPROVED FACILITY READINESS AND GREATER COVERAGE OF EVIDENCE-BASED INTERVENTIONS? Clinical governance practices in place Improved facility readiness to provide EmONC Increased coverage of key interventions INSTITUTIONALIZATION OF PRACTICES TO IMPROVE CLINICAL GOVERNANCE LESSONS LEARNED AND RECOMMENDATIONS APPENDIX 1: EVIDENCE-BASED INTERVENTIONS APPENDIX 2: PERFORMANCE STANDARDS FOR HOSPITALS AND PUSKESMAS APPENDIX 3: HOSPITAL PERFORMANCE BY TOOL APPENDIX 4: EMAS RESOURCES FOR CLINICAL GOVERNANCE REFERENCES ENDNOTES... 31

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4 EXECUTIVE SUMMARY The Ministry of Health (MOH) of Indonesia is working to reduce the high levels of maternal and neonatal mortality. In support of these efforts, the United States Agency for International Development-funded Expanding Maternal and Neonatal Survival (EMAS) Program developed a strategy to strengthen clinical governance in 150 hospitals and 300 community health centers (puskesmas) across six provinces. EMAS drew upon the experience of its partner, Budi Kemuliaan Health Institution (known as Lembaga Kesehatan Budi Kemuliaan [LKBK]), that effectively uses clinical governance in its large maternity hospital in Jakarta to catalyze providers and managers within the health system, to change the culture of clinical care, and to make health workers more accountable for providing quality care. EMAS selected several mutually-reinforcing clinical governance practices that could be transferred to other facilities within 9 16 months. These practices included: performance standards; maternal and neonatal death reviews and near-miss reviews; emergency drills; clinical dashboards; and standardized service statistics on the provision of evidence-based interventions for maternal and newborn health (MNH). Increased frequency and rigor of these practices are expected to increase accountability and improve learning based on review of prior performance. Clinical governance was introduced at each EMAS-supported facility via a systematic mentoring process that provides on-site peer-to-peer support. To more closely examine the effect of good clinical governance on the quality of care, progress was monitored on clinical governance practices. These practices were expected to result in increases in facility readiness to offer MNH emergency care and increase coverage of key evidence-based lifesaving interventions. EMAS experience has shown that clinical governance catalyzed providers and managers, changed the culture of clinical care in health facilities, and made health services more accountable for providing quality care. As of mid-2015, EMAS used mentoring to strengthen clinical governance within 22 hospitals and 93 puskesmas in Phase 1 (beginning in 2012) and then expanded into an additional 51 hospitals and 122 puskesmas in Phase 2 (from 2013). Results of this support include: The EMAS-introduced practices were well-received, as evidenced by uptake. For example, death review processes are in place at all EMAS-supported facilities. From Year Two to Year Three, EMASsupported Phase 1 hospitals that conducted the reviews for maternal deaths increased from 48% to 70% and for newborn deaths from 39% to 44%. In the same period, puskesmas also audited higher percentages of deaths. Good clinical governance has led to increases in compliance with performance standards for facility readiness to respond to emergencies. Baseline scores in all facilities were negligible (<10%). By the end of Year Three, a majority of Phase 1 hospitals had achieved at least 80% of the performance standards. Similar increases have been seen in Phase 2 facilities. By Year Four, coverage of key MNH interventions had increased. From January March 2013 to the same period in 2015, Phase 1 hospitals increased uterotonic use in the third stage of labor from 92% to 100% and provision of antenatal corticosteroids for preterm birth from 42% to 75%. Increases in coverage of other interventions were reported, and data from Phase 2 facilities showed similar improvements. P a g e 2 EMAS: Clinical Governance Technical Report, September 2015

5 1. INTRODUCTION In Indonesia, the Ministry of Health (MOH) has implemented numerous policies to strengthen the health system in support of maternal and newborn health (MNH) (Van Lerberghe et al. 2014). Providers, including more than 200,000 midwives, have been trained at all levels of the health system (National Academy of Sciences 2013). Comprehensive emergency obstetric and newborn care (EmONC) facilities are equipped and staffed (World Bank 2014). Currently, 63% of births occur in health facilities, and over 80% of deliveries are attended by a skilled provider (Central Bureau of Statistics et al. 2013). Yet, the maternal mortality ratio is one of the highest in Southeast Asia at 359 per 100,000 live births, and there has been no progress in reducing newborn deaths for more than a decade (Central Bureau of Statistics et al. 2013). Clinical governance To accelerate reductions in maternal, perinatal, and newborn mortality, a fresh approach was needed. Clinical governance was identified as a way to catalyze providers and managers within the health system, to change the culture of clinical care in health facilities, and make health workers more accountable for providing quality care. Broadly, good governance ensures that an organization fulfills its overall purpose, achieves its intended outcomes for its citizens and service users, and operates in an effective, efficient and ethical manner (Office for Public Management Ltd. and The Chartered Institute of Public Finance and Accountancy 2004). Clinical governance as a concept originated in the 1990s in the United Kingdom s National Health Service (Halligan and Donaldson 2001), and there are numerous clinical governance models from high-income countries (Phillips et al. 2010). Although there is no universally-accepted definition of clinical governance, it can be summarized as a robust framework that acknowledges the importance of adopting a culture of shared accountability for sustaining and improving the quality of services and outcomes for both patients and staff (McSherry and Pearce 2011). Common elements from different models include: accountability, an organizational culture that prioritizes quality and safety, and the importance of data that are relevant to organizational purposes, timely, accurate, valid, reliable, and complete (Ramsay et al. 2010). From the start of the United States Agency for International Development-funded Expanding Maternal and Neonatal Survival (EMAS) program 1 in 2011, strengthening This technical report describes how EMAS has strengthened clinical governance in health facilities in its first three years of implementation including lessons learned and results to date in improving clinical governance and increasing coverage of key clinical interventions. systems for good clinical governance has been the vehicle for turning MOH policies and approaches into high-quality services that are sustained over time. EMAS was launched to accelerate reductions in maternal and newborn mortality by improving the quality of EmONC within health facilities and strengthening the referral network to ensure efficient and effective referrals from puskesmas to hospitals. EMAS also works to strengthen accountability EMAS: Clinical Governance Technical Report, September 2015 P a g e 3

