FACILITATORS MANUAL. Training Programme For Quality Improvement For Maternal and Newborn Health

Transcription

1 FACILITATORS MANUAL Training Programme For Quality Improvement For Maternal and Newborn Health Jan J Hofman May

2 ACKNOWLEDGEMENTS In the first place we would like to thank Dr Joanna Raven from the International Health Group at the Liverpool School of Tropical Medicine (LSTM), who has substantially contributed to the initial design of the current Quality Improvement (QI) training programme, which we jointly conceptualised and of which she facilitated the very first QI training workshop in the PRRINN- MNCH programme. Also we would like to thank the members of the planning and management team of the PRRINN-MNCH programme for recognising the importance of quality of care for improving Maternal Newborn and Child Health in Northern Nigeria and for including a QI component in the PRRINN-MNCH programme. We are grateful to the authors of the WHO publication Beyond the Numbers: reviewing maternal deaths and complications to make pregnancy safer and the WHO staff who contributed to this document, which has been a great inspiration for the current QI training programme, which is designed around the recommended QI methods recommended by WHO in this publication. Our gratitude is also extended to the representatives from the State Ministries of Health in the target states of the PRRINN-MNCH programme (Katsina, Yobe, Zamfara) for their support to the QI initiative in the PRRINN-MNCH programme and their valuable contributions to the QI workshops so far. These include representatives from the State Health Services Management Boards, the State Primary Health Care Management Boards and Primary Health Care Directors and Maternal and Child Health Coordinators at Local Government area (LGA) level. A special word of thanks goes to Dr Adetoro Adegoke from the Maternal & Newborn Health Unit at LSTM, who together with the author of this facilitators manual piloted the QI training programme in Nigeria during its first year and Dr Danladi Abubakar, the national consultant who has been co-facilitating the QI workshops in the 2 nd year, We also thank the PRRINN-MNCH staff who gave logistical and administrative support to the PRRINN-MNCH QI workshops. Finally we thank the participants of the QI workshops and the members of the health facility QI teams, from whom we have learned a lot concerning the implementation of QI activities in Northern Nigeria, which has helped to give the QI training programme its current shape. 1

3 ABBREVIATIONS ANC ARV BEmNC CEmONC CS EmONC FANC FGD FMOH FP HF HIV HMIS LSS MCH MD MDG MMR MNH NPHCDA NGO PAC PHC PMTCT PNC RH SBA SHSMB SMOH SPHCMB SRH TBA ToR VCT WHO Ante Natal Care Anti Retro Viral Basic Emergency Obstetric and Newborn Care Comprehensive Emergency Obstetric and Newborn Care Caesarean Section Essential (Emergency) Obstetric & Newborn Care Focused Ante-Natal Care Focus Group Discussion Federal Ministry Of Health Family Planning Health Facility Human Immuno-deficiency Virus Health Management Information System Live Saving Skills Maternal and Child Health Maternal Death Millennium Development Goals Maternal Mortality Ratio Maternal & Newborn Health National Primary Health Care Development Agency Non Governmental Organisation Post Abortion Care Primary Health Care Prevention of Mother to Child Transmission (of HIV) Post Natal Care Reproductive Health Skilled Birth Attendance State Health Services Management Board State Ministry of Health State Primary Health Care Management Board Sexual and Reproductive Health Traditional Birth Attendant Terms of Reference Voluntary Counseling and Testing World Health Organization 2

4 TABLE OF CONTENTS i ACKNOWLEDGEMENTS... 1 ii ABBREVIATIONS... 2 iii TABLE OF CONTENTS INTRODUCTION BACKGROUND PRINCIPLES AND OUTLINE OF THE TRAINING TEACHING METHODS PLANNING, PREPARING AND REPORTING STRUCTURE AND CONTENT OF THE QI WORKSHOPS THE 1 ST QI WORKSHOP THE 2 ND QI WORKSHOP THE 3 RD QI WORKSHOP THE 4 TH QI WORKSHOP FOLLOW UP AND SUPPORTIVE SUPERVISION OF QI TEAMS REFERENCES ANNEXES I. PROGRAMMES OF THE QI WORKSHOPS II. WORKSHOP EVALUATION FOR III. TASKS FOR AFTER THE 1 ST QI WORKSHOP IV. CASE SCENARIO: WHY DID FATUMA DIE? V. STEPS IN INITIATING AND CONDUCTING FACILITY-BASED MATERNAL AND PERINATAL DEATH REVIEWS VI. DEMONSTRATION OF POOR AND GOOD APPROACH OF MDR VII. MATERNAL DEATH RECORDING & REPORTING FORMS VIII. PERINATAL DEATH RECORDING AND REPORTING FORMS IX. PERINATAL DEATH CASE STUDIES X. CASE DEFINITIONS OF OBSTETRIC COMPLICATIONS XI. CRITERIA FOR AUDIT OF MANAGEMENT OF OBSTETRIC COMPLICATIONS (SOURCE: IMMPACT) XII. CRITERION-BASED AUDIT DATA EXTRACTION SHEET XIII. CRITERION-BASED AUDIT DATA EXTRACTION SHEET PPH XIV. CITERION-BASED AUDIT DATA EXTRACTION SHEET PARTOGRAPH 158 XV. TEMPLATE FOR PRRINN-MNCH REPORTS

5 1. INTRODUCTION Nigeria has some of the highest rates of maternal, neonatal and child mortality in the world. These mortality rates show wide disparities between the north and the south. Although the national IMR and U5MR are 75 and 157 per 1000 live births respectively, rates in the North West geopolitical zone, for example, are 91/1000 (IMR) and 217/1000 (U5MR) respectively. Maternal mortality ratios are far above the national figure of 800/100,000 which is unacceptably high (NDHS, 2008). A population-based study of maternal mortality in Northern Nigeria over the 1990 s found a Maternal Mortality Ratio of 2,420 deaths per 100,000 live births (Adamu, 2003) At least 80% of all maternal deaths result from five complications that are well understood and can be readily treated: haemorrhage, sepsis, eclampsia & pre-eclampsia, obstructed labour and complications of abortion. We know how to prevent these deaths there are existing effective medical and surgical interventions that are relatively inexpensive. Most obstetric complications cannot be predicted and occur suddenly and unexpectedly prompt access to good quality Essential (or Emergency) Obstetric Care (EOC) and Newborn Care (NC) is essential. Key strategies to reduce maternal and newborn mortality are, increasing access to skilled attendance at birth for all pregnant women and to Essential (Emergency) Obstetric Care (EOC) for those mothers who experience life-threatening complications during pregnancy, childbirth and the post-partum period, while Essential Newborn Care is crucial to save newborn lives. Also increasing access and utilization of Family Planning services and Focused Antenatal Care are important to reduce maternal mortality as is prevention of unsafe abortion. To increase access and utilization of these services health facilities which provide such services must be available and accessible. This requires functioning health systems which ensure that sufficient professional staff is available to provide these services and that they have the necessary knowledge and skills as well as the enabling environment to do so, which includes adequate infrastructure, equipment, drugs and other medical supplies. In addition to this, communities need to be sensitized on MNCH issues and mobilized to ensure that women are supported to use essential health services and socio-cultural determinants which affect maternal and newborn health are addressed. However, increasing availability and access to skilled attendance at birth, EOC, ENC and FP services is not enough to reduce mortality rates. In order for such services to be effective in reducing maternal & neonatal mortality and morbidity and in attracting clients and patients and increase utilisation of essential MNCH services, we must ensure adequate and acceptable quality of care. This can be achieved by introduction of Quality Improvement (QI) processes at MNCH facilities, which can make a significant impact on pregnancy outcomes and service utilisation. The PRRINN-MNCH programme was launched in September 2008 to support Nigeria in the achievement of the Millennium Development Goals (MDGs) related to Maternal, Newborn and Child Health (MNCH) in Northern Nigeria. This is a 4 year programme funded by the UK Department for International Development (DfID) and the Norwegian Government. This programme seeks to contribute towards the reduction of maternal, neonatal and child morbidity and mortality in 3 northern states: Katsina, Zamfara and Yobe. The programme is implemented by a consortium of organisations and institutions with expertise in MNCH. The MNCH 4

6 programme linked up with the earlier initiated Partnership for Revitalizing Routine Immunization in Northern Nigeria (PRRINN). The MNCH programme is managed by Health Partners International (HPI), Safe the Children UK and GRID Consulting, with technical support from a range of partners including Johns Hopkins Bloomberg School of Public Health and Liverpool Associates in Tropical Health/Liverpool School of Tropical Medicine (LATH/LSTM). One of the outputs in the PRRINN- MNCH programme is to improve the delivery of MNCH services (including RI) via the strengthened PHC system. In order to initiate ongoing QI processes in the PRRINN-MNCH supported EOC facilities in the 3 target states, the PRRINN-MNCH programme organises a series of QI workshops for representatives from these health facilities. The purpose of these QI workshops is to build capacity in EOC facilities to improve quality of care of MNCH services in an ongoing manner by establishment of QI teams and introduction of QI methods. Different approaches and methods for QI are introduced and the EOC facilities form QI teams, which are leading the QI processes in the health facilities. The QI training programme has been developed and initiated with technical support from staff of the Maternal & Newborn Health (MNH) Unit of the Liverpool School of Tropical Medicine (LSTM), assisted by a Consultant Obstetrician from the Federal Medical Centre in Gusau, Zamfara state. To build in-country capacity within the three PRRINN-MNCH supported Northern states to initiate QI processes in health facilities and train and supervise members of the health facility QI teams as well as senior health staff from the Primary Health Care offices of target LGAs as well as from the State Ministry of Health (SMOH), PRRINN-MNCH supports the training of a pool of master trainers in each of the PRRINN-MNCH supported states, who will be able to deliver the QI training package. This QI Training Manual provides guidance to the trainers of the QI teams and will help them to conduct the QI training workshops and provide ongoing supportive supervision to the health facility QI teams. 5

7 2. BACKGROUND Maternal mortality ratios in Nigeria remain unacceptably high and according to WHO have declined from 1,100 in 1990 to 980 in 2000 and 840 per 100,000 live births in 2008 This shows an average annual decrease of 1.5%, which is insufficient to reach the target of the 5 th MDG, which requires an annual decline of 5.5% (WHO, 2010). Where access and utilization of obstetric services is low, many maternal deaths occur at home, but studies in several countries have shown that a large proportion of maternal deaths occur in hospitals with figures varying from 40% in Viet Nam to 92% in South Africa (Ronsmans & Graham, 2006). These maternal deaths in health facilities include three main types of cases: 1) women who arrived in a moribund state too late to benefit from emergency care; 2) women who arrived with complications who could have been saved if they would have received timely and effective treatment; 3) women admitted for normal delivery who developed complications and died with or without receiving emergency care. Confidential enquiries into maternal deaths and analysis of findings from facility-based maternal death reviews in various countries have shown that across the world a considerable proportion of cases of MD result from avoidable factors and sub-standard care. In the latest edition of Why Mothers Die : Sixth report of the confidential enquiries into maternal deaths in the UK it was reported that 67% of direct maternal deaths in the UK were the result of sub-standard care and 47% of these were considered to be major, where a different treatment might have prevented the death. The 3 rd report of confidential enquiry into maternal deaths in South Africa found that 36.7% of maternal deaths were clearly avoidable within the health care system (Moodley & Pattinson, 2006). In another study in West Africa it was found that 69% of direct maternal deaths were the result of sub-standard care (Bouvier-Colle, 2001). The previous figures indicate that in order to reduce maternal and perinatal mortality it is important to improve quality of MNH care within health facilities, which can be done by identifying and addressing shortcoming in care. Against this background PRRINN-MNCH has initiated QI processes in the EOC facilities which are supported by the programme. The World Health Organization (WHO) recommends to go beyond the numbers in order to reduce maternal mortality and recommends several methods to improve quality of care of MNH services (WHO, 2004). These include facility and community-based maternal and peri-natal death reviews, criterion-based audit, working with standards and confidential enquiries into maternal and perinatal deaths. Several studies have demonstrated that maternal and perinatal death reviews, followed by remedial action, can improve quality of care and reduce maternal and perinatal mortality (Pattinson, 2009). 6

8 3. PRINCIPLES AND APPROACHES OF THE QI TRAINING 3.1 Purpose of the QI training The purpose of the QI training programme is to initiate ongoing QI processes in PRRINN-MNCH supported EOC facilities, whereby health facilities in a continuing process identify quality of care problems, analyse the root causes and come up with interventions to address these problems and improve quality of care with the ultimate aim to reduce maternal, and peri-natal mortality and morbidity and increase client, patient and staff satisfaction. 1.2 Expected Outcomes It is expected that health care providers and health service managers who participate in the QI workshops will: Become aware of the importance of quality of care for the reduction of maternal, newborn and child mortality and reduction of morbidity; Become more knowledgeable about the meaning of quality, quality of care and approaches and methods which can be used to improve quality of care of MNCH services; Be able to assess quality of care in health facilities, considering different perspectives, aspects and dimensions of quality of care, analyse root causes and develop interventions to assess the identified quality of care problems and monitor and evaluate their effectiveness in improving quality of care. Be able to initiate, organize and conduct facility-based maternal and peri-natal death reviews as well as to develop standards for quality of care for various health services, develop criteria for audit of MNCh service provision and conduct criterion-based audit criterion-based audit; Establish QI teams in their health facilities, which will be responsible for assessing quality of care, initiating and monitor QI activities and evaluate their effectiveness in improving quality of care. 1.3 Approach The QI training consists of a series of 4 workshops, each which lasts between 2 and 4 days, which are conducted at intervals of three months. In this way participants gradually build up their knowledge and skills for quality improvement, more over each subsequent workshop starts with a recap of the key issues covered during the previous workshop, reinforcing the earlier acquired knowledge. In between these workshops participants apply the knowledge and skills developed during the workshops within their own health facilities, assessing quality of care, identifying quality of care problems and initiating QI activities. The workshops are facilitated by at least 2 workshop facilitators, who have technical knowledge about and experience with MNH and QI methods for MNH. The workshop facilitators will be assisted during workshops by an administrative assistant from the State PRRINN-MNCH Office, who is responsible for all logistical and administrative arrangements. The workshop facilitators and administrative assistant report to the PRRINN-MNCH Technical Advisor for MNCH. 7

9 Within the PRRINN-MNCH programme the QI training focuses on PRRINN-MNCH supported Emergency Obstetric and Newborn Care (EONC) facilities. Within these health facilities QI teams are formed which are responsible to lead the QI activities in their health facilities. These QI teams report to the Management of the health facility. To support the health facility QI improvement teams and institutionalize QI processes it is important that these teams receive regular supportive supervision, which should start already after the first QI workshop and continue in between the various QI workshops. Primary Health Care Directors and Maternal & Child Health (MCH) coordinators from the PRRINN-MNCH supported LGAs are also involved in the QI training programme and are expected to provide regular supportive supervision to the QI teams of the EOC facilities in their LGA. In addition to this, PRRINN-MNCH has engaged consultants from the Federal Medical Centres (FMC) (one obstetrician and one paediatrician) in the 3 target states to provide regular technical supportive supervision, while MCH Coordinators from the State Ministries of Health (SMOH) and representatives from the State Health Services Management Board (SHSMB) and State Primary Health Care Management Board (SPHCMB) are invited as well to attend the QI training workshops in order to build their capacity to provide additional guidance and support to the QI teams. The QI training programme focuses on Maternal and Newborn Health (MNH), but the principles of QI can also be applied to child health or health care in general. 4. TEACHING METHODS The QI training package is delivered in a series of four training workshops, each which last between 2 and 4 days, with 3 month intervals, during which intervals the health facility QI teams put into practice what they have learned in the workshops. The QI training is based on the adult learning theory and recognises that adult participants of the training workshop have already a lot of knowledge and experience, which is tapped, shared, used and built upon in the learning process. Participants are not considered as passive recipients of knowledge and skills, but actively take part in the learning process and contribute their own knowledge, skills and experience. Active learning is a process whereby training participants engage in activities such as reading, writing, discussion, or problem solving that promote in-depth analysis, synthesis and evaluation of learning content. Besides relatively short interactive introduction lectures much time is spent in the form of active learning, such as brain storming exercises, answering questions, small group work and small group and plenary discussions, including sharing and discussing of experiences. Each workshop starts with a brief interactive recapitulation of the content of the previous workshop, which serves as a reminder to reinforce the knowledge acquired during the 1 st workshop and creates an opportunity for the facilitators to assess whether key issues are well understood. The rest of the first day is used for sharing of experiences, whereby representatives 8

10 from health facility QI teams report on the quality of care problems and their root causes, which they have identified, the activities undertaken to address the problems, the achievements, challenges in implementing QI activities and lessons learned. During each workshop one new QI method is introduced, followed by group work to practice the method. Also other aspects of QI are introduced, such as recording of information from Maternal & Perinatal Death Reviews and Criterion-Based Audit (CBA), how to measure quality of care and monitor and evaluate QI activities. Interactive lectures: Didactic lectures can be interrupted with active learning methods such as asking questions, brainstorming, small group discussion or small group work. One way to encourage participants to engage in thinking about the information presented, is by asking questions. Make sure as facilitator that you pause long enough to give participants time to consider an answer. When responses vary you can involve the participants by taking an informal vote by raising hands or inviting participants to argue their point of view. Also questions can be raised during a lecture, which will be addressed through brainstorming in groups of 2 or three for 5 minutes. Brainstorming is a group thinking technique to generate creative ideas on a specific question or problem. It can be used to identify issues or ideas or as a first step to solve problems. The method was first developed in 1939 by Alex Osborne, an advertising executive, who discovered that group thinking exercises improved quality and quantity of creative ideas for advertisement campaigns. Principles of brainstorming are: 1) Focus on quantity by generating as much ideas as possible; 2) Withhold criticism by suspending judgement or comments when ideas are brought forward; 3) Welcome unusual ideas; 4) Combine and improve ideas; Group work (also called cooperative learning) involves having training participants work together in groups to maximize their own and one another s learning. By working together participants explore concepts and issues by talking, listening, reading, writing and reflecting. By working together participants are exposed to perspectives that may be new or different from their own ideas. Experience has shown that in this way learners learn and retain more for a longer period of time than when the content is presented in another format, such as a lecture or written text. Group work is done by working on group assignments, such as developing indicators for evaluation of QI activities, or case scenarios, such as analysing causes and contributing factors of cases of maternal or perinatal deaths. Group work or group discussions require the group to choose a chair person and a secretary who makes notes. One of them or a separate reporter presents a summary of the discussion or the results of the group work in the plenary session afterwards. It is good practice when the workshop facilitators move around the groups during group work to provide further explanation and guidance and help to control the discussion, facilitate participation of all and provide probing questions to challenge participants and deepen the discussion. Case scenarios based teaching is a special form of group work. Discussion-based teaching helps training participants to develop problem solving skills and critical thinking and apply abstract ideas. A discussion session has a beginning, a middle and an end. At the beginning the facilitator explains the topic and purpose of the discussion and presents questions for discussion. 9

11 Good discussion sessions require preparation, asking yourself what you want the students to learn. Before a discussion takes place: Clarify your goals for the discussion; Plan guiding questions for the discussion; Design activities that will prepare students to discuss, such as giving a background paper for preliminary reading; The workshop facilitator as discussion leader must strike a balance between controlling the group and focusing the discussion and letting its members speak. It is important to ensure that everybody participates. This means that quiet persons have to be actively drawn into the discussion by inviting them to speak and asking them for their opinion. They can also be encouraged by seeking eye contact after posing a question, while on the contrary controlling dominant persons in the group can be attempted by avoiding eye contact or not giving them parole all the time ( Let s now give a chance to someone else to say something. ) As discussion facilitator, give after the discussion a summary of key points and conclusions. 10

12 5. PLANNING, PREPARING AND REPORTING It is important that the QI improvement workshops are planned well in advance. In the last quarter of the year, during the PRRINN-MNCH annual planning meeting, a general outline of the QI training programme for the next year is prepared, which includes the preparation of Terms of Reference (ToR) for the QI workshops. At the beginning of each semester, tentative dates for QI workshops will be set and workshop facilitators will be informed. When dates are changed, this will be communicated by the PRRINN-MNCH Technical Advisor for MNCH as soon as possible to workshop facilitators and PRRINN-MNCH State Offices. 5.1 Responsibilities PRRINN-MNCH is responsible for the overall organization of the QI workshops, which includes: Selecting and inviting participants and workshop facilitators; Booking of workshop venue; Booking accommodation for workshop facilitators and participants when necessary; Arranging for meals and tea/coffee breaks; Providing stationery, LCD projector, laptop computer, projection screen, flip charts and other workshop materials; Photocopying of printed workshop materials and handouts; Preparing the venue the day in advance and ensuring that enough chairs, tables and other workshop materials are available and the hall has been cleaned and prepared, including arrangements for small group work; Registering workshop participants; Arranging who will officially open and close the workshop and hand out the workshop certificates; Preparing workshop certificates; Typing out of workshop proceedings and results of group work from flip charts; Payment of per diems; Workshop facilitators are responsible for: Preparing the workshop programme and submitting the time table one week in advance of the workshop to the PRRINN-MNCH Technical Advisor for MNCH for photocopying; Preparing workshop handouts and submitting them one week in advance of the workshop to the Technical Advisor for MNCH for photocopying; Informing PRRINN-MNCH well in advance what workshop materials are needed for the workshop; Preparing power point presentations for the workshop sessions; Reporting for a briefing meeting with the Technical Advisor for MNCH one day prior to the workshop; Making notes during the workshop on issues arising and discussed; 11

13 Having a debriefing meeting with the State Team Manager and Programme Officer Supply Side (POS) after the state level QI training workshop and preparing a 2 page debriefing memo; Having a debriefing meeting at the PRRINN-MNCH central office in Kano with the MNCH Technical Advisor, Deputy Programme manager and/or Programme Manager if possible; Writing a workshop report, using the standard PRRINN-MNCH template; Submitting the workshop report to the PRRINN-MNCH Technical Advisor for MNCH within 2 weeks after the workshop; When drawing up the workshop programme, the facilitators organizing the workshop must agree who of the facilitators conducts which sessions. Add the facilitators names for each workshop session on the workshop time table. After the programme has been drawn up, the principal workshop facilitator reviews the existing workshop power point presentations and updates them, such as changing the title slide (venue, dates). Workshop power point presentations have been designed for each day s programme. It is advisable that after the briefing meeting with the PRRINN-MNCH Technical Advisor for MNCH before the workshop, the workshop facilitators check with him and the PRRINN-MNCH administrative assistant whether all necessary preparations have been made, workshop materials are available and workshop handouts and other printed materials, such as registration and participant feedback forms, have been photocopied in sufficient amounts. During the QI workshops it is useful at the end of each day for the workshop facilitators to meet together with the PRRINN-MNCH staff and reflect on the proceedings of the day and do the final planning for the next day. 1.4 Workshop Equipment and Materials Workshop equipment and tools include: Two flipchart stands; Two flipchart paper pads; Two boxes of coloured markers A roll of masking tape; A stapler and stapler pins; Two reams of photocopy paper for possible additional handouts; An LCD projector and laptop computer for power-point presentation; One multiple socket block and an extra extension cable; A projection screen or white free wall at head end of the hall; Sufficient chairs and tables (tables: 1 for projector, 1 for registration, 4 for group work, 2 for catering if no separate restaurant or dining room is available); 12

14 Participants workshop materials: One folder for each participant; One note pad for each participant; One ball point pen, pencil and eraser for each participant; One name tag for each participant; Workshop programme, evaluation form and handouts In chapter 7 to 10 of this training manual, in which each QI workshop is described in detail, additional specific workshop materials are mentioned in the beginning of each chapter, including handouts to be photocopied and reference books to be used during group work. 1.5 Reporting After each QI workshop the workshop facilitators are expected to write a workshop report, which has to be submitted to the PRRINN-MNCH MNCH Technical Advisor. Usually 2 days are allocated for this in the ToR for the workshop. It is important that at the end of the workshop the workshop facilitators agree on who is writing which part of the report and who has the end responsibility for the final report. They also should discuss which recommendations to include in the report. The PRRINN-MNCH programme has a standard template for reports, which is presented in annex 15. Examples of reports of QI workshops can be found on the course CD-rom, which can be used as a starting point. To be able to write a full report it is important that during the workshop facilitators make notes of the proceedings, discussions and emerging issues, and collect written or electronic copies of presentations and results of group work, which is usually presented in annexes of the report. It is advisable to collect all flip chart sheets at the end of each day and type out the text. PRRINN- MNCH administrative support staff may help with this. At the end of the workshop, participants are asked to give feedback on the workshop on a workshop evaluation form. One of the workshop facilitators analyses the data from these forms and the findings must be reported in the workshop report. Average scores on the questions which have a Likert scale must be calculated. For this it is helpful to tally the scores for each question on a blank workshop evaluation form, add up the total score and calculate the average score by dividing the total score by the maximum score, which is 10 multiplied by the total respondents who answered the question. The workshop facilitator who is responsible for the report must ensure that at the end of the workshop (s)he obtains from the PRRINN-MNCH administrative support staff a list of the workshop participants, including their designations and health facility, institution or organization they represent. This list has to be presented in an annex of the workshop report. 13

15 6. STRUCTURE AND CONTENT OF THE QI WORKSHOPS 6.1 Structure of the QI Training Programme The QI training is delivered in a series of four QI workshops. After the 1 st QI workshop the PRRINN-MNCH supported health facilities establish QI teams at their health facilities, which are responsible for identifying quality of care issues and improving quality of care and will lead the QI activities in the health facility. In between the workshops the QI teams will apply the knowledge and skills acquired during the workshops within their own health facility by identifying quality of care problems, analysing the root causes and initiating and monitoring & evaluating activities to improve quality of care. The first QI workshop will make participants familiar with the concepts of quality and quality of care and they will learn why quality of care is important for MNCH. During the workshop the different dimensions and perspectives of quality of care are explored, as well as the different aspects of quality of care from a health systems perspective. General approaches to improve quality of care are discussed as well as specific QI methods which have been used to improve quality of MNH services. Participants are encouraged to form QI teams in their health facilities, which will be responsible for quality of care. The composition and roles & responsibilities of these QI teams are discussed. Finally methods and tools to assess quality of care are presented and participants are asked after the workshop to brief other staff at their health facility, particularly the Management, about the proceedings of the workshop, establish QI teams and carry out an assessment of quality of care in their health facilities. The 2 nd QI workshop, after a recapitulation of the content of the previous workshop, starts with sharing of experiences. Each QI team presents what they have done since the 1 st workshop, what quality of care problems they have identified, as well as their root causes, what they have done to address these issues, what was achieved, what challenges they faced in improving quality of care and what lessons they have learned. The rest of the workshop is devoted to facility-based Maternal Death Reviews (MDR). With a case scenario participants are introduced to the three delays model, which is used as an analytical framework for maternal death reviews. It is explained how maternal death reviews can help to understand why mothers are dying and to identify weaknesses in the provision of maternal health care, which have to be analysed and translated into action in order to address the shortcomings in care. The concept, principles, advantages and limitations of this method are explained and participants conduct maternal death reviews in small groups, using case scenarios, in order to better understand the process. Data recording and reporting forms for facility-based maternal death reviews are presented and discussed. The 3 rd QI workshop again starts the 1 st day with a recap of the content of the previous workshop, sharing of experiences, including those with MDRs, and discussion of issues arising. The rest of the workshop is spent on two main issues: 1) How to measure quality of care and monitor & evaluate QI activities; 2) Facility-based Peri-Natal Death Reviews (PNDR), which QI method follows the same approach as maternal death reviews, but instead analyses peri-natal deaths, which include stillbirths and early neonatal deaths in health facilities. The 4 th QI workshop as usual starts the 1 st day with a recap of the content of the previous workshop, sharing of experiences and discussion of issues arising. After this the QI method of 14

16 criterion based audit is introduced. During small group work participants explore what aspects of MNCH care can be audited and how to develop criteria for audit. They also carry out a practical audit exercise in small groups. After this, working with standards is discussed and the workshop participants develop in small groups minimum standards for various aspects of MNCH services, which are further discussed in a plenary session. In the following chapters the content of each QI workshop will be discussed in detail. 15

17 7. THE 1 ST QI WORKSHOP The 1 st QI workshop takes 2 days. 7.1 Workshop Objectives The objectives of the 1 st QI workshop are as follows: Explore and define the concepts of quality and quality of care; Explain why quality of care is important for MNCH; Describe different perspectives and dimensions of quality of health care and explain the three health system levels; Contextualise how quality can be improved; Learn how to assess quality of care in health facilities; Agree on recommended composition, roles and responsibilities of health facility QI teams; At the end of the workshop, participants will be able to: Initiate a process of identifying quality of care problems and initiating quality improvement activities in health facilities. Establish health facility QI teams. 7.2 Specific Materials needed for the Workshop Besides the general materials and stationery needed for each workshop as mentioned in chapter 5 on pages 12 & 13, for the 1 st QI workshop the following handouts have to be photocopied for the participants: Workshop programme (see annex 1) Daily power point presentations (printed as handout with 6 slides on one page). Tasks in the health facilities after the workshop (see annex 3) Workshop evaluation form (see annex 2) Workshop certificate 16

18 7.3 Workshop Content DAY 1 Opening and Welcome Remarks Usually the welcoming remarks of the workshop are done by a representative from PRRINN- MNCH, either from the central or the state office, and the workshop is officially opened by the PRRINN-MNCH State Team Manager or Senior Programme Officer. Workshop Objectives After the welcoming remarks one of the facilitators guides the process of introduction of workshop participants. Each facilitator and participant will introduce him/herself to the others in the group. Participants also indicate how they want to be called during the workshop and write this on their name tags, which they wear during the workshop. You may wish to do a brief warm-up exercise to help participants get to know each other and to help them relax. At the end of the workshop, we will be able to: 1. Define quality of care 2. Explain why quality of care is important 3. Describe different perspectives and dimensions of quality of health care and explain the three health system levels 4. Contextualise how quality can be improved As an introduction to the workshop, one of the facilitators explains the purpose of the series of QI workshops, how this training programme is structured and what are the objectives and key activities of the 1 st QI workshop. Display the related power point slides. Workshop Objectives At the end of the workshop, we will be able to: 5. Initiate a process of identifying quality of care problems and quality improvement issues in the facilities 6. Establish quality improvement teams in the facilities Outline of Day 1 Defining quality and quality of care Models of quality of care Perceptions of quality: group exercise What is quality: exercise After explaining the objectives of the workshop, one of the facilitators presents the outline of activities of day 1 of the workshop, displaying the power point slide. 17

19 What is Quality? During the first workshop exercise participants will explore the meaning of quality. This is done by buzzing in pairs or threes for 5 minutes. What is Quality? Exercise: In pairs or threes, think about what is quality and think about when you last bought an item, such as clothes, furniture, a bicycle, motorcycle, refrigerator, radio or TV: Why did you buy that particular item? Why did you buy it from that shop? They are asked to think about the meaning of quality by thinking about when they last bought an item, such as clothes, shoes, furniture, a bicycle, motorcycle, refrigerator, radio or TV. Why did they buy that particular item and why from that particular shop? Ask them to write the points which come up on a piece of paper. After 5 minutes go around and ask each group to present one point at the time and list all the points on a flip chart paper. Aspects of quality which may come up are: durability, reliability, reputation, recognized brand, prompt service, consumer friendly, competent and helpful shop attendant, availability (desired product is in stock),affordability, right price (value for money), durability, high standard, attractiveness of item, comfort, pleasant environment, convenient opening hours of shop. Wind up the discussion by saying that from the exercise we see that quality has many aspects, which we can also apply to health care services. What is Quality in Health Care? The next exercise takes quality a step further and participants will explore the meaning of quality in health care. What is quality in health care? Exercise: In pairs or threes, think about quality in health care. What makes up good quality care? What makes up bad quality of care? This is again done by buzzing in pairs or threes. Encourage the participants to discuss what constitutes good and poor quality care. Give 5 minutes. After 5 minutes, ask each group in turn to present one aspect of good and one of bad quality health care. Then go around the groups again. List all the points on two flip chart papers, one for good quality health care and the other for bad quality health care. Aspects of good quality health care may include: warm and cordial welcome, friendly staff, competent staff, prompt service, affordable services, proper history taking and examination, making a correct diagnosis, right treatment, clear treatment instructions, availability of drugs and equipment, good health outcomes, information & advice given, clean environment. Aspects of bad quality health care may include: negative attitudes and bad behaviour of staff, long waiting times, staff not around or coming late, no skilled staff, no drugs (patient has to buy elsewhere), dirty environment, poor health outcomes, no drugs, lack of equipment. 18

20 Definitions of Quality in Health Care In the next session, one of the facilitators will give a short introduction lecture about different definitions of quality of care as presented in the scientific literature in the last few decades. Definitions of quality in health care the application of medical science and technology in a manner that maximises its benefit to health without correspondingly increasing the risk (Donabedian, 1980) proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society and that have the ability to produce an impact on mortality, morbidity and disability (Roemer & Montoya-Aguilla 1988) Definitions of quality in health care the sum of its four components: technical quality, resource consumption, patient satisfaction, values (Wilson and Goldsmith, 1995) the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional practice (Institute of Medicine, 2001) Or simply said: Doing the right thing right at the right time In the panel below some background information is given on definitions of quality of care. Workshop facilitators are also recommended to read the background literature as can be found on the course CD-rom. Background information for introduction lecture on definitions of quality of care: Defining and therefore measuring quality of care has initially tended to focus on biomedical outcomes. An earlier definition indicates this: the application of medical science and technology in a manner that maximises its benefit to health without correspondingly increasing the risk (Donabedian, 1980). An important distinction between the quality of the actual care and the expected quality of care based on standards is made in this definition: quality of care is proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society and that have the ability to produce an impact on mortality, morbidity and disability (Roemer & Montoya- Aguilla, 1988). In addition to biomedical outcomes, this definition adds safety and affordability as aspects of quality care. Some definitions are more inclusive and now address user and provider satisfaction, social, emotional, medical and financial outcomes as well as aspects of equity and performance according to standards and guidelines. Wilson and Goldsmith (1995) describe quality of care as: the sum of its four components: technical quality (measured by patients health status improvement), resource consumption (measured by the costs of care), patient satisfaction (measured by patient perception of the subjective or interpersonal aspects of care), values (measured by the acceptability of any trade-offs that must be made among the three previous outcomes). More recent definitions of quality of care include one by the Institute of Medicine (2001): the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional practice. This definition makes it clear that quality of care is a means of closing the gap between the desired and actual health outcomes. 19

21 Quality of Care in the Context of Maternal & Newborn Health Quality in Maternal & Newborn Health (MNH) care: important differences Most users of maternal health care services are well. Some users will develop conditions requiring a higher level of obstetric care. After discussing the definitions of quality of care, one of the facilitators gives a short introduction on the meaning of quality of care in the context of MNH, displaying the related Power Point slides. The panel on the next page gives some background information on quality of care of MNH services. At least 2 different clients: mother and baby (ies) Culturally and emotionally sensitive area. How is quality defined in the area of MNH care? quality of care is the degree to which maternal health services for individuals and populations increase the likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and uphold basic reproductive rights (Hulton et al. 2000) How is quality defined in the area of MNH care? high quality of care of maternity services involves providing a minimum level of care to all pregnant women and their newborn babies and a higher level of care to those who need it. This should be done while obtaining the best possible medical outcome, and while providing care that satisfies women, their families and their care providers. Such care should maintain sound managerial and financial performance and develop existing services in order to raise the standards of care provided to all women (Pittrof et al. 2002) 20

22 Background information for introduction on quality of care of MNH services: Defining quality of maternal health care poses some extra challenges. There are some quality issues that are specific to maternal health. Most users of maternity services are well. Minimum care should therefore be provided to all pregnant women and their babies. It should be evidence based and cost effective. Some users will develop conditions requiring a higher level of maternity care. 8-15% of women will develop complications, and although screening of women may ensure that some women receive a higher level of care, we cannot predict who. Providing higher-level care should not interfere with providing minimum care to the entire population. Availability of good quality EOC. Maternity care is aimed at least at two recipients the mother and baby. Outcomes for both mother and baby are important and advantages and disadvantages for both need to be counterbalanced. As childbirth is a culturally and emotionally sensitive area, non-biomedical outcomes may be more important than for other areas of health care. Satisfaction depends on values given to specific medical outcomes which vary between cultures and individuals. Defining quality in the context of maternal health, Hulton et al (2000) incorporated the concept of both effective and timely access, and of reproductive health rights: quality of care is the degree to which maternal health services for individuals and populations increase the likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and uphold basic reproductive rights. The authors recognised the importance of two components of care: the quality of the provision of care and quality of care as experienced by users. The use of services and outcomes are the result not only of the provision of care but also of women s experience of that care. Provision of care may be deemed of high quality against recognised standards of care but unacceptable to the woman and her family. Conversely, some aspects of care may be popular with women but may be ineffective or harmful to health. More recently Pittrof et al (2002) pointed out that maternity care has 4 specific aspects: 1) most users of maternity services are well; 2) some users will develop conditions requiring a higher level of maternity care; 3) maternity care is aimed at least at two recipients the mother and baby; 4) non-biomedical outcomes may be more important than for other areas of health care because childbirth is a culturally and emotionally sensitive area. Pittrof et al (2002) proposed the following definition of quality of maternity care: high quality of care maternity services involves providing a minimum level of care to all pregnant women and their newborn babies and a higher level of care to those who need it. This should be done while obtaining the best possible medical outcome, and while providing care that satisfies women and their families and their care providers. Such care should maintain sound managerial and financial performance and develop existing services in order to raise the standards of care provided to all women. 21

23 Why is Quality of Care Important? After the discussion of quality of care in the context of MNH, workshop participants will do a small group exercise. Should we be concerned with quality of care? Exercise (10 minutes): In pairs, discuss: Should we be concerned? Why should we be concerned? Why is quality of care important? In groups of two or three they are asked to discuss why we should be concerned about quality of care and why quality of care is important. They have 10 minutes. Go round and collect from each group their responses and stick them on a flip chart. In the panel on the next page some information is given on why quality of health care is important. Importance of quality in health care Quality of health care affects: Outcome (morbidity, mortality, disability) Patient satisfaction. Health worker satisfaction and motivation. Health seeking behaviour. Utilisation of services including HF deliveries). Timing of presentation at health facility. Willingness to pay for care Importance of quality in health care Good quality of care leads to: Higher standards Patient satisfaction Better relations between colleagues, patients and communities we serve Increased use of our facilities More funds Staff satisfaction Models of Quality of Care One of the workshop facilitators will give an introductory presentation on the different models for looking at quality of care, which provide an analytical framework. The panels on the next pages give some background information. Models: Quality in Health Care Model: different perspectives Different perspectives Women and families Different elements Technical competency Interpersonal relations Effectiveness Health system Structure Women and families Quality of Care Health care providers Health care providers Equity Safety Patient centredness Process Managers Managers Timeliness + continuity Outcome IN PARTNERSHIP WITH Liverpool School of Tropical Medicine Efficiency Liverpool Associates in Tropical Health The panels on pages 20, 21 and 22 provide background information on models of quality of care. 22