6 amongst government, the community and health system by supporting district-level civic forums that engage civil society in MNH issues and pokjas (working groups) that help resolve issues and barriers identified by health facilities and others that impact maternal and newborn survival. 2 EMAS is a partnership of five organizations Jhpiego (lead partner), Lembaga Kesehatan Budi Kemuliaan (LKBK), Muhammadiyah, Save the Children, and RTI International. Over five years, EMAS is working with at least 150 hospitals (both public and private) and more than 300 puskesmas across the six provinces (North Sumatra, Banten, West Java, Central Java, East Java, and South Sulawesi) where nearly 50% of maternal and neonatal deaths in Indonesia occur. 2. EMAS APPROACH TO STRENGTHENING CLINICAL GOVERNANCE IN HOSPITALS The idea of focusing on clinical governance as a means to improve and sustain quality EmONC came from the first-hand experience of EMAS partner, LKBK. As the Budi Kemuliaan Health Institution, LKBK operates health facilities (a hospital and maternity clinics), conducts research, and runs training courses and a midwifery school. The LKBK hospital is the largest and oldest maternity hospital in Indonesia Budi Kemuliaan Maternity and Children Hospital, known as RSIA Budi Kemuliaan. With good clinical governance and respectful care as its organizational philosophy, the hospital exemplifies how strategic leadership, accountability and a culture of learning result in highquality maternal and newborn care. Assisting an average of 7,000 deliveries a year, RSIA Budi Kemuliaan achieved the World Health Organization (WHO) recommended direct obstetric case fatality rate of less than 1% in 2014 (WHO 2009). With a mission to serve all socio-economic classes, over half of women (57.5%) receiving inpatient care in 2014 were covered by national health insurance. By any measure, LKBK runs a high-performing hospital and credits its success to good clinical governance (Box 1). Using RSIA Budi Kemuliaan as an inspiration and a model, EMAS developed a systematic approach for building strong clinical governance systems as a means to increase accountability and drive quality improvement within its supported facilities. EMAS uses the term clinical governance to capture its activities at different levels within the facility, including clinical practice by providers and clinical management (i.e., Box 1. Clinical Governance at Work: Budi Kemuliaan Maternity and Children Hospital Models How a Hospital Can be a Learning Organization Since 2006, Budi Kemuliaan Maternity and Children Hospital (RSIA Budi Kemuliaan) has worked to improve clinical governance hospitalwide. The hospital embraces accountability, learning, strategic leadership, informed decisionmaking, and a commitment to quality, respectful care. RSIA Budi Kemuliaan models these principles and its clinical governance systems to EMASsupported hospitals and puskesmas across six provinces. Key approaches include: Nurturing strategic leadership and learning organization throughout the health facility by putting clear and accountable systems and structures in place. Creating a culture of quality assurance by using mortality audits, near-miss reviews, routine clinical meetings, and emergency drills. Conducting weekly meetings to discuss nearmiss cases and clinical dashboards that show how individual wards/units are performing against pre-determined targets. Encouraging clinical managers to use dashboards daily to monitor performance. Instituting more formal channels of communication among hospital management, specialists, other providers, and unit heads. Improving referral processes by making concerted efforts to network with all midwives in their catchment area. processes and procedures to deliver quality care) by ward/unit managers (Brennan and Flynn 2013). The clinical governance experience at RSIA Budi Kemuliaan helped define the cornerstones of the EMAS approach: P a g e 4 EMAS: Clinical Governance Technical Report, September 2015

7 Respecting patients Efforts to improve quality begin with a shared vision of respect for women and their newborns. Consensus among leadership and staff in a health facility and in local government leads to action to improve performance of health facilities so all mothers and babies receive the highest quality of care. Principles of Good Care EMAS developed a set of Principles of Good Care as the norm to ensure quality and safety. The principles include communication (among staff and with patients), workplace organization, privacy, infection prevention, and documentation. They serve as a way to build consensus and set a vision. Improving clinical effectiveness To ensure MOH national clinical guidelines are implemented and followed, tools are used to help health care providers to deliver this standard of care. Data are generated and presented visually on dashboards to monitor performance. Quality improvement processes are facilitated to identify gaps and create action plans. Wards/units and providers are accountable for providing quality care. Strengthening communication Processes that support open and regular communication (as part of the learning organization 3 culture) are introduced and institutionalized across different cadres of staff, across units, and with management. Collecting client feedback also is an important part of strengthening communication with clients and the community. Building strong leadership at all levels of management Providers (including professionals and frontline leaders) and managers in health facilities are inspired and supported to measure progress, make changes that improve and sustain quality maternal and newborn health services, advocate, and foster a culture of quality and learning. To help facilities establish good clinical governance, EMAS drew upon LKBK s experience and selected several mutuallyreinforcing practices that could be transferred to other facilities within 9 16 months. EMAS developed a causal pathway (Figure 1) to monitor progress in establishing clinical governance practices in EMAS-supported facilities, which were expected to result in improved facility readiness to provide EmONC and increase coverage of key evidence-based lifesaving interventions. 4 Principles of good care EMAS: Clinical Governance Technical Report, September 2015 P a g e 5

8 Figure 1. Causal pathway to strengthen clinical governance as a means to improve quality of EmONC and increase coverage of key life-saving MNH interventions THEORY OF CHANGE: CLINICAL GOVERNANCE 1) EMAS-supported clinical governance practices in place 2) Improved facility readiness to offer EmONC services INCREASED COVERAGE OF KEY INTERVENTIONS The expectation is that improved clinical governance would lead to high coverage of key practices (i.e., evidence-based interventions selected by EMAS described in Appendix 1) which in turn should improve clinical outcomes and increase survival. To further illustrate how EMAS designed and implemented activities intended to strengthen clinical governance, Figure 2 depicts how EMAS used clinical mentoring to introduce the concept of clinical governance and selected clinical governance practices. Use of these good governance practices catalyzed changes within the health facility greater communication, teamwork, data use, strategic leadership, learning, and clinical excellence. These types of organizational properties interact positively with each other and have a synergistic effect that strengthens clinical governance. Figure 2. EMAS tools and practices to strengthen clinical governance in health facilities P a g e 6 EMAS: Clinical Governance Technical Report, September 2015

9 Mentoring to strengthen clinical governance To introduce and strengthen clinical governance throughout a large number of facilities, EMAS developed a unique process of on-site peer-to-peer clinical mentoring at targeted health facilities. Through this pendampingan (meaning side by side ) approach, staff of the mentoring hospitals conduct a cycle of exchange visits. This approach was innovative for several reasons. Unlike a traditional mentoring relationship between a senior professional and a younger mentee, EMAS developed leaders or champions who work with peers to model best practices and help address problems. Instead of focusing on individuals, mentoring occurs in teams. For example, a team of five to seven providers from RSIA Budi Kemuliaan visited an EMAS-supported hospital and worked in multiple wards over several days. This design fostered a sense of teamwork among staff at supported facilities. Mentoring occurs on-site at the supported facility so it is very practical and targeted to specific qualities and needs of each site and at each visit. Because of the nature of the relationship between mentors and mentees, communication by phone or SMS continued regularly between visits. EMAS introduced clinical governance practices in puskesmas and hospitals through mentoring over a series of mentoring visits (see the EMAS technical report on clinical mentoring for more detail). The mentoring cycle includes two visits by hospital/health center leadership, district officials, and EmONC providers (specialists, doctors, and midwives) to the mentoring hospital (e.g., RSIA Budi Kemuliaan) to learn about their clinical governance and to observe their practices, teamwork, and the learning organizational culture. By the end of these visits, facilitated discussion often described by participants as an awakening (kebangunan) built commitment within health facilities and district health office (DHO) management. The mentoring cycle also includes four to six mentoring visits by the mentoring hospital to each mentee hospital and selected mentee puskesmas in a district to introduce the tools and practices to improve clinical governance. A team of five to seven doctors, midwives, and nurses from the mentoring hospital work side by side with mentees throughout one week. Typically, mentee facilities start to use performance standards, which assess the facility s readiness to provide emergency care. Standards are used to conduct a baseline assessment, develop an action plan, and advocate for changes with stakeholders. Over the course of the mentoring cycle, other tools and practices are introduced, explored and/or strengthened for good clinical governance. During each mentoring visit, progress on the action plan is reviewed and updated. The process is very participatory and engages all staff in the facility to nurture strong hospital leadership and increase dialogue. Mentoring visits are conducted until a facility achieves the desired level of good clinical governance, and then those facilities become mentors for additional facilities. Quality, accountability, data use, and learning in clinical governance Accountability is at the heart of good clinical governance. While clinical governance in other health systems holds individuals accountable for poor performance (e.g., termination, litigation), EMAS emphasized social, professional, and personal accountability as a way to catalyze change. In the way EMAS sets a vision and awakens staff and district officials, there is a feeling of accountability to society, mothers and the new generation (i.e., newborns) that inspires a commitment to improvement. Within daily management and clinical practice, EMAS promotes accountability for quality EmONC at different levels by creating systems, clarifying roles, and encouraging discussion across units and with management. Community feedback mechanisms and the relationships with the DHO, district working groups (Pokjas), and civic forums extend accountability beyond the facility. EMAS: Clinical Governance Technical Report, September 2015 P a g e 7

10 By design, health facilities are expected to provide quality health care for all. Clinical competence and emergency readiness for maternal and newborn health are supported by EMAS. Providers individually need to have updated knowledge and skills, and collectively they need to work effectively as a team. In order to truly hold facilities and providers accountable, performance needs to be measured and tracked over time. Data use for measuring and monitoring performance and outcomes is a routine practice in high-performing, well-governed organizations. When EMAS began working in target facilities, data use and visualization to measure performance and inform decision-making were not practiced. Data collection and reporting were disconnected from performance. Increasing access to and use of relevant and reliable data on EmONC to assess performance has been a priority for strengthening governance in EMAS-supported facilities (see the EMAS technical report on strengthening data systems for more information). EMAS strengthened health information recording and reporting practices to ensure that quality data on key health outcomes were available. Increased accountability was possible only because changes were made to data collection systems to produce relevant data of sufficient quality that adequately reflects actual performance and clinical outcomes. At the organizational level, strategic leadership and a learning culture were modeled by LKBK and introduced primarily through clinical governance practices that involved data use and Data use and action plans. The idea of a health facility with an visualization on organizational commitment to learning was very the ward new in all facilities. EMAS strengthened organizational learning by giving staff simple ways (e.g., clinical dashboards) to see what they were doing well and when changes were needed. Mentoring visits focused on improved data quality, visualization, and feedback into decision-making and quality improvement within facilities. EMAS staff visits and data for decision-making (D4D) workshops also helped facilities to use their data and realize its importance. Data use gave staff practical experience about how a learning organization operates and how an organization s culture can encourage learning. Clinical governance created more constructive opportunities for communication and teamwork. Health care providers, management, and district officials openly assessed and discussed issues related to quality of EmONC. Prior to EMAS, these groups rarely sat together for discussion, but the introduction of practices such as performance standards and drills created a joint purpose. Communication improved on many levels: among different cadre of providers who work together, across wards/units, between providers and management, and between the puskesmas and hospital staff. Even communication and support from district officials for facilities improved as a result of clinical governance activities, particularly action planning which brings disparate groups together to review challenges and find solutions. Finally, accountability includes the facility s accountability to its clients and community it serves, which is fundamental component of clinical governance frameworks. LKBK s emphasis on respectful care and P a g e 8 EMAS: Clinical Governance Technical Report, September 2015

11 communication brought the idea of external accountability into the EMAS approach, and community feedback is part of clinical management tools for hospitals. External accountability is supported by other EMAS program activities that improve the referral system and engage civic forums and district working groups. Tools and practices to strengthen clinical governance EMAS promoted the larger issues of accountability, communication, and learning within the health facilities through the introduction and use of five practices purposefully selected to strengthen clinical governance. Table 1 summarizes each practice. Table 1. Facility-based tools and approaches by level as defined by Brennan and Flynn, 2013 Practices and Tools Description Frequency Hospital Management: Clinical governance is structures, systems, and standards applied to create a culture, and direct and control clinical activities. Clinical accountability and responsibility, a sub-set of clinical governance, involves monitoring and oversight of clinical activities, including regulation, audit, assurance and compliance 1. Performance standards 2. Maternal and neonatal death reviews and nearmiss reviews (facility) A set of tools that define facility readiness to prevent and manage selected complications and include management (e.g., infection prevention, clinical governance, client feedback). The content is consistent with MOH national clinical guidelines. Reviews use a simplified case review process for every maternal death, fresh stillbirth, and neonatal death (> 2000 grams), as mandated. (MOH 2010) Quarterly, with an action plan to address gaps Within 24 hours Ward/unit management: Clinical management includes processes and procedures to efficiently, effectively and systematically deliver high quality, safe clinical care 3. Emergency drills Maternal and neonatal emergencies are simulated to practice emergency responsiveness, improve teamwork, maintain skills and resolve possible delays (e.g., client flow, emergency trolleys). Drills are scheduled and logged in a register when conducted. As needed 4. Clinical dashboards Color-coded charts display the most important clinical and operational indicators, chosen by each unit/ward. They are used by staff to assess performance and taken action when sub-optimal performance is indicated. Weekly Provider: Clinical Practice is delivery by clinicians of high quality, safe clinical care in compliance with clinical policies and performance standards, in the interest of patients 5. Service statistics on the provision of evidence-based interventions for Data on the provision of selected evidence-based interventions* are aggregated monthly from the standardized registers by EMAS staff and analyzed to track coverage. Monthly performance is charted on laminated D4D posters Daily recording, monthly reporting EMAS: Clinical Governance Technical Report, September 2015 P a g e 9