24 Background to importance of quality in health care Quality of care affects health care in the following ways: 1. Outcome: Quality of health care will affect if and how well the woman and newborn recover. This is not just about reducing mortality, but also morbidity (illnesses and disability) 2. Patient satisfaction: Quality of care determines how satisfied is the woman and her family are with the care that she received. When information spreads, this will in turn affect other people s perceptions of the services and create a bad reputation. 3. Health worker satisfaction: When health workers know they provide good quality services and they receive positive feedback it creates job satisfaction and motivates staff in their work. 4. Health seeking behaviour: If quality is poor, this will affect people s confidence in the services and also affect behaviour, such as compliance to treatment and advice. If quality of care is poor women and families will choose other facilities or other health care providers such as traditional healers and they may be reluctant to use health services, even when this is necessary, such as in case of an emergency or serious condition. 5. Utilisation of services: Women and families will talk with others and this will affect their perceptions of the health facility. Clients and patients will not use any services, even essential ones, if they perceive the quality as poor. The result may be that a woman does not receive antenatal care or will not benefit from a skilled attendant during child birth. This may have a negative impact on the health status of women in the population. 6. Timing of presentation at health facility: Patients come late, because they are reluctant to use services if they have no confidence in them. They only come for emergencies or when the condition has deteriorated to a desperate level and by the time they arrive in the hospital it is too late to save the mother or baby s life. 7. Willingness to pay for care: If people do not see the value in the care they receive, they are not willing to pay for poor care and will not use facilities which charge fees. They prefer to spend money on other things. If we are seriously concerned about quality of care it will help us achieve many things: Higher standards of care, better outcomes and reduced mortality and morbidity. Satisfied patients Staff satisfaction if I feel like I have provided good care, then I feel happy, and this motivates me to continue to provide good care and improve care. Improved relationships between colleagues work together as a team, motivate each other to provide good quality of care Improved relationships between staff, patients and communities staff are responding to needs of patients and communities, better communication. Increased use of facilities and earlier use of facilities Increased use of services may lead to an increase in funds, such as more income from user fees and more likely financial support from donors. This may help improve the quality even further as a result of affordability to purchase equipment, send staff for training, and maintain the facility and improve working environment. Poor quality health services may result in waste of money, time and even lives. 23

25 Background information on models of quality of care Quality of care can be viewed from different perspectives (Ovretveit, 1992): 1. the view of patients, clients, potential users and the community at large; 2. the view of health care providers; 3. the view of health planners, managers and programme coordinators. These groups of people have different backgrounds, interests, priorities and concerns. Therefore they see quality of care from different perspectives and have different ideas about what constitutes quality of care and what is most important. Quality of care has different aspects or elements, such as effectiveness (in curing or preventing diseases, reducing mortality, morbidity and disability), technical competency, interpersonal relations, equity, safety, patient centredness (responsiveness to client s and patient s needs and expectations), timeliness and continuity and efficiency. Technical competence This refers to knowledge, skills and actual performance of health care providers, managers Interpersonal relations This refers to relationships between health care providers and clients, managers and providers, health team and community. Good interpersonal relations create trust and credibility. Inadequate communication can negatively affect effectiveness of care, such as poor compliance with recommendations and poor care and treatment as a result of miscommunication and misunderstanding.. Patient centredness This refers to being responsive to the needs and expectations of clients, patients and the community at large, it includes user-friendly services and convenient lay-out of facilities, respect for clients and patients cultural values, beliefs and practices, involving clients and patients in decision making and ensuring privacy and confidentiality. Equity This means that services are provided fairly and with consideration for those who need the services most. Effectiveness Services when provided correctly produce the desired results and have good health outcomes. Efficiency This means producing the greatest benefits within resources available and not wasting resources needlessly. Safety We must ensure that in providing treatment and care we take safety precautions to avoid doing harm to our patients, ourselves and others. This includes a safe environment, safe procedures and treatments and infection and accident prevention measures. Timeliness and continuity This refers to accessibility and continuity of care, including avoiding delays in accessing and receiving care and availability of 24/7 obstetric care. Access to care includes geographic access (availability of transport, distance from home, travel time to health facility), financial access (ability and willingness to pay for services) and organisational access (hours of service, waiting time, human resources, emergency referral system). Amenities Refers to aspects of services not directly related to clinical effectiveness, but which enhance the client/patient s satisfaction and likelihood to return. 24

26 Dimensions of the health system: Background information on models of quality of care Quality of care is also related to different dimensions of the health care system and can be measured at these different points in the system. The quality of resources, quality of management, quality of health care activities and quality of outcome - all of which constitute quality of care, can be measured (Donabedian, 1980). It is important to focus on all three dimensions of the health system as health outcomes are dependent on the structural aspects and processes of the health system. Structure: refers to the characteristics of the resources in the health delivery system (what has to be in place to provide services), for example number of qualified staff, functioning equipment, number of road worthy vehicles, policy guidelines, and management systems. These may be easy to measure but are not always informative unless they are related to the process and outcome. Process: examining the process of care embodies what is actually done to and for the patient and how it is done. Collection of this data depends on having good systems of recording and reporting. Process measures include things such as waiting time, being given a clear diagnosis, examining the patient properly, prescribing the correct treatment, interpersonal communication. Outcome: measurement of the effect or outcomes of care is generally still more difficult to carry out and is less frequently done. Outcome measures include for example mortality, patient satisfaction, coverage, and attendance levels. 25

27 Perspectives of Quality of Care After the introduction to models of quality of health care, workshop participants are divided into three groups for a small group exercise on perspectives of quality of care. Group 1 will discuss quality of MNH care from the perspective of the mother using maternal health services; Group 2 will discuss quality of MNH care from the perspective of the health care provider (midwife, doctor, CHEW); Group 3 will discuss quality of MNH care from the perspective of the health planner, manager or programme coordinator; Group exercise: perception of quality Group 1: represents women using MNH services Group 2: represents health care providers Group 3: represents health planners, managers 1. Identify health care quality factors from your perspective 2. How can you measure these factors in your facility? 3. For each factor, is this a structure, process or outcome factor? 4. Can this factor be addressed at health facility level? Example of feedback from exercise on perspectives of quality of care Patient quality Measurement Structure Within factor Process our Outcome control Prompt Exit interview Process Yes Service Observation The following questions guide the group work: 1. Identify important quality factors from your perspective. Group 1: as a mother what do you expect from maternal health services. Group 2: as a healthcare provider list your expectations and requirements, to provide the highest quality of care. Group 3: as a health planner/manager list your expectations & requirements, necessary to manage services efficiently and effectively. 2. How can you measure these factors in your facility? 3. For each factor, is this a structure, process or outcome measure? 4. Can this factor be addressed at facility level? Each group will present their findings in the form of a table as shown on the slide above. After the factors have been presented by the groups, ask the workshop participants what differences they observe between the perspectives of the three groups. What implications has this for improving quality of care? Wind up the discussion by saying that it is important for health care providers to be aware of the needs and expectations of clients & patients and consider these when improving quality of care. At the same time, when providing quality services they have to consider the quality concerns from a manager s perspective. Health planners & managers also must be aware of the needs and concerns of both health care providers and patients & clients and plan health services accordingly and provide support to health care providers by addressing their needs in terms of structural factors in order for them to provide quality health care. 26

28 When closing the day, give a brief summary of the main issues which have been discussed during the day, thank the workshop participants for their active participation and ask for a volunteer from the workshop participants to close the day with a prayer. Afterwards the workshop facilitators conduct a brief meeting to review the proceedings of the day and reflect on what went well and what went less well and how to go about the next day s programme. Also discuss the issues which were arising during the discussions and how to address them the next day. DAY 2 Opening and Recap of Previous Day After welcoming the workshop participants, start the 2 nd day with an opening prayer, followed by a recap of the key issues discussed during the 1 st day. Ask workshop participants what they learned yesterday. This can be done by asking the group in general and wait for spontaneous responses or go round the group and ask each participant to mention something important (s)he has learned yesterday. Present the Power Point slides with summary of key issues from the previous day. Also present specific issues arising during the discussions of the previous day and discuss them further if necessary. What is Good and What is Bad Quality Antenatal Care? In order to apply the concepts of quality of care which have been discussed the previous day, the workshop participants will explore the aspects of quality of antenatal care. This is started off with two role plays. At the beginning of the day, workshop facilitators select five workshop participants for the role plays and ask them to prepare two short (10 minute) role play and present it to the workshop audience. The first role play shows an example of good antenatal care. The second role play demonstrates bad antenatal care. The first role play has 2 actors: a pregnant mother and the nurse-midwife at the antenatal clinic. The 2 nd role play has 3 actors: a pregnant mother and two nurse-midwives, in order to show lack of privacy. After the role plays, ask the workshop participants what aspects of good antenatal care they observed in the 1 st role play. List the points on a flip chart. Then ask what aspects of bad quality antenatal care they saw in the 2 nd role play and list them on a second flip chart. Afterwards workshop participants are divided in 3 groups for group work on what constitutes good quality antenatal care: Group 1 discusses and lists aspects from the health care provider perspective which are related to structure; Group 2 discusses and lists aspects from the health care provider perspective which are related to process; Group 3 discusses aspects from the client s perspective, in terms of what the client expects; Give the groups 30 minutes for this group work. After the tea/coffee break the groups present the results of their group work, which are discussed in the plenary sessions. 27

29 Quality Assurance One of the workshop facilitators gives a brief introduction to explain the concept of quality assurance. What is Quality Assurance? QA is all the arrangements and activities that are meant to safeguard, maintain and promote quality of care (Donabedian). QA is a systematic and planned approach to assessing, monitoring and improving the quality of health services. It can promote confidence, improve communications and allows clearer understanding of community needs and expectations. Quality Assurance 1. Oriented towards meeting the needs and expectations of the patient and community. 2. Focuses on the way we work (how we deliver health services). 3. Employs standards to ensure an acceptable level of quality of care. 4. Uses data to analyse how we are working and delivering health services according to these standards. 5. Encourages a multi-disciplinary team approach to problem solving and quality improvement Quality assurance triangle Quality assurance is a systematic and planned approach to improve and maintain quality of care. It has three key aspects: Defining quality, which means setting standards for desired quality levels. IN PARTNERSHIP WITH Liverpool School of Tropical Medicine Liverpool Associates in Tropical Health Measuring quality, which means assessing actual quality of care and compare it with desired standards. Improving quality, which means planning and implementing interventions. How can we Improve Quality of MNH Care? In this session a brief introduction is given to the broad approaches to improve quality of care, the specific methods which are used to improve quality of MNH care and the methods and tools, which are used to assess quality of care. 28

30 Background Information on the Quality Improvement Approach Our broad approach to improve quality of MNH services has three main strategies: 1. Create a culture of quality 2. Identify champions to lead the process of quality improvement 3. Establish health facility Quality Improvement (QI) teams Creating a culture of quality means changing health workers mindset at all levels of the health care system by creating awareness on the importance of quality of care and positioning quality of care as a cross-cutting issue, which guides health workers in their daily work. It also means creating commitment of health care providers to improve and maintain quality standards of health care, whereby health workers are enabled to see patients and clients as consumers of services, which are responsive to their needs and expectations. It means as well promoting more respectful attitudes to patients and clients. In a culture of quality identifying shortcomings in care and service provision is seen as opportunities to improve quality of care in a constructive way, avoiding a culture of fault finding and blame, whereby individual people are accused or penalised. Instead through a teamwork approach identified quality of care problems are analysed and addressed by finding and implementing solutions for the problems. Champions are people who will drive the process of quality improvement and who have demonstrated an interest in quality of care and are committed to actively pursue the improvement of quality of care. Champions with leadership skills for quality improvement can be identified among policy makers, health planners and managers as well as health care providers, such as doctors, nurse-midwives and CHEWs. At each health facility a champion has to be identified who will lead the QI process at the health facility. Health facility Quality Improvement (QI) teams are instrumental in putting in place continuing QI processes at health facility level and translating quality improvement into action. They take charge of quality of care by identifying and analysing quality of care problems, finding solutions to solve them and planning and implementing interventions to address the problems and improve quality of care. They will also monitor the QI activities and evaluate progress and effectiveness. The health facility QI teams are multi-disciplinary in composition, preferably consist of not more than 8-10 members and meet regularly. They report to the Management of the health facility. QI committees can also be established at LGA or state level, but their roles will be different. Methods to improve quality of care of MNH services Maternal death reviews Facility based Community based (verbal autopsy) Confidential enquiries into maternal deaths Near miss reviews Peri-natal death reviews Setting standards of care Criterion-based audit Development and use of clinical protocols Supportive supervision For more details it is recommended to read the following publications: Lewis G. (2003) Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. British Medical Bulletin; 67: WHO. (2004) Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. Geneva, WHO. 29

31 Methods to Improve Quality of MNH Care For background information on these methods we refer to the WHO publication Beyond the numbers: reviewing maternal deaths and complications or a shorter article by Gwynneth Lewis with the same title. Both can be found on the CD-Rom of the QI training Programme. After explaining the overall approach to quality improvement, the various methods which are used to improve quality of care of MNH services are presented. The principles of these methods are explained in brief. Tell the participants that these methods will be discussed in detail in subsequent QI workshops. The methods are listed in the panel on the previous page. Methods to improve quality of care of MNH services Maternal death reviews Facility based Community based (verbal autopsy) Confidential enquiries into maternal deaths. Near miss reviews. Peri-natal death reviews. Setting standards of care. Criterion based audit. Development and use of clinical protocols. Supportive supervision Maternal death reviews: Facility-based Definition: A qualitative, in-depth investigation of the causes of and circumstances surrounding MDs occurring at health facilities It requires committed and skilled individuals at the facility to drive the process and follow through on recommendations It may be expanded to include community factors Maternal death reviews: Community-based Definition: A community-based method of maternal death review, which aims to identify weaknesses in the maternal health care system, with a view to remedy them It focuses on maternal care at community level and barriers in accessing essential obstetric care Confidential enquiries into maternal (and peri-natal) deaths Definition: A systematic multidisciplinary anonymous investigation of all or a representative sample of maternal deaths occurring at an area, regional or national level. It identifies the numbers, causes and avoidable or remediable factors It summarizes maternal deaths from reporting health facilities region or country wide. An expert panel reviews the maternal deaths. Near-miss reviews Same process as maternal death reviews, but reviewing near misses (women who almost died) Cases of severe maternal morbidity or near misses occur in larger numbers than deaths. It enables more robust conclusions to be drawn about risk factors and avoidable factors. Definition of Near miss : Near-miss reviews A woman who nearly died but survived a complication that occurred during pregnancy, child birth or within 42 days of termination of pregnancy. Survivors live to tell their part of the story. Can be less threatening to health providers. 30

32 Peri-natal death reviews Same process as maternal death reviews, but reviewing stillbirths and early neonatal deaths. Can be done at same time as maternal death review. Setting standards Standards for the provision of maternal, newborn and child health care indicate the quality of services that health care providers are expected to provide Examples of standards A woman s right to privacy and confidentiality is respected. Every woman in labour in a health facility is monitored with a partograph and active management of the third stage is practiced. All staff implement infection prevention measures. At each antenatal visit the blood pressure is measured and position of baby and foetal heart are assessed Criterion-based audit Definition: an objective, systematic and critical analysis of the quality of obstetric care against set criteria of best practice Pre-requisites: evidence-based standards that are the source of criteria. written records: if it is not written down, it did not happen! Criterion-based audit Example: Topic: Blood transfusion in case of PPH Criteria: All women estimated a loss of at least 1500 ml blood should receive blood transfusion Blood transfusion should begin within one hour of decision Fluid balance chart should be maintained during transfusion Measure current practice Feedback the findings and set local targets. Implemented changes in practice. Re-evaluated practice and give feedback 31

33 Methods and Tools for Assessment of Quality of Care In this session the methods and tools for assessment of quality of care are discussed. Methods & tools for quality assessment Data collection method: Data collection tool: In-depth interview Questionnaire Exit interview Questionnaire Focus Group Discussion FGD topic guide Direct observation Check list Review of records Check list Data collection sheet Patient complaints Suggestion box Household survey Questionnaire A combination of quantitative and qualitative methods is used. Quantitative methods involve counting and produce numbers and figures. Qualitative methods collect narrative information on people s opinions, perceptions and experiences related to health services. The 1 st power point slide summarises the methods in a table together with the data collection tools, which are used. Afterwards the different methods are discussed. In-depth interviews and Focus Group Discussions (FGD) With clients or patients, people in the community, health care providers, managers. In depth exploration of: Access to and use of services. Barriers and enablers to using care. Barriers & enablers to providing quality of care Perceptions of quality of care. Expectations of quality of care Observations Observations (direct, participatory) of provision of care using checklists: Antenatal care - History taking Postnatal care - Examination Intra-partum care - Investigations Post-natal care - Communication FP services - Prescription of treatment - Dispensing of drugs - Nursing care Client exit interviews Household interviews Interview clients after they have used services e.g. after antenatal visit, after discharge from maternity, after postnatal visit. Ask questions about: Care they received Perceptions of the care Satisfaction Concerns and complaints A household survey is more difficult, cumbersome, time-consuming and costly as other methods. Include questions on: Care provided. Perceptions of quality of care. Reasons for use and non-use of services. Reasons for choice of service provider. Expectations of MNCH services. 32

34 Patient complaints and incidents Complaints/Suggestion box. Letters. Meetings Patients may express complaints about the care they received or report incidents. These complaints tell something about the quality of care. We can find out about it through suggestion boxes placed in health facilities, in which patients or clients can deposit complaints or suggestions for improvement of quality of care. The health facility management may have received letters, while we may also hear complaints at meetings with community leaders or with the facility health committee. The most single important condition for success in quality assurance is the determination to make it work. If we are truly committed to quality, almost any reasonable method will work. Whatever method we use in quality assurance, what is most important to make changes is commitment and determination to make things work. If we are not, the most elegantly constructed of mechanisms will fail (Donabedian 1996) IN PARTNERSHIP WITH Liverpool School of Tropical Medicine Liverpool Associates in Tropical Health Quality Improvement Teams Although quality of care should be everybody s concern in a health facility, to ensure that quality of care will improve in a continuous process somebody has to take the overall responsibility for QI in the health facility. Otherwise nothing may change. To make things happen it is useful to have a special health facility QI team, which is responsible for looking into quality of care issues and which takes the lead in improving quality of care. Quality Improvement (QI) teams: Key points The workshop participants are advised to establish QI teams in their health facilities. Multi-disciplinary Keen and motivated Act as champions of quality Regular meetings Clear roles Action and review Disseminate findings and action plans Initiate quality improvement activities 33

35 Quality Improvement (QI) teams Group exercise Divide into small groups by facilities. Discuss: In the health facility, who should be in the QI team and why? What are the roles of the QI team? How often will you meet? How will you record your meetings? For a group work exercise the workshop participants are divided in groups according to the health facilities. Participants from LGA and state level are divided over the groups. Present the power point slide with the points for discussion. The exercise takes 30 minutes, after which the groups briefly report the results of their group work. Tasks for after the Workshop Tasks for after the workshop 1. Establish a QI team in your facility. 2. Update QI team members on concepts of Quality of Care and Quality Improvement and roles of the QI team 3. Identify quality of care issues: - Interviews with health care providers - Interviews with managers - Interviews with women 4. QI meetings in your facilities discuss findings from interviews and develop action plans. Present the power point slide and distribute and discuss the handout (see annex 3). The first page of the handout describes the tasks which the workshop participants are expected to undertake after the workshop. After presenting the tasks, explain the guidelines and tools the members of the QI team need to assess quality of care (see handout). Go through the questionnaire. Closing Remarks Workshop participants are kindly requested to fill in and return the workshop evaluation form. A representative of PRRINN-MNCH makes the closing remarks, the workshop certificates are handed out and a volunteer closes the workshop with a prayer. 34

36 8. THE 2 ND QI WORKSHOP In the invitation for the 2 nd QI workshop, participants from each health facility are asked to prepare a 10 minute presentation on what they have done since the 1 st QI workshop, including the composition of their QI teams, the findings from the assessment of quality of care, the root causes of the quality of care problems identified, the planned QI activities and the activities which actually have been carried out, as well as the achievements and challenges they faced in implementing the activities and lessons learned. 8.1 Workshop Objectives The objectives of the 2 nd QI workshop are as follows: Share experiences to improve the QI activities in health facilities. Learn how to analyze maternal deaths, using the 3 delays model. Learn the purpose, principles, strengths and limitations of facility-based maternal death audit and how it can improve MNH services. Learn how to initiate, organise and conduct a facility-based maternal death review. Learn how to document information from maternal death reviews on maternal death review forms. 8.2 Specific Materials needed for the Workshop Besides the general materials and stationery needed for each workshop as mentioned in chapter 5 on pages 12 & 13, for the 2 nd QI workshop the following handouts have to be photocopied for the participants: Workshop programme (see annex 1) Daily power point presentations (printed as handout with 6 slides on one page). Workshop evaluation form (see annex 2) Workshop certificate Case scenario: Why did Fatuma die? (see annex 4) Steps in initiating and conducting maternal & perinatal death reviews (see annex 5). Case scenarios of good and bad MDRs (see annex 6) Maternal death review form (MDR 1) (see annex 7) Maternal death follow up form (MDR 2) (see annex 7) Maternal death notification form (MDR 3) (see annex 7) Maternal death interview guide (see annex 7) 35

37 8.3 Workshop Content DAY 1 Opening and Welcome Remarks Usually the welcoming remarks of the workshop are done by a representative from PRRINN- MNCH, either from the central or the state office, and the workshop is officially opened by the PRRINN-MNCH State Team Manager or Senior Programme Officer. After the welcoming remarks one of the facilitators guides the process of introduction of workshop participants. Most participants will know each other from the first Qi workshop, but there may be a few new people who did not attend the first QI workshop. One of the facilitators explains the objectives and key activities of this 2 nd QI workshop. Workshop Objectives At the end of the workshop, we will be able to: 1. Improve our QI activities. 2. Analyze maternal deaths, using the 3 delays model. 3. Describe what maternal death audit is and how it can improve MNH services. 4. Identify the strengths and weaknesses of this method. 5. Organise and conduct a maternal death audit. 6. Document information from maternal death audits on maternal death audit forms. Workshop Activities Present activities of QI teams since previous workshop & share experiences. Learn the concepts of the 3 delays model and review a case scenario. Learn the concepts of facility-based maternal death audit (maternal death review). Conduct maternal death reviews in small groups. Review data collection & reporting tools for facility-based MD reviews. Discuss and agree on QI activities after workshop After explaining the objectives and key activities of the workshop, one facilitator gives a recap of the content of the previous workshop, which is important to refresh participants memories (the 1 st workshop probably was at least 3 months ago) and reinforce what they learned during the 1 st workshop. This can be done by posing to the workshop participants the question What did we do and learn during the previous workshop? Another facilitator writes the responses from the participants on a flip chart. After this it is useful to summarise the main issues from the 1 st workshop, supported by power point slides. Presentations from health facility QI teams Reporting on QI activities Each HF QI team gives a 10 minutes presentation, followed by 5 minutes questions + discussion. Composition of QI team. What have you done since the last workshop? What quality of care issues did you identify (findings from interviews) and what root causes? What QI activities have been planned and initiated (QI action plan)? What have been the achievements of the QI activities, challenges and lessons learned? Representatives from each health facility QI team are invited to give a brief presentation on what they have done since the previous workshop. Each presentation should not take more than 10 minutes, followed by 5 minutes for questions and comments. These presentations usually take most of the rest of the day and provoke a lot of discussion. 36

38 It is useful if one of the facilitators lists important emerging issues on a flip chart, which can be taken up later for further discussion. Also it is useful to make notes of the quality of care problems, which have been identified. During the presentations, presenters can be asked whether they had any difficulties in conducting the interviews and who conducted the interviews. An issue which has to be raised is that patients and clients interviewed may not feel free to respond when they are interviewed by health care workers from the facility about what they think about the quality of services and care. They may feel reluctant to express negative opinions. Therefore it is better to involve outsiders in the interviewing of patients and clients through exit interviews. The QI teams could ask assistance from members of the health facility health committee or volunteers from the community. Another issue to be discussed, is the usefulness of probing. When during interviews people are reluctant to criticise or express negative feelings about the health services or fail to come up with suggestions for improvement, probing can be used. This means, asking additional questions to invite a response when people don t say much spontaneously, such as Is there really nothing you are not satisfied about or what could be improved? Are you sure everything is fully meeting your expectations? Feel free to say anything. Have you always been attended to promptly and are health workers always treating you well? Was everything always clearly explained to you? Were you always pleased with the treatment you received, with the condition of the health facility or the way health workers treat you? It must also be discussed that it is important that the QI teams try to analyse the quality of care problems they have identified and try to find out the reasons for these problems by repeatedly asking the question why?. In this way they try to find the root causes for the problems. It is important to understand why problems exist and what factors contribute to these problems. This will help in finding solutions for solving the problems. It is likely that many of the quality of care problems, which are presented by the HF QI teams, are related to the structural aspects of quality of care in terms of lack of resources, such as shortage of professional staff, lack of equipment, non-availability of drugs, water supply, electricity or an ambulance. Solving these problems is often beyond the capacity of the QI teams or health facilities and requires support or action from a higher level such as the LGA administration, Health Services Management Board (HSMB), State Primary Health Care Management Board (SPHCMB) or State Ministry of Health (SMOH). What health facilities can do is limited to advocacy at higher level for support, which requires clear advocacy messages and good arguments why support is important, or making requests for additional resources. Preoccupation with lack of resources as quality of care problems may result in QI teams placing the responsibility for improving quality of care with higher authorities and they may deny their own role in improving quality of care. They should consider quality of care rather than quality of resources, which must be seen more as part of the underlying contributing factors which affect the actual quality of care than as quality of care problems on their own. QI teams are advised to focus more on problems which they can solve themselves and which are related to the process dimension of quality of care, or with other words related to what is happening in the health facility and how things are done. They should focus more on quality of care issues related to performance of services and health workers and identify sub-standard 37

39 care, treatment, and interpersonal communication, which may be related to weaknesses in organization and management besides lack of resources. Process-related quality of care issues may include sub-standard management of clients and patients in terms of history taking, examination, treatment and monitoring of patients, but also poor interpersonal communication, such as unfriendly behaviour, not explaining findings, diagnosis and treatment to patients or poor counselling and health education, and poor punctuality of staff, record keeping, cleanliness, waste disposal and infection prevention practices. Workshop facilitators should also point out to the QI teams that the quality of care assessment interviews, particularly the exit interviews with clients and patients, can be repeated later on, e.g. after 6 months, to see whether the situation has improved or to identify new quality of care concerns. After the presentations from the HF QI teams, if time allows, some of the emerging issues can be further discussed, exploring the reasons and possible ways to address them. The Three Delays Model Workshop facilitators are recommended to read the following papers about the three delays model (available on the course CD-rom). Thaddeus S, Maine D (1994). Too far to walk: maternal mortality in context. Social Science and Medicine; 38 (8): Gabrysh S, Campbell O (2009). Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy & Childbirth; 9: 34. At the end of the day s programme and introduction is given to the Three Delays Model, which is an important framework to analyse access to essential obstetric care and analyse contributing factors to maternal and peri-natal deaths when conducting maternal and peri-natal death reviews. Three Delays Model Delay in recognizing or understanding the danger signs and need to seek professional help and in deciding to seek help. Delay in taking women to hospital. Delay in receiving the right treatment once at the hospital. To explore the concept of the three delays model, workshop participants read and discuss for one hour in small groups the case scenario Why did Fatuma die? (see annex 4) From the story they must identify and discuss the factors which have contributed to the death of Fatuma. In the plenary session, one of the workshop facilitators goes round the groups and let them briefly present and explains two or three contributing factors at the time before moving to the next group. These factors are listed by another facilitator on flip charts and grouped according to level of delay. At the end of the session the different contributing factors for each level of delay are summarised and it is explained that this framework helps us to find out why women are dying and identify what are the modifiable factors, which we have to address to prevent 38

40 maternal deaths in future. We can do this by conducting maternal death reviews, which will be discussed the next day. CASE SCENARIO: WHY DID FATUMA DIE? This is the story of Fatuma Odeh, a 15 years old schoolgirl from Bonankoro, a rural village in Nigeria, at 12 km from Tsanyawa health centre. Fatuma was learning at the nearby secondary school in form 2. At school she met her boyfriend Mussah. Because she was worried to become pregnant, which would mean the end of her education, she went to Tsanyawa HC to ask for family planning. However, the nurse refused to give her assistance and told her that she was too young for such things and that she should concentrate on school instead of meeting boys. What could she do now? If she refused to have sex with Mussah, he would leave her for another girlfriend and she did not want to loose him as her boyfriend, because he was really nice to her and bought her soap and other things, which she needed for school and her parents were not able to provide. Sometime later Fatuma missed her monthly periods. She also felt nauseated in the mornings and suspected that she was pregnant. She was very upset and tried to hide her pregnancy as long as possible. When she told Mussah about her pregnancy, he denied that it was him who made her pregnant and he ended their relationship. She did not want to attend antenatal clinic, because she felt embarrassed and was afraid of what the nurse would say to her. For sure she would shout at her. When she was about 6 months pregnant her mother noticed that she was pregnant and told her father. Her father was very angry and called her bad names and shouted at her that she had brought shame to the family and threatened to chase her from the house. Her mother tried to cool him down, but because Fatuma was feeling ashamed and afraid of her father, she ran away from home and went to stay with her grandmother. Of course she could not go back to school, because meanwhile the news had already spread. When she was 8 months pregnant she noticed that her feet became swollen and later even her hands became swollen as well. Her grandmother took her to a traditional healer who gave her some herbs, which she had to prepare as a concoction and drink three times a day. There was no improvement. Finally she gathered courage and went to the health centre. It was difficult to walk the long distance with her swollen feet, which were painful and made her feel tired. The midwife told her to rest at home and if there would be no improvement to go to the district hospital, where she would have to stay until she would give birth. But how could she go there and who could go with her to look after her? The hospital is far and she had no money to go there. So she stayed at home. A month later, she woke up one morning with a bad headache and felt dizzy. She told her grandmother that she was not feeling well and could not fetch water that morning. Her grandmother bought her some aspirin, but when she came back from the shop she found Fatuma laying in the house, shaking all over her body. She immediately called the village TBA for help and when Mai Oumou came, the twitchings had subsided, but Fatuma was unconscious. Mai Oumou told Fatuma s grandmother to take her as quick as possible to the hospital. Grandmother sent someone to inform Fatuma s mother, who arrived after an hour. When her mother saw Fatuma she started crying. Meanwhile Fatuma had started having fits again. Fatuma s mother rushed home to tell her husband and ask his permission to take Fatuma to the hospital. Meanwhile, grandmother tried to find transport to take Fatuma to the hospital, but the owner of the only pick-up in the village charged 1,000.= Naira to take her to the hospital. Although Fatuma s father agreed to taking Fatuma to the hospital, he had no money to pay for transport. (Continues on next page) 39

41 Finally, with the help of some neighbours, they carried Fatuma to the health centre, where she got an injection and the fits stopped for a while. The midwife explained that Fatuma had to go to the big hospital as soon as possible and someone had to go there on bicycle to call for an ambulance, since she has no radio or phone to call the hospital herself. One of the neighbours volunteered and rushed on his bicycle to the district hospital, which was 4 hours cycling away. Fortunately the ambulance was around, but there was no fuel in the tank. The hospital administrator had to be searched for to issue a purchase order to buy fuel and an hour later the ambulance left to collect Fatuma from Tsanyawa health centre. Meanwhile Fatuma was unconscious and was breathing heavily. When they finally arrived in the hospital it was already dark. The midwife examined Fatuma, put her on an IV-drip and told Fatuma s mother that she urgently needed a Caesarean section, but in order to carry out the operation Fatuma s guardians first had to buy the necessary supplies such as gloves, IV fluids, IV canula, anaesthetic drugs. Most pharmacies were already closed and it was difficult and it took time to find a pharmacy. When they finally came back, the doctor on duty was nowhere to be found and it took until after midnight before they found him in one of the nightclubs in town. By the time the operation theatre was ready for the Caesarean section, Fatuma had stopped breathing. Why did Fatuma die? DAY 2 Opening and Recap of Previous Day After welcoming the workshop participants, start the 2 nd day with an opening prayer, followed by a recap of the key issues discussed during the 1 st day. Ask workshop participants what they learned yesterday. This can be done by going round the group and ask each participant to mention something important (s)he has learned yesterday. Present the Power Point slides with summary of key issues arising from the previous day s presentations and discussions and observations by the workshop facilitators. This might be an opportunity to further discuss some emerging issues. After this, the outline of the programme for the day is presented. The day s programme will focus on the concepts of facility-based Maternal Death Review (MDR). Workshop facilitators can find more detailed background information on facility-based MDR in the WHO publication Beyond the numbers (available on the course CD-rom). Programme Day 2 Introduction to facility-based MD review. DVD: My sister myself. How to prepare for and conduct facility-based MD reviews. Discussion of case scenarios of good and bad MD reviews (group work). DVD: Beyond the numbers 40

42 Introduction to Facility-based Maternal Death Reviews The definition of Facility-based Maternal Death Review is presented and explained, followed by an explanation of why MDRs are important and what the purpose is. It is well-known that besides medical or obstetric causes also socio-cultural and economic circumstances as well as health service provision and health system factors play a role in the causation of maternal deaths. By reviewing cases of maternal death we try to identify these factors in order to address them and solve problems which have been identified. Health system factors are organizational and administrative issues, which we called structural dimensions of quality of care. Health care service provision aspects are issues related to the process of provision of care. By collecting information on the circumstances surrounding the death of the woman, we try to get the detailed story of what happened, which will help us to understand what went wrong. Knowing this and understanding why she died will help us to find solutions for the problems which contributed to the death and take action. Ideally we also would like to attempt to investigate community factors involved in each case by tracing each death back into the community to ascertain the sequence of events, but sending a data collector to the community requires a more sophisticated and expensive approach and sensitivity and is more difficult to achieve, but could be tried where feasible and in cases where it seems particularly important to do so. Introduction to facility-based MD review Definition: A qualitative, in-depth investigation of the causes of and circumstances surrounding MDs occurring at health facilities. It requires committed and skilled individuals at the facility to drive the process and follow through on recommendations. Why? Because approximately eight million women suffer pregnancy-related complications and over 350,000 die each year! It may be expanded to include community factors Why? Knowing the level of mortality is not enough; we need to understand why women are dying and what the underlying contributing factors are. Avoiding maternal death is possible, even in resource poor countries, but it requires the right kind of information on which to base programmes. Each death or case of life threatening complication has a story to tell and can provide information on practical ways of addressing the problem Why? Most maternal deaths are avoidable. Each death or morbid case tells a story: what could have been done better. Many changes for improvement cost nothing. Even a simple review can help save another woman s or baby s life. 41

43 Purpose of facility-based MD review To answer the question: Why mothers are dying? To identify avoidable or remediable factors: notably shortcomings in care, in service provision or in the health system. To initiate action to prevent further MDs. To improve quality of care. Advantages of facility-based MD review Learning experience. Improves professional practice. Improves training. Improves resources (staffing, drugs, equipment). Less expensive than other methods. To save lives. Starting point for criteria-based audit Advantages of facility-based MDRs are discussed. It is a good learning experience for all staff. A lot of lessons can be learned from the stories behind the MDs about why women are dying. It also helps to identify where the clinical care that a particular patient received was below standard, so that steps can be taken to ensure that this is not repeated. This in turn may result in the development of new procedures or guidelines for case management or in service training of staff. When a problem area has been identified a criterion-based audit can be conducted to get more detail about where performance is falling short. Those responsible for either pre-service or in-service training may respond to the findings of a facility-based MDR by focusing in-service training on the important problems identified, making changes in the curriculum, or focusing supportive supervision. Findings can be used to persuade managers, the LGA or the SHSMB to address the resource needs (staffing, equipment and drugs) of the maternity service when powerful facts can be presented how lack of resources has lead to death of women and newborns. Health managers at LGA or state level could be provided with a summary of the review findings to help them identify service needs and prioritize resources. Facility-based MDRs do not cost much money All what is needed are recording forms and perhaps refreshments for the review team during the review meetings. However, they take staff time. Also the limitations of facility-based MDRs are discussed, presenting the corresponding power point slide. Limitations of facility-based MD review It does not provide information about women dying in the community. It usually does not provide information on what happened before the woman reached the hospital and on the community factors related to the death. If hospital record keeping is poor, information may be inadequate to draw conclusions 42

44 My Sister Myself Film: My Sister My self Maternal deaths What are the factors contributing to the maternal deaths? After this introduction to MDRs the film My Sister Myself is shown (available on the course CD-rom) and workshop participants are asked afterwards what they observed when viewing the film. What would help / work? What quality factors did you see? Observed quality of care factors include: cleanliness, organized services, availability of (emergency) drugs and equipment, friendly and motivated staff, use of partograph, availability of posters, no fees, making women comfortable, privacy in labour room, good communication, availability of blood for blood transfusion, functional referral system, emergency preparedness, mother and baby are together. Principles of facility-based Maternal Death Reviews After the film the principles of facility-based MDRs are discussed, while displaying the related power point slides. Principles of facility-based MD review Confidential. Anonymous (no name). Non-threatening environment (no blame). Sole purpose is to save lives, to improve care and not to punish staff. Will only be successful if there is a commitment to act upon the findings Principles of facility-based MD review Reviews are done regularly at multi-disciplinary team meetings. They can be done at a single health facility (such as a referral hospital) or across several facilities. They can include a review of peri-natal deaths. They can be a starting point for more detailed criteria-based audit. The session facilitator afterwards presents the slide with the figure of the maternal mortality and morbidity surveillance cycle, on which the process of MDR is based, and explains the main steps of the MDR process. This is an ongoing process of identifying cases, collecting and analyzing information, using it to formulate recommendations for action and evaluating the outcome. The ultimate purpose of the surveillance process is action not just to count and calculate the rates. Each MDR should end with an action plan. Recommendations for the action plan should be simple, affordable, effective, evidence-based, widely disseminated and - last but not least carried out. 43

45 Maternal mortality or morbidity surveillance cycle Evaluation and refinement Identification of cases Data collection Recommendations should be Simple Affordable Effective Evidence based Widely disseminated Carried out! Recommendations and action Analysis of findings IN PARTNERSHIP WITH Liverpool School of Tropical Medicine Source: Liverpool WHO, Associates Beyond in the Tropical numbers Health Clinical recommendations will be similar to guidelines in the Integrated Management of Pregnancy And Childbirth (WHO) After this the process of initiating facility-based MDRs is discussed, displaying the 2 power point slides with the 10 steps of this process. Process of initiating facility-based MD reviews 1. Set up the facility-based maternal deaths review process 2. Decide on the scope of the facility-based maternal deaths review 3. Develop data collection forms. 4. Select collaborators and train data collectors 5. Identify cases of maternal death Process of initiating facility-based MD reviews 6. Identify sources of data. 7. Collect data at the health facility or facilities, and in the community if appropriate. 8. Synthesize the data, interpret the results, and draw conclusions. 9. Utilize the findings. 10. Decide whether to repeat the facility-based maternal deaths review at a later date or make it a continuous process Steps in Initiating and Conducting Facility-based Maternal Death Reviews Next the session facilitator discusses the steps more in detail, displaying the related power point slides. The steps are also presented in a handout (annex 2) Workshop facilitators are recommended to read section 5.4 from the WHO document Beyond the numbers (available on the course CD-rom), which provides background information on the steps in undertaking MDRs. Someone with experience and authority is needed to take overall responsibility for the coordination. This person must be interested and committed to take on the responsibility and drive the process. Health professionals initiating and/or conducting a facility-based MDR need the required authority and support, and this may have to be sought at different levels, for example: management of the health facility, principal medical officer or officer in-charge, head of the maternity or obstetric department, LGA PHC director. 44