12 MNH Practices and Tools Description hung on walls in the facilities to visually display the trends over time. Frequency (including on wall charts) *See Appendix 1 for the list of evidence-based interventions for which service statistics are routinely collected by EMAS. 3. IMPLEMENTATION: STRENGTHENING CLINICAL GOVERNANCE IN EMAS- SUPPORTED FACILITIES EMAS worked to strengthen clinical governance in 22 hospitals and 93 puskesmas in Phase 1 (beginning in 2012) and then expanded into an additional 62 hospitals and 122 puskesmas in Phase 2 (from 2013). In all facilities, selected clinical governance practices and tools have been introduced and established through mentoring. These practices and tools reinforce each other to change the organizational culture and are supported by concerted efforts to engage leadership at all level. Each of the five practices to strengthen clinical governance is described below. Performance standards Building on Jhpiego s global experience, EMAS developed a set of performance standards to operationalize evidencebased practices for EmONC based on the existing national clinical guidelines. These standards focus on facility readiness for responding to obstetric and neonatal emergencies. They address the top causes of mortality postpartum hemorrhage (PPH), eclampsia, sepsis, and obstructed labor for mothers; and asphyxia, sepsis, and low birth weight/pre-term birth for newborns. Infection prevention standards also are included. EMAS compiled two sets of performance standards (see Appendix 2). For hospitals, there are 16 tools and a total of 118 standards. They are designed for use in the delivery room, postpartum ward, perinatal ward and neonatal intensive care Box 2. Examples of Clinical Governance performance standards Health facility uses clinical dashboards to monitor and evaluate its activity trend and quality. Health facility performs routine review/audit on near miss cases. Health facility performs audit on each intrauterine death case and neonatal death. unit (NICU), operating room, and emergency unit. Hospitals also use clinical management standards that measure some clinical governance practices and mechanisms for client feedback (see Box 2). For puskesmas, there are 5 tools (a total of 39 standards) on maternal and newborn care and infection prevention. Facilities can score their performance every quarter and compare scores over time to measure progress. Overall, facilities aim to score 80% or higher on each tool and collectively as an indication that they are prepared to provide evidence-based EmONC services. Standards were used quarterly to assess facility readiness, and findings were shared with the existing teams (such as the hospital EmONC [PONEK] team) and prioritized in an action plan. This process engaged the units and management to work as a team within the facility. Scores were calculated for each facility and tracked over time. EMAS aggregated facility progress and reported program progress quarterly and annually (see Figures 5a and 5b in Results section). EMAS staff and mentoring teams P a g e 10 EMAS: Clinical Governance Technical Report, September 2015

13 helped staff conduct the quarterly assessments and over time, facility staff began to conduct them independently. To date, performance standards have been well-received by facility staff and management, as well as district and provincial health offices. Private sector facilities, such as Muhammadiyah hospitals, have shown high acceptance of these tools. EMAS continues to work with the MOH to institutionalize their use within existing quality assurance and/or accreditation processes. Service statistics records of the evidence-based practices Service statistics are the data in patient records and ward/unit registers that record the type of care provided and health outcomes. These data are routinely collected in health facilities. Because the health management information system (HMIS) is decentralized in Indonesia, there is considerable variation across wards/units and facilities in terms of what data are recorded, and data is rarely meaningful. The flexibility within the decentralized HMIS was an opportunity for EMAS to help facilities strengthen and standardize the data collection process so staff could measure and track performance. EMAS introduced pre-printed standardized registers (in place of commonly-used blank books with hand-written data columns) to strengthen the recording and reporting systems in facilities. The new registers include specific data elements directly related to measuring coverage and quality of key MNH interventions. The registers were developed and pilot-tested in close coordination with the MOH to fit within the existing reporting structure. The standardized registers also made it possible to aggregate and compare data across EMAS-supported facilities. Standardized registers have helped facility staff by streamlining data recording, easing routine reporting, and enabling monitoring of meaningful clinical indicators (such as oxytocin use in the third stage of labor and early initiation of breastfeeding). The new registers have been quickly adopted in EMAS and non- EMAS districts, as demonstrated by many District Health Office (DHOs) using their own funds to print the registers for the village midwives and non-emas supported puskesmas to use. With meaningful data now routinely collected, EMAS conducted workshops on data for decision making (D4D) at all facilities in 2014, which quickly resulted in positive changes in record-keeping, reporting, and data quality. In facilities, staff began to use D4D laminated posters to graph data on performance standards, key interventions (see Appendix 1), and maternal and newborn deaths. Practical use and visualization of facility-level data has been valuable for facility staff to see their progress, as well as an important contribution to EMAS program-level monitoring. Some data also are presented at the districtlevel Pokja meetings for monitoring/follow up by external stakeholders. Clinical dashboards Complementing efforts to collect and use quality service statistics, EMAS introduced clinical dashboards into health facilities as another tool to strengthen clinical governance. Clinical dashboards are visual displays of the most important clinical and operational information that help staff use data to assess their performance by monitoring key indicators that need to be improved or maintained. They help users stay aware of the current situation and anticipate future implications, such as a short-staffed unit with a high volume of patients. They strengthen the use of data (e.g., service statistics) within clinical practice (i.e., link practice to outcomes). Dashboards visually highlight issues and trigger discussions and meaningful action to address them. Because they help evaluate whether the relevant action plans have been sufficiently implemented, dashboards help strengthen facility quality improvement processes and management. Dashboards also are a communication tool and help with facilitative supervision. Regular EMAS: Clinical Governance Technical Report, September 2015 P a g e 11

14 use of key information in a visual format as a way to assess performance is a good example of how good clinical governance promotes a culture of organizational learning. As of March 2015, the majority of Phase 1 (67%) The EMAS clinical dashboard, adapted from and Phase 2 hospitals (59%)* were actively using RSIA Budi Kemuliaan, has four predetermined groups of categories: clinical dashboards. activity, adequacy of manpower/workforce, *49 of 51 Phase 2 hospitals reported clinical indicators, and the incidence of risk/complaints. Facilities use dashboards in different units (emergency unit, labor and delivery room, postpartum ward, neonatal/pediatrics wards and operating room). There are different templates for hospitals and puskesmas. Introduced for quality assurance, dashboards are one of the first clinical governance practices introduced in facilities. Units/wards choose which data are most meaningful to collect and track in the dashboard, as well as how frequently the dashboard should be updated, reviewed, and discussed. They set a standard definition and an expected target. Actual performance is color-coded so data can visually be interpreted quickly where there is a problem. Green is used when the target is achieved (within 10%), yellow when the variation is 10% or more, and red when the variation exceeds 20%. Areas shaded yellow or red require further analysis to understand the problem and address it (see Box 3 as an example). Dashboards are not prescriptive; EMAS does not suggest every facility use identical indicators or dashboards. EMAS guidelines, however, include examples of possible information to track on dashboards such as the total number of deliveries, percent of cesarean sections and assisted vaginal deliveries (i.e., vacuum or forceps extraction). The majority of EMAS-supported facilities use the suggested indicators and targets. There also is variation in how often dashboards are completed and reviewed (i.e., daily, weekly, monthly), how they are completed (i.e., by hand or on a computer), and how they are displayed (i.e., paper on a bulletin board, on a designated whiteboard or on flat-screen monitor). Because dashboards (or other data visualization tools) were rarely used in facilities prior to EMAS, the effective use of dashboards required changes in how wards/units collected and used information. Clinical dashboards now are in place in all EMAS-supported facilities and are being used for decision-making. EMAS program reports at the end of 2014 showed variation across health facilities in terms of how actively dashboards are Box 3. Monthly Clinical Dashboard from Tangerang Hospital, Banten Province EMAS began working at Tangerang Hospital (RSUD Tangerang) in Phase 2, and introduced the clinical dashboards as a way to strengthen clinical governance. The staff there prioritized 17 indicators on the dedicated whiteboard in the labor and delivery unit and set the range of performance in the green, yellow and red-shaded columns. In the second week (Minggu II) of April, the labor and delivery unit was busier than expected (i.e., more than 78 normal deliveries). Staff flagged this in red, and it also is reflected in the yellow-shaded staff: patient ratios. During the same week, there were 2 near-miss cases (shaded red), which staff noted in the last column had arrived in this condition. Newborn care this week also was a concern. There were 7 asphyxiated newborns (shaded yellow) and less than 80% of newborns were breastfed within an hour (listed as IMD, shaded red). This is a practical example of how the clinical dashboards uses service statistics from the unit in a way that alerts staff to problems and engages them to discuss how to address them. P a g e 12 EMAS: Clinical Governance Technical Report, September 2015