46 Agreement will have to be reached about the costs and the use of personnel to conduct the review. Aggregating the results of a series of individual reviews and the collection of data on community factors, if thought feasible, require more resources than a simple review of individual cases limited to an analysis of facility-related factors. A facility-based MDR team has to be formed, which could be the same as the QI team or different. This team has the main responsibility for conducting the reviews, although the collaboration of a number of other people is essential. The team would normally consist of two to four individuals, with a balanced mix of professions and skills, but may be larger if the review is being conducted across a number of facilities, say at a district level. The team could, for example, consist of a nurse-midwife, an obstetrician, a public health doctor, and someone with community experience. Each of the team members may have different responsibilities for gathering data, depending on their skills. The most important criteria are that the members should have an interest in, and commitment to, investigating maternal deaths, and be able to devote sufficient time to the work to be done. If a community element is part of the review, they should have knowledge of the local language and an ability to develop rapport with community members. The inclusion of at least one senior person is important, to give the team some authority and to facilitate relationships with the facility management and other agencies. Step 1: Setting up the review process Psychological preparation of health workers to develop commitment and allay fears & anxiety. Identify coordinator (committed champion). Get required authority and support from different levels (e.g.: MO in charge). Agreement about costs and use of staff to do review. Establish a multidisciplinary MD review team (e.g.: doctor, midwive(s), administrator, lab technician, pharmacist). Step 2: Decide on scope of review At one health facility. At general hospitals in the state or part of it. At LGA level. At state level Step 3: Develop data collection forms Data collection forms are needed to record the findings from the MD reviews or to report to the SMOH. Developing data collection forms can be time consuming. Pilot study of forms: review team conducts data collection and analysis for one or two deaths. reflects on process and tool Step 4: Select collaborators and data collectors A data collector is needed to identify cases, retrieve patient case notes and interview staff. In one facility, the review team alone can conduct the review. Review across several facilities: Senior person in each facility to gain cooperation Staff with at least 3 years experience to be data collectors. 45

47 Step 5: Identify cases of maternal deaths Step 5: Identify cases of maternal deaths Health facility registers: Admission and discharge registers. Operating theatre register. Delivery register. Nursing register. Mortuary registers. Gynaecological ward register Any others Informal records held by health workers Step 6: Identify sources of data Gaining a complete and accurate picture needs data from multiple sources: Registers Inpatient case notes, including partograph Antenatal card. Women s handheld records. Discharge letters. Interviews with doctors, midwives, other hospital staff, community birth attendants, relatives. Step 7: Collect data As soon as possible after the death. Findings are recorded / reported anonymously. Sensitive, non-judgmental approach. Collect data from review of records. Interview all staff involved in care. Plan and conduct community data collection (if necessary and possible) Step 8: Synthesize and interpret data, draw conclusions Review individual maternal deaths: Hold a meeting of all those involved in case. Details of the case and its management should be presented. Confidentiality: Do not mention any names. Discussion: avoid blaming people for what went wrong. Identification of avoidable factors, shortcomings in care and root causes (ask why?) Step 8: Synthesize and interpret data, draw conclusions From time to time synthesize results of all cases over a certain period to identify any patterns: MDA team prepares synthesis. Present to group of staff anonymous cases. Agree on significant findings e.g. insufficient use of blood transfusions. Identify reasons for this finding interpretation. Draw conclusions Step 9: Utilize findings All lessons learned are acted upon. Develop an action plan: What needs to be done. Who is going to do it. Date by which it should be done Communicate the action plan to the stakeholders involved. Step 10: Repeat MDR at a later date and make it a continuous process Reflect on experience Resources needed Benefits gained Draw lessons on conducting review to improve subsequent reviews Follow up on previous action plan Review implementation of the action plan 46

48 Steps in Initiating and Conducting Facility-based Maternal and Peri-natal Death Reviews 1. Set up the facility-based deaths review process. Psychological preparation of health workers to develop commitment and allay fears & anxiety; Identify MDR coordinator (committed champion). Get required authority and support from different levels (e.g.: PMO in charge). Agreement about costs and use of staff to do review. Establish a multidisciplinary review team (e.g.: doctor, midwive(s), administrator, lab technician, pharmacist, chair of health committee) 2. Decide on the scope of the facility-based deaths review: e.g.: in one hospital, at different health facilities, at LGA level with different health facilities together. 3. Develop data collection forms and pilot them. 4. Select collaborators and train data collectors. In one facility, review team alone can conduct the review. Review across several facilities: - Senior person in each facility to gain cooperation. - Staff with at least 3 years experience to be data collectors 5. Identify sources of data and cases of maternal and peri-natal death. Health facility registers: a. Maternity ward admission and discharge registers b. Neonatal special care unit register c. Operating theatre register d. Delivery register e. Mortuary register f. Gynaecological ward register g. Emergency Room register 6. Collect data at the health facility or facilities (and keep them in a special file), and extend data collection in the community if appropriate. Patient case notes, including laboratory forms and medication forms. Antenatal card Nursing reports Interviews with patient s relatives and health care providers who were involved in the case in order to obtain additional information on what happened. 7. Synthesize the data, interpret the results, and draw conclusions. Hold a meeting of the review committee. Present the details of the case and its management. Ensure confidentiality: Do not mention any names (neither of patient nor staff). Avoid blaming people for what went wrong! Identify shortcomings in care, avoidable factors and their root causes (ask: why? ) 8. Utilize the findings and prepare after each review an action plan. 9. Communicate the action plan to relevant staff in the health facility and facilitate implementation. 10. Decide how often to have review meetings. 11. Review the previous action plan(s) and their implementation at each MDR meeting. 47

49 Next, the session facilitator gives some examples of modifiable factors which may be identified during MDRs and presents them on the 3 power point slides, followed by examples of what action could be undertaken to address the problems. Some avoidable factors: Health system related (administrative) Delay in transport between HFs; Lack of communication between health facilities; Delay in admission procedure; Delay in receiving necessary treatment; Lack of blood transfusion facilities; Lack of (appropriately trained) staff; Lack of laboratory facilities; Lack of equipment, supplies, drugs; Lack of ICU beds; Poor communication between health workers; Some avoidable factors: Health care provider related Delay in being attended by midwife/clinician; Poor assessment of patient; Inadequate resuscitation; Wrong diagnosis Inadequate treatment prescribed or given; Delay in receiving treatment; Poor monitoring of patient; Poor nursing care; Omission or delay in referring to higher level or consulting more senior health worker; Some avoidable factors: Patient / community related No ante-natal care; Inadequate ante-natal care attendance; Poor compliance to health worker advice; Delay in recognising the problem; Delay in deciding to seek professional care; Unsafe induced abortion; Preference for traditional medical treatment; Lack of transport; Delay in referral by TBA; Some possible resulting actions In-service training of staff; Improving supervision of staff; Provision of equipment; Improving availability of emergency drugs; Improving blood transfusion services; Reviewing/adapting duty rosters; Developing standard treatment protocols; Reviewing/formulating administrative procedures; Improving record keeping; Recruitment of extra staff; Example: MD review in Malawi Nov 2008: Workshop on how to do MD review. Hospital QI teams conducted MD reviews: Presentation of case Discussion of causes of death Identified main avoidable factors (provider, administrative, community, family) Developed action plan Reviewed up to 4 MDs per meeting Example: MD review in Malawi Activity Nov 06 May 07 MDR committees established 6/9 9/9 After this the facilitator gives an example of experiences with introduction of MD reviews in Malawi, where in November 2006 MDRs were introduced in 9 hospitals in three districts. The first slide describes to process of introducing and conducting MDRs, which is very similar to that in Northern Nigeria. The other slides give additional information on what has happened, including a quote from a health care provider who was member of the MDR committee and some examples of cases which had been reviewed. The last slide about the Malawi experience shows some of the actions undertaken. Facility based MDR conducted 4/9 9/9 Follow up of recommendations after MDR 1/9 9/9 IN PARTNERSHIP WITH Liverpool School of Tropical Medicine Liverpool Associates in Tropical Health 48

50 Example : MD review in Malawi Quote from health care provider who is a member of one of the hospital MD review committees: When we started, QI teams were unable to identify provider related factors. QI teams tended to attribute all factors to the patient and the community. Now QI teams think more critically and are able to identify these factors Example: MD review in Malawi Age Delivery mode Cause of death 28 CS Severe preeclampsia 21 SVD PPH Ruptured uterus 21 CS Cardiac arrest Avoidable factors Not identified at ANC. Specialist not consulted at hospital. Long second stage of labour Possible incorrect anaesthetic 18 CS Peritonitis Stayed with TBA for 2 days 22 SVD Sepsis Possible perforation during evacuation IN PARTNERSHIP WITH Liverpool School of Tropical Medicine Liverpool Associates in Tropical Health Example: MD review in Malawi Examples of actions from action plan: 1. Daily morning meeting to discuss management of patients. 2. Midwives can call senior clinician. 3. Interns only do procedure following approval by senior clinician. 4. Clinicians will not leave patients in an emergency. 5. Partographs are reviewed for FH recording After the presentation of the experiences in Malawi, the workshop facilitator shares some experiences with MDRs in Northern Nigeria. Examples of Good and Bad MDRs (small group work) Workshop participants are divided into small groups of 6 to 9 people and read and discuss in their groups one of 2 case scenarios. Groups present their results after 30 minutes, which are written down on flip charts. Case scenarios of good and bad MD review Small group work: Groups 1 & 2 review case scenario 1 Groups 3 & 4 review case scenario 2 List your points Report back your findings in plenary after 30 minutes Case scenarios of good and bad MD review Case scenario 1: Bad approach What were the problems in the way this MD review was done? How could it have been done in a better way? Case scenario 2: Good approach What you think of how this MD review was done? In what ways was this done well? What problems were identified? What improvements would you make? The case scenarios on good and bad MDRs are presented on the next pages and in annex 6. 49

51 Demonstration of Poor Approach of Maternal Death Review Scene In a district hospital, a midwife Florence is having a conversation with another midwife about conducting a maternal death review. Florence: I have been asked by the manager to look at all the maternal deaths in the hospital over the last month. What a waste of time. I have more important things to do, but I suppose I have to do this. I have looked at the delivery register and found one death. Midwife 2: I thought there were some more than that do you remember that lady who had a fit? Florence: Oh well, there is only one in the register, so I am just going to look at that one. Midwife 2: How are you going to do that? Florence: Well, I have got the notes here and I am just going to go through them and see what is written and then make some conclusions from that. I think I will speak with Gertrude she is the midwife who looked after this woman she made a lot of mistakes, you know. I don t know what she was doing. Midwife 2: Were there no other staff involved? Florence: I don t think so it s just Gertrude s name in the notes. I will let you know how my conversation with Gertrude goes. Later Florence interviews Gertrude about the maternal death. This is on the ward, where other patients and staff can hear. Florence: Sit down, Gertrude I want to talk to you about when Mrs Beatrice died. Well, I can see from the notes of Mrs Beatrice that you looked after her when she died. Gertrude: Yes, I did, but also the doctor was there. Florence: I am just interested in what you did. So Mrs Beatrice came in at 10am, but you didn t call for the doctor until 12am I can t understand what you were doing. Couldn t you tell that she was in danger? Didn t you know what to do? Gertrude: I was trying to... (Florence interrupts) Florence: Well, it is clear from the notes that you didn t call the doctor in time, and that you did not even put up an infusion. (Florence looks briefly at notes and then casts them aside). Gertrude: I tried to put up an infusion but I could not... (Florence interrupts). Florence: I am not interested in your excuses. I just want to know what you did. In this hospital we don t work like that. Gertrude: I tried to... (Florence interrupts). Florence: Anyway it seems that because of you, this woman died. This is very sad for the family you know. Gertrude: Yes, I know it s very sad. I m sorry if I did anything wrong. I did call the doctor straightaway, but he was in the operating theatre and the other doctor was on holiday. Florence: It s no use trying to blame other people. Did you not have any training about how to deal with a haemorrhage? This is basic midwifery care. Gertrude: (She starts to cry). I don t know what I did wrong. I tried to help. I am useless. Florence: Yes, you let Beatrice down. I will have to report this all to the manager. (She writes a few things down on loose piece of paper). Gertrude is still crying and Florence walks off. The other staff and patients just look at Gertrude. 50

52 On the following day, there is a hospital meeting with the manager, Florence, Gertrude and the rest of the staff. Florence: I would like to present to you the maternal death case of Mrs Beatrice. She died on 8 March from a postpartum haemorrhage. When she came in she was looked after by Sister Gertrude. She did not call the doctor or put an intravenous infusion up. She didn t seem to know what she was doing. It is clear that she received substandard care. Subsequently, Mrs Beatrice died. Manager: Yes, this is a clear case of substandard care. What Gertrude did was just not good enough. Gertrude, you should have done better than this. Gertrude: Looks very upset and is unable to speak. Other staff looked frightened. Manager: So we must stop these sad events happening. We must not let this happen again. Demonstration of Good Approach of Maternal Death Review Scene In a district hospital, the QI committee is holding a meeting in the meeting room to discuss maternal death reviews. The QI committee consists of head midwife, head obstetrician, anaesthetist, hospital manager, senior midwife and obstetrician. There are no other people in the meeting room and the doors and windows are closed. Head midwife: First of all we need to identify all the maternal deaths that have occurred in the last month. I have looked at the delivery register, the admission register, the gynae ward book and the mortuary records. I have found 3 maternal deaths. Doctor: did you look at the operating theatre book? Sometimes they are put in there. Head midwife: yes, I did. There were no deaths recorded in there. Cecelia, David and I have been looking at the three cases. We have looked at the inpatient notes, the antenatal records and the registers to gather some information about the circumstances surrounding the deaths. We have also identified the people we would like to interview. So for case 1 we would like to interview the two midwives who were on duty at that time, the doctor, the anaesthetist and the laboratory technician. Doctor: what about the other doctors on duty? Head midwife: At the moment I don t think we need to. But following these initial interviews we may need to interview some more people. Doctor: Good. Any other comments?... that seems to be fine. So let s meet next week to discuss the cases in detail. THE HEAD MIDWIFE AND GLORIA ARE IN THE HEAD MIDWIFE S OFFICE. THEY ARE SITTING SIDE BY SIDE AND ARE HAVING A CUP OF TEA. Head midwife: thank you for coming this afternoon, Gloria. I appreciate you taking the time to come her. As I mentioned before, the QI team are looking at all the maternal deaths that have happened in the hospital in the last month. As I am sure you know, we can learn a lot from these sad cases. We can look at what we do and see if we can do anything better, so as to avoid these deaths from happening. I know you were involved in looking after Mrs Delia earlier this month, so I would like to ask you a few questions. We are also speaking with the other midwives and doctors involved. So the process is that we look at all the records, talk with the midwives and doctors who were involved in Mrs Delia s care, discuss and identify what care could have been different, and then identify what we can do in the hospital. Is this alright with you? Do you have any questions? Gloria: I am a little bit frightened about this. I have never been involved in anything like this. 51

53 Head midwife: Please do not worry. The aim of this is to try and improve the care we provide in this hospital so that these deaths do not happen again. It is good for us all to reflect on what we do and think about how we can do anything better. i will be making some notes as we speak as these will help us when we are analysing the case. Gloria: OK. Head midwife: So in your own words, can you tell me about the day Mrs Delia came to the hospital. Gloria: Well it was on the Tuesday early morning at about 8am that she came in. Mrs Delia, she was in a terrible state. She was bleeding a lot and was moaning. Her mother was with her and she was very distressed. I tried to do put an intravenous infusion in but this was impossible. I couldn t find a vein. So then I called the doctor but he didn t come for a while. (Pauses). Head midwife: OK. What happened next? Gloria: I tried to mop up the blood. I wasn t sure if the placenta had been delivered. The baby was born but I am not sure when I couldn t get any sense from her mother. Head Midwife: did you try to examine Delia and see if the placenta was delivered? Gloria: I had a look but I couldn t see the placenta. I don t really know what to do if the placenta hasn t delivered. The doctor eventually came and then he decided to take Delia to theatre. I don t think he tried to deliver the placenta. He gave her some IV fluids. Head midwife: (looks at the inpatient records) Were you able to give any drugs? Gloria: I looked in the cupboard for some oxytocin, but there was none there. I think it had all been used up. I told the mother to go and buy some from the pharmacy but she refused to leave her daughter. Head Midwife: Do you have any more things to add? Gloria: I don t think so. Head Midwife: Thank you Gloria. You have been very helpful with this. MEETING SCENE: QI COMMITTEE Doctor: So how did you get on with the first case, Mrs Delia. Head Midwife: Well, here are the inpatient notes, the antenatal record, and the registers. Cecelia and I talked with the midwives involved in the case and also the doctors, anaesthetist and laboratory technician. Let s have a look at the notes and our findings from the interviews all together. All committee members look at notes. Doctor: So what do you think the cause of death is? Midwife: Postpartum haemorrhage. It looks like she had a home delivery with a TBA and then she had d retained placenta which had partially separated and she haemorrhaged. Doctor: So when did she come into the hospital? Midwife: It seems like she came several hours after the delivery. I think there may be some issues that we need to explore about Delia having a home delivery, and her transfer to the hospital. Perhaps we should try to interview the TBA and her relatives? Head midwife: Yes, that may be a good idea, but we will have to do that very sensitively. Doctor: So let s have a look at what happened when she did arrive at the hospital? What are the avoidable factors? Midwife: It looks like she came in at about 2pm and was seen by the midwife. The midwife was unable to get an intravenous line in her arms. The doctor came at 4pm and was able to get a line in, and they gave some intravenous fluids it looks like 1 litre was given. They tried to get some blood but they were unable to contact the laboratory staff. She was still bleeding vaginally and they were preparing to take her to theatre, but she died before this was done. Head midwife: I think there are several points here to consider. Firstly, that the midwife was unable to get an intravenous line. Secondly, there was a delay in the doctor arriving. Thirdly, they were unable to contact the laboratory staff. 52

54 Doctor: Also the amount of IV fluids given. Did anyone say about what methods they used to stop the bleeding? Or was this recorded anywhere? Midwife: Nothing was recorded or discussed in the interviews. Doctor: So I think we have come up with the avoidable factors here. Let s think why these things happened, so that we can think of ways so that they will not happen again. Midwife: The midwife said that she had heard about venous cut down, but she had not been taught this and felt she could not do this. So perhaps this could be part of our in service training. Doctor: Yes, that s a good idea. I think that the doctor was away from the hospital having his break at this time. Perhaps we need to think about ensuring that there is always a doctor on the hospital premises. We need to think about some ways to make sure that this happens. Head midwife: About the amount of IV fluids given. We have plenty of IV fluids here, so that is not the problem. Having discussed this with the midwives and doctors, I think it seems that staff do not know how much and how quickly to give fluids in a case like this. Perhaps we need to develop a clinical protocol for managing haemorrhage and do some training with all the staff. Midwife: we could put the protocol on the wall of the labour room so we can all see it. We could also have a protocol and training on Doctor: Good. There may be some protocols in the city hospital. We should contact them and ask if we could have a copy. Now, let s consider the problem about the laboratory. This woman clearly needed some blood, but the laboratory staff could not be contacted. So we need to make sure that we can contact the lab technician day and night. Let s discuss this with the lab staff and see if we can post their mobile numbers in the labour room. Head midwife: let s write all this up in an action plan with clear timelines and responsibilities. And lest review how we have got on next month. Beyond the Numbers After the group work the film Beyond the Numbers is shown, which takes about 20 minutes, and participants are asked what they observed. Responses are written down on a flip chart. Conducting Maternal Death Reviews (group work) The last activity of the day is a practical exercise in conducting MDRs in small groups, using 4 case scenarios, which workshop facilitators have to prepare in advance as fake patient case notes and other written information (e.g. referral letter, laboratory forms, partograph form). Group work on 4 case scenarios 1. Read and discuss the case scenario; 2. Identify causes and contributing factors of the maternal death; 3. Identify substandard care / avoidable factors; 4. What information you would need to know, is missing? 5. Formulate action plan; 6. Present group work in plenary session; The workshop facilitator presents the slide with instructions for the group work. After 1 hour the 4 groups present the results of their group work. 53

55 DAY 3 Opening and Recap of Previous Day Outline of day 3 Reviewing tools for recording and reporting of data of facility-based maternal death reviews. Group exercise: Filling in MD review form. Discussing and agreeing what we will do after this workshop. Tools for MD reviews Tools for data recording and reporting have been developed in a QI workshop for EOC facilities from the 1 st MNCH clusters in the three northern states. Maternal death review form Maternal death follow up form Maternal death notification form As usual the day starts with a welcoming remark and opening prayer, followed by a recap of the key issues discussed during the previous day by asking the workshop participants what they learned yesterday. This can be done by going round the group and ask each participant to mention something important (s)he has learned yesterday. Present the Power Point slide with the outline of the programme for day 3. The MDR data recording and reporting forms which have been approved by the SMOH are presented and explained. There are 4 forms (see annex 7): 1. MD review form (MDR 1) 2. MD follow-up form (MDR 2) 3. MD notification form (MDR 3) 4. MD interview guide The MD review form is used to record the findings from the MDR and is filled in triplicate, one copy to be retained by the health facility and 2 copies sent to the LGA MCH coordinator, who forwards 1 copy to the SMOH RH coordinator. The MD follow up form is filled in at the subsequent meeting of the MD review committee to follow up on the action plan which was drawn up after reviewing the MD and kept in the health facility. The MD notification form is filled in triplicate, one copy is retained at the health facility and 2 copies are submitted to the LGA MCH coordinator, who forwards 1 copy to the SMOH RH coordinator. The MD interview guide can be used to interview health care providers who were involved in the case in order to obtain additional information on what happened. The questions can be adapted according to local needs. If time allows a group exercise can be done in which the 4 groups from the group work of the previous day on the MD case scenarios fill in a MD review form with the data from the case scenarios. Each health facility represented in the workshop is provided with an initial supply of forms so that they can start conducting MDRs after the workshop. Since MDs are rare events in PHC facilities, PHC facilities will receive 4 sets of forms and general hospitals 10 sets. 54

56 Next Steps for the Way Forward after the Workshop What next? Discussion of agreed activities for the way forward after the workshop: What will workshop participants do next? What has to be done to initiate MD review in PRRINN-MNCH-supported EOC facilities? How can BEOC facilities take part? What are the roles of LGA PHC offices, SMOH, SHSMB and SPHCMB? How will QI teams be supported in conducting MD audit and carrying out other QI activities? Finally the next steps for the way forward after the workshop are discussed and agreed activities are listed on a flip chart. Specific issues to be raised are: What will workshop participants do? (e.g. briefing other members of the QI team, HF management and other relevant staff, continue monthly QI meetings, etc) What has to be done to initiate MDR in PRRINN-MNCH-supported EOC facilities? How can BEOC facilities take part? How will QI teams be supported in conducting MDRs and carrying out other QI activities? What are the roles of LGA PHC offices, SMOH, SHSMB and SPHCMB in supporting QI? Closing Remarks Workshop participants are kindly requested to fill in and return the workshop evaluation form. A representative of PRRINN-MNCH makes the closing remarks, the workshop certificates are handed out and a volunteer closes the workshop with a prayer. 55

57 9. THE 3 RD QI WORKSHOP 9.1 Workshop Objectives The objectives of the 3 rd QI workshop are as follows: Share experiences with improving quality of care and with MD reviews. Learn how to monitor QI activities, evaluate progress, using indicators, and measure quality of care. Learn the purpose, principles, strengths and limitations of facility-based peri-natal death review and how it can improve MNH services. Learn how to initiate, organise and conduct a peri-natal death review. Learn how to document information from peri-natal death reviews on peri-natal death review forms. 9.2 Specific Materials Needed for the Workshop Besides the general materials and stationery needed for each workshop as mentioned in chapter 5 on page for the 3 rd QI workshop the following handouts have to be photocopied for the participants: Workshop programme (see annex 1) Daily power point presentations (printed as handout with 6 slides on one page). Workshop evaluation form (see annex 2) Workshop certificate Peri-natal death review form (PNDR 1) (see annex 8) Peri-natal death follow up form (PNDR 2) (see annex 8) Peri-natal death notification form (PNDR 3) (see annex 8) Peri-natal mortality case studies (see annex 9) Besides a copy of each of the last 3 forms for each workshop participant, additional copies are needed for each health facility to take home: 5 copies of each form for PHC facilities and 10 for general hospitals. 9.3 Workshop Content DAY 1 Opening and Welcome Remarks Usually the welcoming remarks of the workshop are done by a representative from PRRINN- MNCH, either from the central or the state office, and the workshop is officially opened by the PRRINN-MNCH State Team Manager or Senior Programme Officer. After the welcoming remarks one of the facilitators guides the process of introduction of workshop participants. Most participants will know each other from the first QI workshop, but there may be a few new people who did not attend the previous QI workshop. 56

58 One of the facilitators explains the objectives and key activities of this 3 rd QI workshop. Workshop Objectives At the end of the workshop, we will be able to: 1. Improve our maternal death reviews at our HFs. 2. Monitor our QI activities and measure progress. 3. Describe what peri-natal death review is and how it can improve MNH services. 4. Identify the strengths and weaknesses of this method. 5. Organise and conduct a peri-natal death review. 6. Document information from per-inatal death reviews on data recording forms. Workshop Activities Present activities of QI teams since previous workshop & share experiences, particularly with maternal death reviews. Learn how to evaluate our QI activities and identify indicators to measure progress. Learn the concepts of peri-natal death reviews. Review data collection & reporting tools for facility-based peri-natal death reviews. Conduct peri-natal death reviews in small groups. Discuss the way forward after the workshop. After explaining the objectives and key activities of the workshop, one facilitator gives a recap of the content of the previous workshop, which is important to refresh participants memories (the previous workshop probably was at least 3 months ago) and reinforce what they learned during that workshop. This can be done by posing to the workshop participants the question What did we do and learn during the previous workshop? Another facilitator writes the responses from the participants on a flip chart. After this it is useful to summarise the main issues from the previous workshop, supported by power point slides. Presentations from Health Facility QI Teams Reporting on QI activities Each HF QI team gives a 10 minutes presentation, followed by 5 minutes questions + discussion. What quality of care issues did you identify for action and what root causes? For each quality of care problem, what QI activities have been planned? What activities have been carried out and what have been the achievements? What are the challenges in improving quality of care and what are the lessons learned? Representatives from each health facility QI team are invited to give a brief presentation on what they have done since the previous workshop. Each presentation should not take more than 10 minutes, followed by 5 minutes for questions and comments. These presentations usually take most of the rest of the day and provoke a lot of discussion. It is useful if one of the facilitators lists important emerging issues on a flip chart, which can be taken up later for further discussion. Also it is useful to make notes of the quality of care problems, which have been identified. After the presentations from the health facility QI teams the session facilitator invites PHC directors, MCH coordinators and representatives from the SMOH, SPHCMB, SHSMB and PRRINN-MNCH to give feedback about the observations they have made during supportive supervision of the QI teams. Selected emerging issues can be explored and discussed more in detail when time permits. 57

59 DAY 2 Opening and Recap of Previous Day After welcoming the workshop participants, start the 2 nd day with an opening prayer, followed by a recap of the key issues discussed during the 1 st day. Ask workshop participants what they learned yesterday. This can be done by asking the group in general and wait for spontaneous responses or go round the group and ask each participant to mention something important (s)he has learned yesterday. Present the power point slides with summary of key issues from the previous day. Also present specific issues arising during the discussions of the previous day and discuss them further if necessary. Outline of activities of day 2 Presentation and discussion of experiences with MDR in GHs. Present the outline of activities of the 2 nd day of the workshop. Presentation and discussion of case studies. How to evaluate QI activities and measure progress. Group Work: Developing indicators for our action plans and explain how to measure them. Presentation of Experiences with Facility-based MD Reviews Representatives from general hospitals are invited to share their experiences with initiating and conducting facility-based MDRs, including reporting how many MDs they identified in the past 3 months, how many MDs they have managed to review, what problems were identified and what action was undertaken to address them. Presentation and Discussion of MD Cases Representatives from general hospitals that have experienced and reviewed cases of MDs are invited to present one MD case each, indicating the key findings, the causes and contributing factors of the death, the modifiable factors and shortcomings in care which were identified, the action plan which was formulated and the achievements of implementing the action plan. Workshop participants are given an opportunity to ask questions and give comments. 58

60 How to Measure Quality of Care and Evaluate Progress of QI Activities One of the workshop facilitators gives an introduction to the topic and presents the related power point slides. After the presentation of the first slide with main purposes of evaluation, the process of evaluation is presented in a framework in which evaluation is related to the audit cycle. In QI evaluation means comparing actual performance with best practice or with standards which specify what health workers are expected to do. Evaluation An important component of QI; Evaluation: A key component of QI A means of assessing whether you are achieving what you set out to achieve; 1. Information gathering & Analysis 2. Developing action plan A way of demonstrating to others the progress made; Actual Practice BEST PRAC TICE Helps identifying possible adjustments you might wish to make to the approach of the action plan. 4. Evaluating progress and follow up 3. Implementing solutions Source: EngenderHealth (2003) The difference between monitoring and evaluation is explained after first posing the question to the workshop participants What is the difference between monitoring and evaluation? Monitoring & Evaluation Question: What is the difference between monitoring and evaluation? Monitoring is the continuous process of observing whether planned activities are implemented and how. Evaluation is the process of periodically assessing the results of activities or a programme. It is usually done towards the end of a project or a planned activity. What is Evaluation? Evaluation is: systematic learning from experience. Evaluation is concerned with assessment of: achievement of objectives (effectiveness). costs of the achievements (efficiency). fairness in sharing of benefits (equity) What to monitor or evaluate? Inputs (resources put into the programme) Were resources available, sufficient, and used appropriately? If not, why not? Process (activities) Were activities carried out according plan? If not, why not? Outputs (deliverables of the programme) Were services provided appropriate & adequate? Outcomes (results of the programme) Were programme objectives achieved? Impact Has the health of the population improved? INPUTS STRATEGY DEVELOPMENT POLICY & PLANNING Monitoring & Evaluation PROCESS MONITORING OUTPUTS EVALUATION OUTCOMES IMPACTS 59

61 Monitoring and evaluation takes place at different levels of the programme planning process. Inputs refers to the resources which are needed and which can be assessed as well. Process refers to what is actually happening or the activities of the programme or within the health facility. It also includes performance of health workers or how activities are carried out. Activities and performance can be monitored and evaluated as well. Outputs refers to the results of the activities or deliverables of the programme, such as number of health workers trained, patients treated, health facilities refurbished or children vaccinated. Outcomes refer to the results of the programme in terms of achievement of objectives. Impact is the ultimate effect of the programme or services on the health of the people, which can also be evaluated. However, this is not always easy because it is often difficult to get reliable data on reduction of mortality (number of deaths) or morbidity (frequency of diseases). After discussing what we can monitor and evaluate in relation to health care, the workshop facilitator explains why monitoring and evaluation are important, showing the related power point slides. Why do we need M&E? We need evaluation to be sure: that we have reached our planned destination. that we have achieved the desired results. that we have used our resources efficiently. We need monitoring to ensure: that we are on the right road. that activities are leading to the desired results. that our activities are completed as planned. that problems in implementation are detected early Why should we evaluate QI activities? Purpose: To lead staff through a review of progress made in implementing the action plan. ensure actions taken are making desired changes in quality of services. make decision regarding which assessment activities are necessary for further information gathering and analysis When should we monitor & evaluate? 1. Frequent review of process and progress (monitoring). 2. Evaluating results should be done biannually or annually or after expected completion of activity or at the end of a project. - Evaluate the current status of MNH in your facility. - Identify areas for improvement & develop action plan. - Celebrate progress on key indicators. How should we evaluate? We need to collect information to measure what changes have occurred and whether our activities have been effective in achieving our targets or objectives (desired outputs and outcomes). We need indicators which measure whether activities were carried out and measure the resulting change. We need data to measure the indicators. We need to know how and from where to collect these data Health Indicators When we monitor or evaluate we need indicators which show us how we are doing. Indicators are used to measure our performance and the results of our activities. 60

62 Indicators For M&E we need data to assess indicators Question: What is an indicator? An indicator is: a variable which helps to measure change Question: What type of health-related indicators do you know? Health Indicators There are different types of health indicators, according to what is measured: 1. Health status indicators 2. Health care provision indicators. 3. Health policy indicators. 4. Socio-economic indicators related to health Health Indicators Indicators of health status: Frequency of disease (incidence, prevalence). Mortality (maternal mortality ratio, infant mortality rate, case fatality rate). Nutritional status (% of under-5 children who are stunted or wasted) Health Indicators Indicators of health care provision: Indicators of service availability or coverage: (health centres per 100,000 population, BEOC facilities per 500,000 population, no. of midwives per 10,000 population) Indicators of service utilization: (vaccination coverage, utilisation of antenatal care, contraceptive prevalence, % of deliveries assisted by a skilled attendant). Indicators of quality of care: (availability of resources, patient/client satisfaction) Health Indicators Indicators of health policy: % of national budget allocated to health. % of health budget allocated to PHC services or to maternal and child health. Urban/rural distribution of health facilities or health care providers Health Indicators Socio-economic indicators related to health: Adult literacy rate (males versus females) Gross domestic product (GDP) % of households with access to clean water. Health Indicators Rates and Ratios: Question: What is the difference between a rate and a ratio? Rate: is an equation in which the numerator is part of the denominator. Ratio: is an equation in which numerator is related to denominator, but not necessarily part of it. In epidemiology: a rate is: the number of persons with a state or event related to disease per unit of population per unit of time. 61

63 Indicators for M&E of Quality of Care After the general introduction to Monitoring and Evaluation (M&E) and indicators, the discussion will focus on M&E and indicators of quality of care. How can we evaluate quality of care? 1. Develop key indicators; 2. Identify what data to collect; 3. Decide how to collect the data (methods); 4. Develop data collection tools; 5. Collect data; 6. Analyse data and calculate indicators; 7. Assess progress: compare with baseline; How can we evaluate quality of care? 1. Develop key Indicators: Indicators should take into consideration the different perspectives and dimensions of quality of care. When we want to monitor or evaluate quality of care and use indicators we have to consider the different perspectives and dimensions of quality of care when formulating indicators for measuring quality of care. Perspectives of quality of care Quality of care has different perspectives: Women and families Quality of Care Managers Health care providers Dimensions of quality of care Quality of care has different dimensions: Effectiveness Technical competence Interpersonal relations Equity Efficiency Patient / client satisfaction (client centredness) Timeliness and continuity Amenities Safety Besides indicators related to the different perspectives of quality of care, quality of care indicators can also measure different dimensions of quality of care, such as indicators which measure effectiveness or safety of treatment, efficiency of services, quality of interpersonal communication, knowledge and technical competence of health care providers, patient/client satisfaction. 62

64 Dimensions of the health system Quality of care is related to different dimensions of the health system. Quality of structure: Policy, resources, organisation, management systems (things that have to be in place) Quality of process: Service delivery and the way it is done Quality of outcomes Desired effects or outcomes of care mortality, satisfaction, coverage, When selecting quality of care indicators also dimensions of the health system should be considered. The quality of resources, quality of management, quality of health care activities and quality of outcome - all of which constitute quality of care - can be measured. It is important to focus on all three dimensions as health outcomes are dependent on quality of processes and structural aspects. Some indicators must measure structural aspects of quality of care, others process or outcomes. Examples of quality of care indicators Client & patient perspective: % of clients who are satisfied with the care. % of clients who feel that they were given adequate information and clear advice. % of patients who can correctly describe the treatment prescribed. % of clients who participated actively in discussion and choice of care. % of clients who believe provider will keep her information confidential. Examples of quality of care indicators Health care provider perspective: Number of HCPs with good IPC skills. Number of encounters where HCPs treat clients with respect/courtesy. % of HCPs performing clinical procedures according to guidelines/protocols. % of consultations where HCP gave adequate information & explained treatment to patient. Other staff Number of other staff who treat clients with dignity and respect Examples of quality of care indicators Management perspective: Availability of 24/7 maternity services at HF. Availability of essential drugs and supplies: no stock-outs (specify drugs or supplies). Availability of life-saving drugs in labour ward. Privacy (during history taking, exam and care). Availability of evidence based guidelines and clinical protocols. % of clients attended to within 1 hour. ANC attendance (increase in ANC 1 st and 4+ visits No of HF deliveries (increase in deliveries by SBA) How can we evaluate quality of care? 1. Develop key indicators; 2. Identify what data to collect; 3. Decide how to collect the data (methods); 4. Develop data collection tools; 5. Collect data; 6. Analyse data and calculate indicators; 7. Assess progress: compare with baseline; For each quality of care indicator we must determine what data have to be collected to calculate the indicator. Then we have to decide how we will collect these data or what data collection method we will use (e.g. interview, focus group discussion (FGD), observation, record review) and what data collection tools we need (e.g. questionnaire, FGD topic guide, observation checklist, data collection form). Next we must prepare data collection tools. 63

65 Methods and tools for data collection Data collection method In depth interview Exit interview Focus group discussion Direct observation Review of records Collecting patient complaints Household survey Data collection tool Questionnaire Questionnaire FGD topic guide Checklist Checklist, Data collection sheet Suggestion box Meeting with health committee Questionnaire Methods and tools to measure improvement in quality of care Client perspective: 1. Measuring (improvement in) client satisfaction Client exit interviews, using questionnaires Focus Group Discussions (FGDs), using topic guides Service statistics on uptake of specific services Household interviews, using questionnaires 2. Understanding why clients do not use services FGDs with potential users or drop-outs or defaulters Household interviews with potential users. Methods and tools to measure improvement in quality of care Health care provider perspective: Measuring (improvement of) knowledge, skills & performance of health workers Questionnaire: e.g. pre & post tests Provider observation, using a checklist Mystery clients, using a checklist Review of records, using a checklist Methods and tools to measure improvement in quality of care Health facility management perspective: Measuring facilities capability or readiness to provide quality services Facility audits or assessments Provider surveys/fgds Mystery clients Review of records Client flow analysis Observation using checklists (e.g. equipment/supplies) Group work on developing indicators After the introduction on M&E, indicators and how to collect data, workshop participants will do small group work. They are grouped according to health facilities, review their action plans, For 3 of their activities they must develop indicators, which they can use to monitor the activity and evaluate progress and indicate as well how to collect information. After 1 hour the groups present the results of their group work in a 5 minute presentation and the proposed indicators are discussed. A workshop participant is invited to close the day with a prayer. 64

66 DAY 3 Opening and Recap of Previous Day As usual, after welcoming the participants and the opening prayer, the programme for day 3 starts with a recap of the key issues discussed during the 2 nd day. Ask workshop participants what they learned yesterday. This can be done by asking the group in general and wait for spontaneous responses or go round the group and ask each participant to mention something important (s)he has learned yesterday. Present the power point slides with summary of key issues from the previous day. Also present specific issues arising during the discussions of the previous day and discuss them further if necessary. Outline of activities of day 3 Introduction to perinatal mortality and perinatal death review. Reviewing data collection and reporting tools for peri-natal death reviews. Present the outline of activities of the 3 rd day of the workshop. The focus of this day s programme is on Peri- Natal Death Review (PNDR). Group work on case studies. Discussion of next steps for the way forward after this workshop. General Background to Peri-Natal Death Review Workshop facilitators are recommended to read the following papers: Lawn JE, Cousens S, Zupan J, for The Lancet Neonatal Survial Steering Team. Four million neonatal deaths: When? Where? Why? Lancet (2005); 365: Lawn JE, Yakoob MY, Haws RA, Soomro T, Darmstadt GL, Bhutta ZA (2009). 3.2 million stillbirths: epidemiology and overview of the evidence review. BMC Pregnancy and Childbirth; 9 (supll 1): S2. Definitions Stillbirths = infants born death from weeks gestation (definition varies per country) Early fetal death = death of a fetus weighing at least 500gr or measuring 25 cm or more or after 22 weeks gestation (ICD-10) One of the workshop facilitators starts this session with explaining some definitions and indicators related to peri-natal and neonatal mortality. Late fetal death = death of a fetus weighing at least 1000gr or measuring 35cm or more or after 28 weeks gestation 65