15 used. Dashboards are actively being used in the wards in most facilities, but more effort is needed to increase the commitment and support from management to address problems flagged by the dashboards (particularly issues around human resources and policy). Some facilities have incorporated dashboards into reporting, daily morning rounds, and monthly reports to mid-level management. Some hospitals have used the dashboard during routine management meeting, and the results are reported to the hospital quality committee. There are a number of facilities where dashboards successfully helped advocate for additional staff or clinical resources. Generally, the DHOs and facility managers are supportive of this clinical governance practice because it gives them an easy tool to monitor what is happening in the facility. Maternal and neonatal death reviews and near-miss reviews In facilities, reviews of maternal and newborn deaths are an important component of clinical governance and a significant focus of clinical mentoring. It is expected that if facilities routinely complete these reviews with timely and critical discussion involving leaders, that corrective actions will be taken and future mortality and morbidity can be prevented. Reviews of facility-based deaths are part of the district process to audit every maternal and perinatal death, as mandated by the MOH Maternal-Perinatal Audit Guidelines (Pedoman Audit Material Perinatal [AMP]). Prior to EMAS, very few facilities were reviewing deaths or conducting near-miss reviews. EMAS has focused on increasing the frequency and improving the content of these reviews. EMAS recommends that reviews are conducted of all maternal deaths within 24 hours of occurrence, as well as fresh stillbirths (intrapartum deaths) and neonatal deaths (> 2000 grams). EMAS has introduced a simplified case review process to build capacity and promote a thorough, objective review. Facility staff are mentored to conduct simple case audits. The aim is to balance accountability and responsibility, which encourages the group to work together on lessons learned and recommendations that can result in meaningful changes (such as improved communication amongst wards and providers involved in emergency care, and better documentation in medical records). Building on LKBK experience, EMAS also introduced near-miss reviews at hospitals and puskesmas, which were more positive and less threatening for staff particularly at the start of the process to strengthen clinical governance. Longer-term support is still needed to further increase the frequency and improve the quality of reviews. Facility staff are gaining the skills and commitment to generate and use facility data to make decisions. Hospital management is supportive of the review process, but reviews are often delayed or of poor quality because of inadequate documentation or lack of participation from objective specialists. Hospital management participation seems to motivate staff to follow up and to improve performance. In addition to emphasis during clinical mentoring visits, EMAS has mobilized additional experts in each province to increase audit quality and objectivity. EMAS also has engaged broader external and community-based mechanisms (e.g, Pokjas and Civic Forums) in follow-up. EMAS: Clinical Governance Technical Report, September 2015 P a g e 13

16 In the past, they [training participants] received the theory, guidelines, and training, but they almost never practiced the skills. Their skills, and most importantly their confidence, fades without practice. EMAS showed the way; how to work on their emergency responses through emergency drills, and how to do it the right way, on a regular basis. -Dr. Eka Labuhan Batu district North Sumatra Emergency drills With a focus on emergency preparedness and responsiveness, EMAS introduced drills that help the teams of providers practice working together to respond appropriately to common obstetric and neonatal complications. Drills included in the EMAS guidelines are severe pre-eclampsia/eclampsia (PE/E, PPH), shoulder dystocia, umbilical cord prolapse, and newborn resuscitation. For each, EMAS prepared a specific guide on how to prepare and conduct a simulation to practice responsiveness and resolve possible delays (e.g, client flow, emergency trolleys, or workspace organization). Emergency drills The drills are introduced through clinical mentoring and help reinforce performance standards, clinical skills, and MOH accreditation of basic emergency care facilities. Drills are conducted at least once a month, but smaller facilities with fewer emergency cases are encouraged to schedule drills more frequently to stay prepared. Drills are logged in a register when completed with a list of participants. EMAS experience demonstrates that drills build confidence and team work. Drills also have helped staff identify and address other delays in the facility, such as the physical layout of the facility, communication breakdowns/barriers, etc. P a g e 14 EMAS: Clinical Governance Technical Report, September 2015

17 4. RESULTS: DOES IMPROVED CLINICAL GOVERNANCE LEAD TO IMPROVED FACILITY READINESS AND GREATER COVERAGE OF EVIDENCE-BASED INTERVENTIONS? By the end of Year 3 (September 2014), EMAS had worked to strengthen clinical governance practices and improve the quality of care in a total of 84 hospitals and 215 puskesmas in 23 districts and 6 cities. To look more closely at how strengthening clinical governance leads to increased coverage of key lifesaving interventions, EMAS defined expected outputs along the causal pathway (see Figure 3) and monitored whether: Strong clinical governance practices are in place, Facility readiness to provide EmONC has improved as measured by performance standards Coverage of key evidence-based interventions has increased. Figure 3. EMAS clinical governance causal pathway and expected outputs THEORY OF CHANGE: CLINICAL GOVERNANCE 1) Clinical governance practices in place 2) Improved readiness to provide EmONC INCREASED COVERAGE OF KEY INTERVENTIONS Performance standards being used quarterly; facility action plans developed, used and updated Readiness to routinely provide evidence-based practices = compliance with performance standards >80% Changes in coverage of key evidence-based interventions Clinical dashboards in regular use (in wards, with management) High proportion of deaths and near-miss cases reviewed Emergency drills routinely conducted Service statistics routinely collected, analyzed and used EMAS: Clinical Governance Technical Report, September 2015 P a g e 15