67 Definitions Neonatal deaths = deaths within 28 days after birth. Early neonatal deaths = in 1 st week of life. Late neonatal deaths = from 7 to 27 days of life Perinatal deaths = stillbirths (> 28 weeks) and early neonatal deaths Definitions Indicators Neonatal Mortality Rate (NMR) = no. of deaths in the first 28 days of life per 1000 live births Perinatal Mortality Rate (PMR) = no. of stillbirths from 28 weeks plus early neonatal deaths per 1000 still and live births Stillbirth Rate = no. of late foetal deaths per 1000 total births After this, the facilitator continues with outlining the public health importance of perinatal and neonatal mortality. Globally 41% of under-five deaths occur in the neonatal period, of which 75% in the first week of life. Therefore it is important for achieving the third MDG to focus more on interventions which reduce neonatal mortality, which until recently have not received much attention in child survival programmes. Reductions in child mortality are mainly the result of reductions in post-neonatal mortality, while neonatal mortality has not improved significantly. PNDRs can help to identify shortcomings in quality of care, which contribute to PNDs. Studies in various countries, including low-income countries, have shown that PNDRs can reduce perinatal mortality in hospitals by 30% (Pattinson, 2009). Global neonatal and peri-natal mortality Global neonatal mortality 4 million neonatal deaths / year Accounts for 41% of under 5 deaths When? % in 1 st 24hrs after birth - 75% in 1 st week of life 3.2 million still births / year. When? - 30% occurring intra-partum (1 million, which is more than childhood deaths due to malaria) Why is neonatal health important? How big a problem? 8 newborn babies die EVERY MINUTE When do stillbirths and neonatal deaths occur? Compared to other diseases e.g. malaria? - 7.3% of global burden of disease - More deaths than malaria + all vaccine preventable diseases. Change in last 5 years? NMR almost no change (57/1000 births) Next main causes of neonatal deaths and stillbirths are discussed. 66

68 Causes of neonatal deaths Causes of neonatal deaths Direct Causes (estimates largely from verbal autopsy): Infections 36% (sepsis, pneumonia, tetanus, diarrhoea) Prematurity 27% Birth asphyxia 23% Congenital abnormalities 7% Others 7% Almost all preventable! Causes of neonatal deaths Neonatal mortality in Nigeria Mothers Maternal mortality ratio per 100,000 live births: 800 Annual number of maternal deaths: 42,600 Babies Stillbirth rate per 1,000 total births: 30 Annual number of stillbirths: 163,400 Neonatal mortality rate per 1,000 live births: 48 Annual number of neonatal deaths: 255,500 Children Under 5 mortality rate per 1,000 live births: 197 Annual under 5 deaths: 1,048,600 Annual number of postnatal deaths: 793,100 Neonatal mortality as percentage of U-5 mortality: 24% Causes of stillbirths Very few global data on stillbirth. Causes of stillbirths Main primary causes from perinatal care survey in South Africa ( ) Unexplained stillbirth (37.7%) Hypertensive disorder in pregnancy (14.5%) Antepartum haemorrhage (13.3%) Intrapartum asphyxia (11.2%) Preterm labour (10.4%) Causes of stillbirth in Pakistan (verbal autopsies) Source: Pakistan national Demographic & Health Survey Causes of peri-natal deaths 20 Majority of peri-natal deaths are associated with 3rd delay problems (72.5% in a Tanzanian study). In hospital-based studies of perinatal mortality deaths from infections are under represented due to early discharge from hospital after delivery. A large proportion of perinatal deaths were intra-partum and could have been prevented by good intra-partum care. Birth asphyxia is leading cause of intrapartum stillbirths and early neonatal deaths. In Tanzanian study the majority of early neonatal deaths were at night. 67

69 Besides causes of neonatal deaths or stillbirths also underlying contributing factors are important to consider, particularly when conducting PNDRs. These contributing factors are potentially modifiable and may be related to shortcomings in health care or weaknesses in the organization and functioning of health systems as well as to wider socio-cultural and economic determinants of health, while problems in the mother also affect the child. Underlying contributing factors to peri-natal mortality Three delays model can also be applied to analysing peri-natal deaths: Delay in recognizing or understanding the danger signs (both for mother and newborn) and need to seek help and in deciding to seek help. Delay in taking women or newborns to hospital. Delay in receiving the right treatment once at the hospital (treatment involves mother, foetus and newborn) Underlying contributing factors to peri-natal mortality Danger signs in the newborn: Convulsions / twitchings Altered consciousness/lethargy Fever Inability to breastfeed Vomiting & Diarrhoea Difficulties in breathing Underlying contributing factors to peri-natal mortality Maternal morbidity: pre-eclampsia, eclampsia, antepartum haemorrhage, endometritis, syphilis, malaria, anaemia, diabetes Individual & community factors (demand side): Delay in accessing essential MNH care (1 st & 2 nd delay): poor health seeking behaviour, inadequate support by family and community, transport problems, bad roads Health care provision factors (supply side) - Essential MNH Services not available or accessible. - Delay in receiving essential MNH care (3 rd delay)). - Poor quality of essential MNH services Underlying contributing factors to peri-natal mortality Sub-optimal quality of maternal & newborn care: Related to structure/organisation of care: Lack of policies & guidelines. Poor planning: leading to lack of resources (staff, drugs, equipment, supplies). Poor management and coordination Poor interpersonal communication Related to process of care: - Lack of knowledge & skills: leading to poor diagnosis & management, poor monitoring of foetus during labour. - Inadequate provider-patient interaction and counselling. Underlying contributing factors to peri-natal mortality Sub-optimal quality of maternal & newborn care: Poor antenatal care: failure to detect & treat problems such as: anaemia, breech, twins, pre-eclampsia, infections, syphilis failure to prevent problems: tetanus vaccination, IPTp, provision of ITNs, anaemia. Poor intrapartum care: Inadequate monitoring of labour and foetal condition Poor detection & management of problems Delay in referral or consultation of more senior staff Underlying contributing factors to peri-natal mortality Sub-optimal quality of maternal & newborn care: Poor newborn care: Baby not wiped dry and kept warm. Poor newborn resuscitation. Poor monitoring of newborn in neonatal period. Failure to detect problems of newborn. Inadequate management of newborn problems. Delay in referral or consultation of more senior staff After this the workshop facilitator explains the classification of causes of peri-natal deaths, presenting the corresponding power point slide. A differentiation is made between primary and final (immediate) cause. 68

70 Classification of causes of perinatal death Primary cause of death: Underlying obstetric factor or condition which started a train of events that resulted in the death Final cause of death: Pathological process in the infant that actually caused the death, how the foetus or newborn died E.g.: preterm labour and cerebral haemorrhage abruptio placenta or prolonged labour and asphyxia Underlying modifiable contributing factors Introduction to Peri-Natal Death Reviews (PNDRs) As background information, workshop facilitators are recommended to read chapter 5 from the WHO document Beyond the numbers and the following article: Pattinson R, Kerber K, Waiswa P, Day LT, Mussel F et al (2009). Perinatal mortality audit: counting, accountability and overcoming challenges in scaling up in low- and middle-income countries. Int J Gynaec Obstet; 107: S113 S122. Both documents can be found on the course CD-rom. The definition of Facility-based Peri-Natal Death Review is presented and explained, followed by an explanation of why PNDRs are important and what the purpose is. It is well-known that besides medical causes also socio-cultural and economic circumstances as well as health service provision and health system factors play a role in the causation of perinatal deaths. By reviewing cases of peri-natal death we try to identify these factors in order to address them and solve problems which have been identified. Health system factors are organizational and administrative issues, which we called structural dimensions of quality of care. Health care service provision aspects are issues related to the process of provision of care. By collecting information on the circumstances surrounding the death of the foetus or newborn, we try to get the detailed story of what happened, which will help us to understand what went wrong. Knowing this and understanding why the death occurred, will help us to find solutions for the problems which contributed to the death and take action. Ideally we also would like to attempt to investigate community factors involved in each case by tracing each death back into the community to ascertain the sequence of events, but sending a data collector to the community requires a more sophisticated and expensive approach and sensitivity and is more difficult to achieve, but could be tried where feasible and in cases where it seems particularly important to do so. 69

71 Introduction to facility-based Peri-Natal Death Review (PNDR) Definition: A qualitative, in-depth investigation of the causes of and circumstances surrounding perinatal deaths occurring at health facilities. It requires committed and skilled individuals at the facility to drive the process and follow through on recommendations. It may be expanded to include community factors Purpose of facility-based PNDR To answer the question: Why newborns are dying and babies are still born? To identify avoidable or remediable factors: notably shortcomings in care, in service provision or in the health system. To initiate action to prevent further deaths. To improve quality of MNH care The workshop facilitator briefly describes the principles of PNDR, which are basically the same as for MDR. The PNDR is based on the peri-natal mortality or morbidity surveillance cycle. This is the ongoing process of identifying cases, collecting and analyzing information, using it to formulate recommendations for action and evaluating the outcome. The ultimate purpose of the surveillance process is action not simply to count and calculate the rates. Principles of facility-based PNDRs Peri-natal mortality surveillance cycle Similar to maternal death review: Confidential Anonymous (no name) Non-threatening environment (no blame) Sole purpose is to save lives, to improve care and not to punish staff Evaluation and refinement Identification of cases Data collection PNDR will only be successful if there is a commitment to act upon the findings Recommendations and action Analysis of findings Source: WHO, Beyond the numbers The workshop facilitator explains that the process of the PNDR is similar to that of MDR and refers for the steps to a handout which is distributed to the workshop participants, which can be found in annex 2. After this, the facilitator presents the power point slides with examples of modifiable factors, which may be discovered during PNDR. Some possible modifiable factors related to health systems Delay in transport between HFs; Lack of communication between health facilities; Delay in admission procedure; Delay in receiving necessary treatment; Lack of blood transfusion facilities; Lack of (appropriately trained) staff; Lack of newborn resuscitation equipment; Lack of partographs for monitoring of fetal heart; Poor communication between health workers; Some possible modifiable factors related to health care provision Delay in being attended by midwife/clinician; Poor assessment of patient (mother, foetus, newborn) Inadequate newborn resuscitation (lack of skills); Failure to make the correct diagnosis; Inadequate treatment prescribed; Inadequate treatment given; Delay in receiving treatment; Poor monitoring of patient or foetus during labour; Poor nursing care; Omission or delay in referring to higher level or consulting more senior health worker; 70

72 Some possible modifiable factors patient/community related No ante-natal care; Inadequate ante-natal care attendance; Poor compliance to health worker advice; Delay in recognising the problem; Delay in deciding to seek professional care (in case of both maternal or newborn health problem); Poor hygiene and cord care at home; Preference for traditional medical treatment; Lack of transport; Delay in referral by TBA; Some possible resulting actions In-service training of staff (e.g. newborn care); Improving supervision of staff; Provision of equipment (e.g. infant ambu bag); Improving availability of emergency drugs (DRF); Reviewing/adapting duty rosters; Developing standard treatment protocols; Reviewing/formulating administrative procedures; Improving record keeping; Recruitment of extra staff; Introducing Kangaroo Mother Care Strengthening post-natal care (e.g. home visits) Tools for PNDR Tools for data recording and reporting have been developed in a QI workshop for EOC facilities from the 1 st MNCH clusters in the three northern states. Peri-natal death review form Peri-natal death follow up form Peri-natal death notification form The PNDR data recording and reporting forms which have been approved by the SMOH are presented and explained. There are 4 forms (see annex 8): 1. PND review form 2. PND follow-up form 3. PND notification form 4. PND interview guide The PND review form is used to record the findings from the PNDR and is filled in triplicate, one copy to be retained by the health facility and 2 copies sent to the LGA MCH coordinator, who forwards 1 copy to the SMOH RH coordinator. The PND follow up form is filled in at the subsequent meeting of the PND review committee to follow up on the action plan which was drawn up after reviewing the PND and kept in the health facility. The PND notification form is filled in triplicate, one copy is retained at the health facility and 2 copies are submitted to the LGA MCH coordinator, who forwards 1 copy to the SMOH RH coordinator. The PND interview guide can be used to interview health care providers who were involved in the case in order to obtain additional information on what happened. The questions can be adapted according to local needs. Conducting Peri-Natal Death Reviews (group work) Group work on 4 case scenarios Form 4 groups. Each group reviews and discusses one case scenario. 1. Read and discuss the case scenario; 2. Identify causes and contributing factors of the peri-natal death; 3. Identify substandard care / avoidable factors; 4. What information you would need to know, is missing? 5. Formulate action plan; 7. Present group work in plenary session; The workshop facilitator introduces and explains the small group exercise in which workshop participants in 4 groups will conduct PNDR, using 4 case scenarios (see annex 9). The workshop facilitator presents the slide with instructions for the group work. After 1 hour, the 4 groups present the results of their group work. 71

73 Next Steps for the Way Forward after the Workshop What next? Discussion of agreed activities for the way forward after the workshop: What will workshop participants do next? What has to be done to initiate PNDRs in PRRINN-MNCH-supported EOC facilities? What are the roles of LGA PHC offices, SMOH, SHSMB and SPHCMB? How and by whom will QI teams be supported in conducting PNDRs and MDRs and carrying out other QI activities? The next steps for the way forward after the workshop are discussed and agreed activities are listed on a flip chart. Specific issues to be raised are: What will workshop participants do? (e.g. briefing other members of the QI team, HF management and other relevant staff, continue monthly QI meetings, etc) What has to be done to initiate PNDR in PRRINN-MNCH-supported EOC facilities? Also PHC facilities should initiate PNDR when they have a case of a stillbirth or neonatal death, using the PND review form for recording their findings. How will QI teams be supported in conducting PNDRs and MDRs and carrying out other QI activities? What are the roles of LGA PHC offices, SMOH, SHSMB and SPHCMB in supporting QI? Closing Remarks Workshop participants are kindly requested to fill in and return the workshop evaluation form. A representative of PRRINN-MNCH makes the closing remarks, the workshop certificates are handed out and a volunteer closes the workshop with a prayer. 72

74 10. THE 4 TH QI WORKSHOP 10.1 Workshop Objectives The objectives of the 4 th QI workshop are as follows: Share experiences to improve QI activities and peri-natal death reviews. Learn the principles of criterion-based audit. Explore what aspects of MNH care & services can be audited. Learn how to set criteria for audit of MNH care and service provision. Learn how to conduct criterion-based audit in a health facility. Learn how to set standards for MNH care and service provision Specific Materials Needed for the Workshop Besides the general materials and stationery needed for each workshop as mentioned in chapter 5 on page for the 3 rd QI workshop the following handouts have to be photocopied for the participants: Workshop programme (see annex 1) Daily power point presentations (printed as handout with 6 slides on one page). Workshop evaluation form (see annex 2) Workshop certificate Case definitions for criterion-based audit of EOC (see annex 10) IMMPACT: Summary of criteria for optimal management of obstetric complications (see annex 11). Data extraction sheet for criterion-based audit (see annex 12) Data extraction sheet for criterion-based audit example PPH (see annex 13) Data extraction sheet for criterion-based audit use of partograph (see annex 14) Standards for MNH service provision (see course CD-rom) Besides this, 6 copies of the WHO publication Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice are needed as reference material during the workshop, which are available at the PRRINN-MNCH office in Kano. In the invitation letter for the workshop the health facilities have been asked to bring 10 used partographs from their health facility and the WHO books they received during one of the previous workshops: Managing complications of pregnancy and child birth; a guide for midwives and doctors. Managing newborn problems; a guide for doctors, nurses and midwives. 73

75 10.3 Workshop Content DAY 1 Usually the welcoming remarks of the workshop are done by a representative from PRRINN- MNCH, either from the central or the state office, and the workshop is officially opened by the PRRINN-MNCH State Team Manager or Senior Programme Officer. After the welcoming remarks one of the facilitators guides the process of introduction of workshop participants. Most participants will know each other from the first QI workshop, but there may be a few new people who did not attend the previous QI workshop. One of the facilitators explains the objectives and key activities of this 4 th QI workshop. Workshop Objectives At the end of the workshop, we will be able to: 1. Improve our QI activities 2. Set criteria for audit of MNH care and service provision. 3. Conduct criteria-based audit in our health facility. 4. Set standards for MNH care and service provision Workshop Activities Present activities of QI teams since previous workshop & share experiences, including with maternal and peri-natal death reviews. Learn how to conduct criterion-based audit Develop criteria for auditing aspects of MNH service provision. Develop standards for MNCH services. After explaining the objectives and key activities of the workshop, one facilitator gives a recap of the content of the previous workshop, which is important to refresh participants memories (the previous workshop probably was at least 3 months ago) and reinforce what they learned during that workshop. This can be done by posing to the workshop participants the question What did we do and learn during the previous workshop? Another facilitator writes the responses from the participants on a flip chart. After this it is useful to summarise the main issues from the previous workshop, supported by power point slides. Presentations from Health Facility QI Teams Reporting on QI activities Each HF QI team gives a 10 minutes presentation, followed by 5 minutes questions + discussion. What quality of care issues did you identify for action and what root causes? For each quality of care problem, what QI activities have been planned? What activities have been carried out and what have been the achievements? What are the challenges in improving quality of care and what are the lessons learned? Representatives from each health facility QI team are invited to give a brief presentation on what they have done since the previous workshop. Each presentation should not take more than 10 minutes, followed by 5 minutes for questions and comments. These presentations usually take most of the rest of the day and provoke a lot of discussion. 74

76 It is useful if one of the facilitators lists important emerging issues on a flip chart, which can be taken up later for further discussion. Also it is useful to make notes of the quality of care problems, which have been identified. After the presentations from the health facility QI teams the session facilitator invites PHC directors, MCH coordinators and representatives from the SMOH, SPHCMB, SHSMB and PRRINN-MNCH to give feedback about the observations they have made during supportive supervision of the QI teams. Selected emerging issues can be explored and discussed more in detail when time permits. DAY 2 Opening and Recap of Previous Day After welcoming the workshop participants, start the 2 nd day with an opening prayer, followed by a recap of the key issues discussed during the 1 st day. Ask workshop participants what they learned yesterday. This can be done by going around the group and ask each participant to mention something important (s)he has learned yesterday. Present the Power Point slides with summary of key issues arising from the previous day s presentations and discussions and observations by the workshop facilitators. This might be an opportunity to further discuss some emerging issues. After this, the outline of the programme for the day is presented. The day s programme will focus on the concepts of criterion-based audit (CBA). Programme outline day 2 Key activities: Sharing experiences with maternal and peri-natal reviews. Learn how to conduct criterion-based audit. Review case definitions for major obstetric complications. Develop criteria for auditing MNH services Workshop facilitators can find more detailed background information on criterion-based audit in the following publications (available on the course CD-rom): WHO (2004). Beyond the numbers. Geneva, WHO. Graham W, Wagaarachi P, Penney G, et al (2000). Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries. Bulletin of the WHO; 78 (5): Wagaarachchi P, Graham WP, Penney GC, McCaw-Bins A et al (2001). Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries. Int J Gynecol Obstet; 74: Kongnyuy, E.J. & van den Broek, N. (2008). Criteria for clinical audit of women friendly care and providers' perception in Malawi. BMC Pregnancy and Childbirth, vol

77 Sharing Experiences with Maternal and Peri-natal Death Reviews The workshop facilitator asks the participants which health facilities have started reviewing perinatal deaths and lists the facilities on a flip chart and asks them how many stillbirths and neonatal deaths they had in the last 3 months and how many they managed to review. Representatives from those health facilities are invited to share their experiences with initiating and conducting facility-based PNDRs, including challenges. Other facilities are asked to tell why they did not start and what constraints or difficulties they faced, which are further discussed. One reason might be that they did not experienced any PNDs. If they had cases, the reasons for not starting PNDRs need to be explored and addressed. The names of these health facilities are noted down for special attention during supportive supervision. Presentation and Discussion of MD and PND Cases Representatives from general hospitals that have experienced and reviewed cases of MDs and PNDs are invited each to present one MD case and one PND case, indicating the key findings, the causes and contributing factors of the death, the modifiable factors and shortcomings in care which were identified, the action plan which was formulated and the achievements of implementing the action plan. Workshop participants are given an opportunity to ask questions and give comments. PHC facilities which have conducted PNDRs are also given an opportunity to present. Health facility QI teams are encouraged in their quarterly cluster meetings to present selected cases of MDs and PNDs and discuss them together. Introduction to Criterion-Based Audit (CBA) One of the workshop facilitators gives an introduction to Criterion-Based Audit (CBA) and starts with presenting a slide with an overview of the specific QI methods, which are used for improving quality of MNH. These methods have been discussed in previous workshops and the last one to discuss in this workshop is CBA. The next slide presents the purposes which these methods have in common. Audit and review methods to improve quality of MNH services Facility-based maternal death reviews. Facility-based near miss reviews. Facility-based perinatal death reviews Community-based maternal & perinatal death reviews. Confidential enquiries into maternal deaths. Criterion-based clinical audit Commitment to act upon findings is a key prerequisite for success Purpose of these reviews Monitor & evaluate quality of care. Identify failures and weaknesses in the health care system & shortcomings in provision of care. Make recommendations for change, which are: simple, cheap, effective, widely disseminated, evidence-based Act on results to: improve quality of care reduce maternal & newborn mortality & morbidity Increase client/patient satisfaction 76