18 Clinical governance practices in place Clinical governance has resonated well with staff and managers in EMAS-supported facilities. The EMASintroduced practices (e.g., performance standards, clinical dashboards, simplified death audit case review process) were acceptable, as evidenced by uptake. Performance standards: All EMAS-supported facilities used the performance standards quarterly as requested and reported the percentage of performance standards achieved. No change in standards use or reporting was noted when facility staff began self-assessing performance instead of jointly with EMAS staff or mentors. As a result of the quarterly assessments, facilities have routinely developed and updated their action plans, as reported to EMAS by mentors and district and provincial teams. There is evidence that new practices introduced in the performance standards are in place, such as a posted roster that clearly displays emergency response teams for each shift. In additional to clinical performance standards, hospitals measure several aspects of clinical governance. Those scores remain lower than desired due to challenges in routinely conducting death audits and near-miss reviews. Average scores for all performance standards are outlined in Appendix 3. Clinical dashboards: Use of dashboards is reported by hospitals within the quarterly performance assessment using standards (i.e., Clinical Performance and Evaluation tool). As of March 2015, 67% of Phase 1 hospitals (i.e., 14 of 21 hospitals that reported) and 59% of Phase 2 hospitals (i.e., 49 of 51 hospitals that reported) were actively using dashboards. During mentoring visits and EMAS monitoring, dashboards have been observed as widely used in hospital wards and puskesmas. Death and near-miss reviews: The near-miss and death review processes are in place at all EMAS-supported facilities. Noting that the denominator fluctuates because not all facilities report a death each quarter, the proportion of maternal and neonatal death reviews have increased steadily (see Figure 4), but are lower than desired, especially for neonatal deaths. Phase 1 hospitals conducted reviews on 90% of maternal deaths in Quarter 3 of Year 4, up from 48% in Year 2, and reviewed 59% of all newborn deaths (up from 39% in Year Two). Phase 2 hospitals reviewed 83% of maternal deaths, and 55% of newborn deaths during the same period. By the middle of Year Four, 82% of Phase 1 and 92% of Phase 2 hospitals reported conducting regularly scheduled near-miss reviews if any occurred in that quarter (data not shown). Emergency drills: Routine emergency drills are reported by hospitals and puskesmas quarterly as part of their assessment using performance standards (i.e., emergency response tools have one standard on drills for puskesmas and two standards within hospital standards). As of March 2015, 73% of Phase 1 hospitals and 67% of Phase 2 hospitals (i.e., 33 of the 49 hospitals that reported) had conducted maternal-neonatal emergency drills in the past quarter. Although data on drill frequency are not reported, mentoring teams review and discuss the log with facility staff. Availability of service statistics: Standardized registers are universally in use, and relevant data are available from EMAS-supported facilities. EMAS staff use the registers to aggregate data for monthly reports. Data visualization using the D4D posters continues to help improve the quality of recorded data and encourage broader follow up action. P a g e 16 EMAS: Clinical Governance Technical Report, September 2015

19 Figure 4. Percentage of maternal and neonatal deaths reviewed in Phase 1 and Phase 2 EMASsupported facilities (hospitals and puskesmas with a death in the quarter) 5 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 82% 89% 90% 83% 70% 85% 71% 56% 59% 48% 53% 61% 55% 44% 39% 37% 33% 24% Year 2 Year 3 Year 4, Q1 Year 4, Q2 Year 4, Q3 Phase 1 Maternal Deaths Phase 1 Neonatal Deaths >2000 grams Phase 2 Maternal Deaths Phase 2 Neonatal Deaths >2000 grams Improved facility readiness to provide EmONC Good clinical governance is expected to lead to improvements in facility readiness to provide EmONC, and this is exactly what EMAS has seen. Readiness is measured by facilities quarterly using performance standards. The best example comes from the facilities that have worked to strengthen clinical governance for the longest time. The majority of the hospitals that first received EMAS support (22 in Phase 1) have made significant progress in improving MNH performance (see Figure 5a). Considering few hospitals were able to score above 50% on the set of MNH care standards at the start (baseline), it is significant that by the end of Year Three, a majority of Phase 1 hospitals had achieved 80% which is the desired performance level. By the middle of Year Four, hospitals were consistently scoring over 80% on most tools and above 90% for four tools (active management of the third stage of labor for PPH prevention, PE/E, obstructed labor, ACS). Scores on maternal and newborn emergency response were notably lower (see Appendix 3 for more detail). Progress on infection prevention is impressive with 86% of Phase 1 hospitals achieving 80% or more of the standards. Infection prevention is important within a facility to protect both patients (mothers and newborns) and providers from infection, and it signals the capacity to address a crosscutting systems issue. Similar trends are seen in Figure 5b among Phase 2 hospitals. Puskesmas have shown similar improvements in performance on maternal and newborn care and infection prevention (see Figure 6a and 6b) 6. EMAS: Clinical Governance Technical Report, September 2015 P a g e 17

20 Figure 5a. Average compliance with performance standards by EMAS-supported hospitals, measured quarterly at 22 Phase 1 hospitals 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline Y2Q1 Y2Q2 Y2Q3 Y2Q4 Y3Q1 Y3Q2 Y3Q3 Y3Q4 Y4Q1 Y4Q2 Y4Q3 Y4Q4 Maternal Neonatal Infection Prevention Clinical Governance Figure 5b. Average compliance with performance standards by EMAS-supported hospitals, measured quarterly at 50 Phase 2 hospitals 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline Y3Q1 Y3Q2 Y3Q3 Y3Q4 Y4Q1 Y4Q2 Y4Q3 Y4Q4 Maternal Neonatal Infection Prevention Clinical Governance P a g e 18 EMAS: Clinical Governance Technical Report, September 2015

21 Figure 6a. Average compliance with performance standards by EMAS-supported puskesmas, measured quarterly at 93 Phase 1 puskesmas 6 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline Y2Q1 Y2Q2 Y2Q3 Y2Q4 Y3Q1 Y3Q2 Y3Q3 Y3Q4 Y4Q1 Y4Q2 Y4Q3 Y4Q4 Maternal Neonatal Infection Prevention Figure 6b. Average compliance with performance standards by EMAS-supported puskesmas, measured quarterly at 122 Phase 2 puskesmas 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline Y3Q1 Y3Q2 Y3Q3 Y3Q4 Y4Q1 Y4Q2 Y4Q3 Y4Q4 Maternal Neonatal Infection Prevention EMAS: Clinical Governance Technical Report, September 2015 P a g e 19

22 Increased coverage of key interventions With notable improvements in facility readiness at EMAS-supported facilities, EMAS monitored the coverage of key practices (see Appendix 1). By Year Four, EMAS has seen increased coverage of evidence-based maternal and neonatal interventions in the facilities it supports as well as an aggregate at the program level. Figures 7 and 8 illustrate how coverage of six key interventions has increased in both Phase 1 and 2 hospitals. Data from Phase 1 hospitals shows coverage increases in all six key interventions. For example, from January March 2013 to January March 2015, uterotonic use in the third stage of labor increased from 92% to 100%, initiation of early breastfeeding increased from 42% to 68%, antenatal corticosteroids use for pre-term birth increased from 42% to 75%, and magnesium sulfate for treatment of severe PE/E increased from 85% to 95%. As a proxy indicator for the referral system, hospitals also track the proportion of incoming referrals for PE/E that have received at least one dose of magnesium sulfate prior to referral, and the proportion of newborns with suspected infection who have received at least one dose of antibiotic prior to referral. Although this stabilization practice prior to referral has more than doubled for PE/E referrals, provision of antibiotics for newborns remains far lower than desired. Figure 7. Coverage of evidence-based maternal health interventions 7 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% YR2 Q1 YR2 Q2 YR2 Q3 YR2 Q4 YR3 Q1 YR3 Q2 YR3 Q3 YR3 Q4 YR4 Q1 YR4 Q2 Phase 1 % of PE/E cases treated with MgSO₄ Phase 2 % of PE/E cases treated with MgSO₄ Phase 1 % of referred PE/E cases treated with MgSO₄ before referral (hospital only) Phase 2 % of referred PE/E cases treated with MgSO₄ before referral (hospital only) Phase 1 % of deliveries that receive a uterotonic in the third stage of labor Phase 2 % of deliveries that receive a uterotonic in the third stage of labor P a g e 20 EMAS: Clinical Governance Technical Report, September 2015

23 Figure 8. Coverage of evidence-based neonatal health interventions 7 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% YR2 Q1 YR2 Q2 YR2 Q3 YR2 Q4 YR 3 Q1 YR 3 Q2 YR3 Q3 YR3 Q4 YR4 Q1 YR4 Q2 Phase 1 % of newborns breastfed within 1 hour of delivery Phase 2 % of newborns breastfed within 1 hour of delivery Phase 1 % of newborns delivered between weeks whose mothers received antenatal corticosteroids (hospital only) Phase 2 % of newborns delivered between weeks whose mothers received antenatal corticosteroids (hospital only) Phase 1 % of newborns referred with infection, given antibiotic before referral (hospital only) Phase 2 % of newborns referred with infection, given antibiotic before referral (hospital only) EMAS: Clinical Governance Technical Report, September 2015 P a g e 21

24 5. INSTITUTIONALIZATION OF PRACTICES TO IMPROVE CLINICAL GOVERNANCE Strengthening clinical governance through clinical mentoring has been well-received by providers, managers and DHO officials as a sustainable way of building capacity. When facilities receive support from mentors and then become mentoring facilities, their uptake of practices and tools has accelerated. Although the EMAS approach to strengthening clinical governance was conceptualized and implemented as a mutually-reinforcing set of practices, EMAS reviewed each component in 2014 to assess the progress on institutionalizing each practice within facility, district and MOH systems (see Figure 9). Figure 9. Current status of institutionalizing practices and tools to strengthen clinical governance Early Stage Advanced Stage Death reviews, near-miss reviews: Although death and near-miss reviews are an essential element of good clinical governance and supported by national policy, more effort is required to institutionalize this practice in facilities so thorough and objective reviews are done for every death or near-miss case. The process requires skilled and objective facilitation that engages a mix of participants. Requires: greater expertise and objectivity, commitment from hospital leadership; champions within the facility Clinical dashboards: Use within a ward is sustainable but long-term use is only viable and meaningful if management responds to identified needs. Requires: greater commitment from hospital leadership to address identified needs and use them within management processes Emergency drills: Drills are run at the discretion of the facility and are simple (e.g., low resource, not timeintensive) to conduct. While they help ensure BEmONC services function 24/7, sustainability within a facility or the health system. Requires: owners and champions with the facility Performance standards: Directly aligned with hospital and puskesmas accreditation standards with capacity wellestablished among facility staff to conduct quarterly assessments. Requires: greater political commitment (facility, district) to use formally for monitoring (e.g.,part of accreditation standards) Service statistics on EmONC service provision: Commitment and ownership in place in EMAS-supported districts, and resources to print annual registers are available. Requires: Continued capacity to consistently record and use data from registers to monitor coverage of key practices P a g e 22 EMAS: Clinical Governance Technical Report, September 2015

25 6. LESSONS LEARNED AND RECOMMENDATIONS EMAS-supported facilities have embraced the tools and practices that strengthen clinical governance, along with clinical mentoring. Progress on fully adopting and incorporating new practices has been steady. Providers, managers/leaders, DHO officials, and district stakeholders (such as members of local parliament and planning officials) recognize the value of the components and have expressed how EMAS support truly builds capacity. Because clinical governance changes how services and facilities are managed, it is difficult to determine which practices and tools have contributed the most to changes in clinical practice and coverage of key interventions. Many components are inter-related and mutually-reinforcing. It also is unclear if any practices are less essential and could be made optional. Good clinical governance requires strategic leadership to transform the culture of health facilities into learning organizations. Nurturing strong leaders is very important yet challenging, due to the complexity of structures and functions. Time is required to increase capacity, commitment and institutionalization. Mentoring builds positive working relationships, which seems to be effective in promoting change. Mentoring brings leaders and teams together analyze, plan, implement, and evaluate. Good clinical governance relies on good quality data to assess and track progress. Standardized data collection tools and systems are critical to generate data that tracks process and immediate outputs. Facility staff are gaining the skills and commitment to generate and use facility data to drive decisions. Data also demonstrate to staff and DHO that meaningful improvements are occurring in their facility. Components of quality of care do improve when facilities have stronger clinical governance practices specifically compliance to standards, capacity to analyze and use data, and improve respectful care. Increases in coverage of key clinical practices are evident, but reductions in related cause-specific case fatality rates have not dropped as expected. For example, provision of a uterotonic during the third stage of labor is over 90% for all EMAS-supported hospitals since early in Program Year 3 (late 2014), but PPH-related case fatality rates have not decreased significantly. Given the low numbers of maternal deaths, EMAS continues monitor these trends on an annual basis. LKBK is an example where good clinical governance has resulted in lower case fatality rates than other large hospitals. Experience to date indicates that strong clinical governance systems in health facilities is highlysustainable and strengthens MOH systems and policies. By working to strengthen clinical governance, EMAS institutionalizes practices and tools that are capable of improving and sustaining quality over the long-term. EMAS has the full support of provincial and district health offices, who look to the program as creating highly-functioning and motivated facilities and referral systems which they can draw upon to expand quality services throughout their districts and provinces. Numerous provincial and district health offices have already independently expanded several EMAS interventions into other districts or facilities. It is important to monitor diffusion into non-emas areas to see which components are used and if there are similar, measurable changes that result. EMAS: Clinical Governance Technical Report, September 2015 P a g e 23

26 APPENDIX 1: EVIDENCE-BASED INTERVENTIONS These interventions were selected by EMAS to be collected from facilities and tracked over time. EMAS standards for hospitals and puskesmas Intervention that prevents/treats complication related to a leading cause of death Recommended by WHO Maternal/Obstetric Care Manage severe PE/E Magnesium sulfate is recommended with magnesium sulfate for the prevention of eclampsia in (MgSO 4 ) women with severe pre- eclampsia in preference to other anticonvulsants. (WHO 2011) Provide MgSO 4 for severe PE/E before referral Provide at least one dose of uterotonic postpartum during the third stage of labor to prevent PPH Neonatal Care Resuscitate asphyxiated newborns with positive-pressure ventilation (PPV) Treat newborns with suspected severe infection/sepsis with antibiotics before referral Initiate breastfeeding for all live births within one hour of birth For settings where it is not possible to administer the full magnesium sulfate regimen, the use of magnesium sulfate loading dose followed by immediate transfer to a higher level health-care facility is recommended for women with severe pre eclampsia and eclampsia. (WHO 2011) The use of uterotonics for the prevention of PPH during the third stage of labour is recommended for all births. Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH. (WHO 2012) In newly-born babies who do not start breathing despite thorough drying and additional stimulation, positive-pressure ventilation should be initiated within one minute after birth. (WHO 2012) Give first dose of both ampicillin and gentamicin IM in thigh before referral for possible serious illness, severe umbilical infection or severe skin infection. (WHO 2014) Help the mother to initiate breastfeeding within 1 hour, when baby is ready Included in National Clinical Guidelines Give IV magnesium sulfate to women with eclampsia (to manage seizures) and severe pre-eclampsia (to prevent seizures). (MOH 2013) Give IV magnesium sulfate to women with eclampsia (to manage seizures) and severe pre-eclampsia (to prevent seizures). (MOH 2013) Within 1 minute of birth, give 10U oxytocin IM in upper thigh. (MOH 2013) If baby is not breathing or is gasping, initiate ventilation with bag and mask. (MOH 2013) For babies who need to be referred, give IM antibiotics and refer immediately. (MOH 2008) Enable sufficient time on the mother s chest for the baby to breastfeed (minimum 1 hour). P a g e 24 EMAS: Clinical Governance Technical Report, September 2015

27 EMAS standards for hospitals and puskesmas Intervention that prevents/treats complication related to a leading cause of death Provide one or more doses of antenatal steroids to women delivering between 24 to 34 weeks gestation (i.e., pre-term birth) Delay cord clamping at least two minutes after delivery for all live births Recommended by WHO Included in National Clinical Guidelines (WHO 2014) (MOH 2013) Antenatal corticosteroid therapy is For mothers between recommended for women at risk of weeks with premature labor preterm birth from 24 weeks to 34 (including ruptured weeks of gestation (when certain membranes), give conditions are met) corticosteroids to promote lung (WHO 2015) maturity." (MOH 2013) Late cord clamping (performed after one to three minutes after birth) is recommended for all births while initiating simultaneous essential newborn care. (WHO 2014; WHO 2014) Using a clamp, at least 2 minutes following birth, clamp and cut the cord. (MOH 2013) EMAS: Clinical Governance Technical Report, September 2015 P a g e 25

28 APPENDIX 2: PERFORMANCE STANDARDS FOR HOSPITALS AND PUSKESMAS EMAS performance standards for hospitals and puskesmas (January 2015 version) Tools Number of standards HOSPITAL 118 MATERNAL 1. Obstetric-Neonatal Emergency Response* 5 2. Active Management of the Third Stage of Labor (AMTSL) to Prevent 6 Postpartum Hemorrhage 3. Postpartum Hemorrhage (PPH) Management 6 4. Management of Severe Pre-eclampsia/Eclampsia (PE/E) 8 5. Management of Maternal Sepsis and Severe Infection 6 6. Obstructed Labor 8 NEONATAL 1. Neonatal Emergency Response* 5 2. Neonatal Resuscitation 6 3. Neonatal Sepsis Management 8 4. Antenatal Corticosteroid (ACS) Provision to Prevent Premature Complication 3 5. Early Breastfeeding Initiation and Exclusive Breastfeeding 6 6. Kangaroo Mother Care (KMC) 6 7. Care for Low Birth Weight (LBW) Neonates 12 CLINICAL MANAGEMENT 1. Clinical Performance and Evaluation 4 2. Client Feedback 2 INFECTION PREVENTION in Hospital and other Health Facilities 27 PUSKESMAS/PRIVATE CLINIC 39 MATERNAL/NEONATAL Obstetric-Neonatal Emergency Response* 5 Obstetric and Neonatal Emergency Care 7 Obstetric-Neonatal Emergency Referral System 6 Supplies and Equipment for Management of BEmONC* 1 Infection Prevention** 20 * These tools include a detailed list of equipment, drugs and supplies for each emergency trolley ** The number of infection prevention standards increased in 2015 from 16 to 20. P a g e 26 EMAS: Clinical Governance Technical Report, September 2015

29 APPENDIX 3: HOSPITAL PERFORMANCE BY TOOL AVERAGE PERFORMANCE BY TOOL, PHASE 1 AND 2 HOSPITALS, JANUARY MARCH 2015 PHASE 1 (n = 22) MATERNAL Tool 1: Emergency response Tool 2: AMSTL Tool 3: PPH Tool 4: PE/E Tool 5: Sepsis & infection Tool 6: Obstructed labor NEONATAL Tool 1: Emergency response Tool 2: Neonatal resusitation Tool 3: Neonatal sepsis Tool 4: Antenatal steroid (ACS) Tool 5: Early and exclusive breastfeeding Tool 6: Kangaroo mother care Tool 7: Care of LBW Neonates INFECTION PREVENTION CLINICAL MANAGEMENT Tool 1: Clinical performance and evaluation Tool 2: Client satisfaction PHASE 2 (n = 50) 0% 20% 40% 60% 80% 100% MATERNAL Tool 1: Emergency response Tool 2: AMSTL Tool 3: PPH Tool 4: PE/E Tool 5: Sepsis & infection Tool 6: Obstructed labor NEONATAL Tool 1: Emergency response Tool 2: Neonatal resusitation Tool 3: Neonatal sepsis Tool 4: Antenatal steroid (ACS) Tool 5: Early and exclusive breastfeeding Tool 6: Kangaroo mother care Tool 7: Care of LBW Neonates INFECTION PREVENTION CLINICAL MANAGEMENT Tool 1: Clinical performance and evaluation Tool 2: Client satisfaction 0% 20% 40% 60% 80% 100% EMAS: Clinical Governance Technical Report, September 2015 P a g e 27

30 APPENDIX 4: EMAS RESOURCES FOR CLINICAL GOVERNANCE Title Monitoring tool: Performance standards for Hospitals, March 2014 Alat Pantau Sistem Kinerja Klinik di Rumah Sakit Language/s Bahasa Indonesian Monitoring tool: Performance standards for Community Health Centers, March 2014 Alat Pantau Sistem Kinerja Klinik di Puskesmas Bahasa Indonesian Technical Guidelines for Implementation of Obstetric and Neonatal Emergency Simulation Pedoman Teknis Penyelenggaraan Simulasi Emergensi Obstetri dan Neonatus English, Bahasa Indonesian Technical Guidelines of Using Dashboard (Petunjuk Praktis Penggunaan Dashboard) English, Bahasa Indonesian P a g e 28 EMAS: Clinical Governance Technical Report, September 2015