78 Criterion-Based Audit Definition: an objective, systematic & critical analysis of the quality of care against set criteria: clinical and nursing aspects. management aspects. human rights aspects (e.g.; dignity, respect, privacy, confidentiality, non-discrimination) Pre-requisites: evidence-based standards (or protocols) that are the source of criteria. registers to identify cases. written patient records: if it is not written down it did not happen! Objectives of Criterion-Based Audit Improve quality of obstetric care by increasing number of best practices used in the health facility. Criterion-based clinical audit: CAN improve clinical and nursing practice CAN promote rational use of limited resources CAN improve staff morale + motivation The previously discussed methods reviewed cases of patients who died or almost died. CBA is different and is concerned with actual quality of care and aims to assess performance of health care providers and quality of services, which are evaluated (audited) and compared with standards, which describe what is supposed to be done and how. Each audit looks at a specific aspect of care, which is assessed by using specific criteria, which are based on standards, guidelines or protocols. Criteria are not the same as protocols. The workshop facilitator explains the difference between criteria and protocols or guidelines. A protocol or clinical guideline sets out step by step in detail all actions to be taken. Criteria are clearly defined selected practices in patient care or treatment or related to aspects of health care management, which are essential, evidence-based and which can be measured and are realistic for the level of care. CBA is basically assessing performance with a checklist. The preparatory steps for initiating CBA are presented and explained. Criteria versus Protocols Sets of criteria of good practice are not the same as protocols or clinical guidelines. A clinical guideline or protocol sets out step by step all actions to be taken in a given situation. Sets of criteria include those practices: - which are essential - which are evidence-based - which can be audited - which are realistic in given circumstances Preparation phase of audit process 1. Form audit team 2. Select topic for audit 3. Define cases / unit for analysis 4. Set criteria of evidence-based good care 5. Identify information sources 6. Design data extraction sheet Form Audit Team The health facility QI team could be the audit team. Possible membership: Health facility in charge/ hospital director Hospital administrator In charge of maternity, MCH, gynaecological ward Doctor(s) Nurse-midwive(s) Other health professionals: lab technician, pharmaceutical technician Cleaners Select Topics for Criterion-Based Audit What can be audited? Service provision Clinical obstetric & midwifery practice Management and organisation Human rights aspects Selection of topics is based on: Severity (high case fatality) Frequency of occurrence (common problem) 77

79 When raising the issue of selection of topics for audit, different aspects of MNCH care can be chosen, such as various MNCH service components, clinical obstetric- nursing- or midwifery practice, management & organization, human rights aspects, such as interpersonal communication. Select Topics for Criterion-Based Audit Small group work: What topics can you think of, which could be audited in your health facility? What audit criteria can you think of for one of these topics? Workshop participants are asked to brain storm in small groups for 30 minutes on what can be audited. After the groups have presented the results of the group work, the workshop facilitator gives additional comments and summarises what can be audited by presenting the related power point slides. Some of these topics can be further narrowed down, such as specific aspects of ANC like counseling, health education, history taking, clinical examination. Possible topic for Criterion-Based Audit Related to service provision: Antenatal care Care of mother in labour Newborn care Pre-operative care (preparation for C/S) Post-operative care (care after C/S) Post partum care Post abortion care Blood transfusion service Family planning services Adolescent-friendly health services Possible topics for Criterion-Based Audit Related to clinical obstetric & midwifery care, e.g. management of obstetric complications: Puerperal sepsis PPH (Pre-)eclampsia Obstructed labour Ruptured uterus Patient with a caesarean section Anaemia in pregnancy Use of partograph Possible topics for Criterion-Based Audit Related to management and organisation: Record keeping Referral system Availability of essential life saving drugs Waiting time before being attended Delay between prescribing and receiving treatment, e.g. blood transfusion, C/S Punctuality of staff Cleanliness of health facility Infection prevention Waste disposal Possible topics for Criterion-Based Audit Related to human rights aspects: Woman-friendliness of intra-partum care Is treatment explained to patients Are patients treated with respect and in a welcoming manner Is confidentiality maintained Is privacy ensured during ANC consultation Is informed consent sought for certain procedures (e.g.: surgery, blood transfusion, HIV testing) 78

80 Identification of cases For identification of cases standard case definitions are needed Example from district hospitals in Ghana: Complication: Essential features: Additional features: Primary PPH Genital tract bleeding At least 1 of the < 24 hrs of delivery following:. Estimated Blood loss > 500 ml. Clinical signs of shock Standard case definitions Presentation and review of standard case definitions (refer to handout): The IMMPACT project in Ghana and Jamaica formulated case definitions of emergency obstetric complications, which were reviewed and adapted in a previous QI workshop. For clinical audit, such as assessment of management of emergency obstetric complications, we take a number of patient case notes for review - e.g. 10 or 20 - and scrutinise the case notes whether the selected criteria for proper care and treatment are met. In order to identify cases we need case definitions, which help us which case notes to include in the CBA. A list of standard case definitions for obstetric complications is distributed and reviewed. This list was adapted from a list, which was developed in a project of IMMPAC, a research group in Aberdeen. A similar list can be drawn up for problems in the newborn child. Steps of the Audit Process After this, the workshop facilitator presents the steps to follow when carrying out a CBA. Steps of the audit process Steps of the audit process Select topic for audit Select criteria Agree on criteria for audit to audit Agree on case definition Measure Re-evaluate current Identify cases practice practice Measure current practice AUDIT CYCLE Identify and analyse problems Develop solutions Feedback Implement changes Implement and identify changes Repeat measurement of practice changes IN PARTNERSHIP WITH Liverpool School of Tropical Medicine Liverpool Associates in Tropical Health Selection of Criteria for CBA In this session the workshop participants will learn how to select and formulate criteria for CBA. The workshop facilitator starts with an introduction, which is followed by small group work. Selected criteria are used as a checklist to assess the quality of health services or the performance of health workers. The data extraction sheet is the actual checklist with the selected criteria as checkpoints. 79

81 Selection of criteria Definition of criteria: Criteria are systematically developed statements that can be used to assess the appropriateness of specific health care decisions, services and outcomes. Standards and guidelines (national, international) can be used to formulate criteria, such as WHO Managing complications of pregnancy and child birth. Selection of criteria Criteria must be: relevant to case management for the level of care (availability of test or treatment). indicative of essential practice. evidence-based. measurable from patient case notes. restricted to not more than 10 per complication or practice to be audited. preferably developed by an expert panel Selection of criteria Criteria of good care can relate to: P: process of care (what has to be done) S: structure of care (what has to be in place, such as different resources) O: outcome of care (what is to be achieved) Example from Ghana: Selection of criteria Criteria for optimal management of obstructed labour: Prompt delivery of foetus should be < 2hours of diagnosis. Urinary bladder should be drained. Observation chart should be maintained (pulse, BP, urine output, temperature). Intravenous access and hydration should be achieved. Broad-spectrum antibiotics should be given. Typing and cross-matching of blood should be carried out. Example from Malawi: Selection of criteria Criteria for an effective emergency referral system for obstetric complications: All referred patients come with a referral form filled in by the referring health facility. Ambulances and drivers are available 24/7 to transport patients. Health centre staff inform referral hospital through mobile phone when an emergency case is referred. All emergency referrals are attended to by a clinician within 30 minutes of arrival. Health centres receive feedback on patients referred Identify information sources for selection of cases It is advisable that different information sources are used to identify cases, such as: Labour ward register Admission register of maternity ward Admission register of gynaecology ward Discharge registers Operation theatre register Measurement of current practice Review a number of patient records from a certain period (e.g. 10). Record findings from each patient record on data collection sheet For each criterion the % of case notes which fulfilled the criterion is given. Direct observations of practice and exit interviews with patients can be used as well to complement record review. Identify and analyse problems and find solutions Based on the findings (scores) from the criteriabased audit, problems are identified Discuss why these problems exist and analyse contributing factors and root causes. Find possible solutions to solve the problems and tackle the root causes and select the most appropriate solutions. Make an action plan Communicate the action plan to staff 80

82 Implement changes Identify what has to be done, when and by whom. Clarify who is responsible for the implementation of different activities of the action plan. Agree when the plan should have been implemented (time for re-audit). Communicate the plan to relevant staff. Carry out the activities of your action plan. Re-evaluate practice After the time in which changes should have been implemented, carry out the same audit. Compare findings of the 2 nd audit with those of the 1 st audit. Effectiveness of the audit is measured by the change in the % of cases which met the criteria of good care. Give feedback to staff about changes in their performance and congratulate staff with achievements. Remember.. A health facility that is always auditing some particular aspect of its care is a facility that is committed to improving the quality of services. Recommended further reading WHO, Dept. of RH and Research. Beyond the numbers: Reviewing maternal deaths and complications to make pregnancy safer. WHO, Geneva Graham W. et al. Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries. Bull of the WHO 2000; 78 (5): Wagaarachchi PT, Graham WJ, Penney GC, et al. Holding up a mirror: changing obstetric practice through criteria-based clinical audit in developing countries. Int J Gynaecol Obstetr 2001; 74: Selection of Criteria (small group work) The last activity of the day is small group. Divide the workshop participants in 4 groups. Each group will develop criteria for a particular aspect of MNCH care. The workshop facilitator emphasizes that this exercise is not about developing a detailed comprehensive treatment guideline or protocol, but drawing up a list of maximum 10 brief and clear criteria for assessing quality care, which are reflecting essential aspects of care and which are measurable, either by record review, observation or interview (e.g. exit interviews with clients or patients). Criteria should focus on process, formulating statements related to expected staff performance and service delivery. As reference material each group receives a copy of the WHO publication Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Group one is given blank copies of the partograph and can also use the WHO book Managing complications of pregnancy and child birth; a guide for midwives and doctors. Group 4 may wish to use as a reference the WHO book Managing newborn problems; a guide for doctors, nurses and midwives. Each group must select a chairperson who chairs the discussion, and a secretary, who makes notes. The groups are given one hour. If time permits, after one hour the groups present the results of the group work on a flip chart. Otherwise this is done the next day. 81

83 Selection of audit criteria for MNH care Group work: In small groups select audit criteria for the following aspects of MNH care: Group 1: Care during labour, using the partograph Group 2: Women-friendliness of intra-partum care Group 3: Antenatal care booking visit Group 4: Newborn care Formulate a set of criteria for audit, considering PSO: process, structure and outcome After each presentation the facilitator gives the workshop participants an opportunity to make comments on the proposed criteria and finally makes his/her own comments. Ask whether criteria are related to structure, process or outcome. Pay attention to how criteria are formulated and whether it is clear what will be assessed and how. DAY 3 Opening and Recap of Previous Day After welcoming the workshop participants, start the 3 rd day with an opening prayer, followed by a recap of the key issues discussed during the 2 nd day. Ask workshop participants what they learned yesterday. This can be done by going around the group and ask each participant to mention something important (s)he has learned yesterday. Present the power point slides with summary of key issues arising from the previous day s presentations and discussions and observations by the workshop facilitators. This might be an opportunity to further discuss some emerging issues. Programme outline day 3 Key activities day 3: Recap of previous day. Presentation of group work of previous day. Develop criteria for auditing of EOC. After this, the outline of the programme for the day is presented. The day s programme will continue to build capacity of QI teams to conduct CBA in their health facilities. Practical exercise in conducting criterion-based audit (use of partograph). Introduction to setting standards Presentations of group work of previous day After each presentation the facilitator gives the workshop participants an opportunity to make comments on the proposed criteria and finally makes his/her own comments. Ask whether criteria are related to structure, process or outcome. Pay attention to how criteria are formulated and whether it is clear what will be assessed and how. 82

84 Selection of criteria for audit of EOC Selection of criteria for audit of EOC Group work: In small groups select audit criteria for the following aspects of EOC: Group 1: Management of primary PPH Group 2: Management of septic abortion Group 3: Management of eclampsia Group 4: Blood transfusion services in GH Similar to the group work of the previous day, workshop participants are split up in groups of 6-10 people. Each group is assigned an obstetric complication. The groups have to develop a maximum of 10 criteria for audit of the management of the assigned obstetric complication. As reference material each group uses a copy of the WHO publication Managing complications of pregnancy and child birth: a guide for midwives and doctors. If there are more than 32 participants it should be considered to have a fifth group, which will take an additional topic such as ruptured uterus or birth asphyxia. If group 5 has as topic birth asphyxia the group may wish to use as a reference the WHO book Managing newborn problems; a guide for doctors, nurses and midwives. Each group must select a chairperson who chairs the discussion, and a secretary, who makes notes. The groups are given one hour after which they present the results of the group work on a flip chart. After each presentation the facilitator gives the workshop participants an opportunity to make comments on the proposed criteria and finally makes his/her own comments. Ask whether criteria are related to structure, process or outcome. Criterion-based audit of the use of the partograph The workshop facilitator introduces this group exercise in which workshop participants in small groups carry out a criterion-based audit of the use of the partograph for which they use the 10 filled in partographs they were asked to bring from their health facility. Ask which health facilities have brought partographs. Divide the participants in small groups and ask them to audit the use of the partograph. Criterion-based audit of the use of the partograph Group work: Review 10 partographs and record your findings on the data collection sheet for criterion-based audit. Check for each partograph for each criterion whether it was done or not. Tick in the column for each partograph Y for yes or N for no. Add up the total Y score for each criterion from all 10 partographs in the last column. Each group uses a set of partographs. Data extraction sheets with defined audit criteria are distributed. Criteria as developed during the group work from the previous day can be used, if there is time for one of the workshop facilitators to type them in a blank data extraction sheet and print out copies of the sheet for the workshop participants. Alternatively a form can be used with criteria from a previous workshop, which has been photocopied in advance. on a flipchart. The areas with low scores are 83

85 identified and it is discussed what might be the reasons for the poor performance in these areas and what QI teams could do to improve the performance for those aspects of care. Introduction to Setting of Standards One of the workshop facilitators gives a 15 minutes introduction to setting of standards, using the related power point slides. Standards of care Standards are statements of the expected quality of care that a service aims to offer They specify what is expected of health care providers in terms of service provision and care They are evidence-based They respect human rights They are related to: P: process (what has to be done) S: structure (what has to be in place) O: outcomes (what is to be achieved) Purpose of standards of care To assist health care planners and programme managers in planning and management. To provide guidance to health care providers on effective service delivery and patient care. To provide a bench mark to assess quality of care and current practice. To maintain and improve quality of care. To increase patient, client and the community s satisfaction with health care Key components of standards Title (which identifies the standard) Standard statement (specific issue(s) to be addressed by the standard) Standard objectives Structure criteria (resources for provision of care) Process criteria (practices) Outcome criteria (achievements, deliverables) Audit indicators Rationale for the standard References to evidence-based literature Objectives of standards Example of human rights aspects of intra-partum care Every pregnant woman seeking health care is attended to by a SBA within 30 minutes of arrival A woman s right to dignity is respected A woman s right to privacy and confidentiality is respected A woman s right to information is respected. A woman is given the choice of having a companion during labour. Structure criteria of standards These refer to the resources that need to be in place, such as: Infrastructure Buildings and space Water supply Light source Drainage and waste disposal Human resources Essential drugs Equipment and supplies Protocols and guidelines Process criteria of standards These refer to what has to be done in terms of treatment, care and interpersonal communication, such as: Counselling Providing information Obtaining informed consent Prescription of treatment Providing treatment Providing nursing care Monitoring of patient s condition Psycho-social support 84

86 Outcome criteria of standards These refer to what has to be achieved, such as: Early diagnosis Reduced case fatality Reduced incidence of complications Reduced delay in receiving care and treatment Improved client/patient satisfaction Improved knowledge Improved health seeking behaviour Increased service utilisation Reduced unmet need for EOC Steps in setting standards Select service component or topic for the standard Form a multidisciplinary review group. Review available evidence and existing policies and guidelines. Jointly develop the standard, with the following key components: Objectives Process criteria Structure criteria Outcome criteria In the PRRINN-MNCH programme simple and practical minimum standards have been developed for MNCH services, which are easy to use as a reference. They have a simplified format with objectives and formulated standards for structure, process and outcome aspects of quality. Workshop participants will the next day do a practical exercise in small groups, developing standards for certain aspects of MNCH services. DAY 4 Opening and Recap of Previous Day As usual, after welcoming the workshop participants, start the 4 th day with an opening prayer, followed by a recap of the key issues discussed during the 3 rd day. Ask workshop participants what they learned yesterday. This can be done by going around the group and ask each participant to mention something important (s)he has learned yesterday. Present the power point slides with summary of key issues arising from the previous day s presentations and discussions and observations by the workshop facilitators. Programme outline of day 4 Recap of day 3 Group work on setting of standards for MNCH services. Discussion of the next steps for the way forward after this last Qi workshop The workshop facilitator presents the programme for day 4 of the workshop. Following the introduction lecture from yesterday on setting standards, this morning workshop participants will in small groups develop standards for some aspects of MNCH service provision. 85

87 Setting standards for MNCH service provision As a brief introduction to the group work and a recap of yesterday s introduction, the workshop facilitator presents the following slides and as an example the standard for post abortion care services, which was developed in Kenya. Standards of care Standards are statements of the expected quality of care that a service aims to offer They specify what is expected of health care providers in terms of service provision and care They are evidence-based They respect human rights They are related to: P: process (what has to be done) S: structure (what has to be in place) O: outcomes (what is to be achieved) Purpose of standards of care To assist health care planners and programme managers in planning and management. To provide guidance to health care providers on effective service delivery and patient care. To provide a bench mark to assess quality of care and current practice. To maintain and improve quality of care. To increase patient, client and the community s satisfaction with health care Example from Kenya of standard for post-abortion care Objectives of standard: Every woman with an incomplete abortion undergoes evacuation (MVA or D+C) within 24 hours of diagnosis. Every woman with an incomplete abortion, who has had uterus evacuation is offered postabortion counseling and other RH services. Women and the community know the dangers of unsafe induced abortion; they are able to identify complications and access PAC promptly. Example from Kenya of standard for post-abortion care Structure Process Outcome Room set aside for evacuation (MVA) MVA set and protocols available for PAC Room with privacy for couselling FP services available, incl. contraceptives Screening services for STIs available Staff available who are trained in PAC History taken, client examined Uterus evacuated using MVA or D+C as per protocol Broad spectrum antibiotics given Post-abortion counselling given, incl FP + HIV counselling HIV testing offered BT if Hb < 7 gr% Reduced incidence of complications Reduced delay in case management Reduced case fatality Reduced recurrence of abortion Women and community aware of dangers of unsafe abortion and signs of complications IN PARTNERSHIP WITH Liverpool School of Tropical Medicine Liverpool Associates in Tropical Health After this an introduction is given to the group work. Depending on total number of workshop participants, divide them in 4 or 5 groups. Each group has to develop standards for a particular component of MNCH services. These standards should include objectives and statements related to structure process and outcomes. Which components of MNCH services are chosen for development of standards has to be decided by the workshop facilitators when planning for the workshop. The group work takes 1½ hour. Setting standards for MNCH care in Northern Nigeria Group work (1½ hour): Formulate standards of best practice for: Group 1: Focused antenatal care (FANC) Group 2: Intra-partum care. Group 3: Care of the newborn in 1 st 24 hours after birth. Group 4: Postnatal care (PNC) Formulate in your standards: Objectives and statements related to structure, process and outcomes. Setting standards for MNCH care in Northern Nigeria Group work: Structure statements refer to what needs to be in place to provide quality of care, including resources, organizational and administrative arrangements of service delivery. Process statements refer to what has to be done and how it should be done (best practice). Outcome statements refer to what has to be achieved. 86

88 Setting standards for MNH care in northern Nigeria Useful references for setting standards and development of criteria for audit of MNH services: For the group work each group is given as a reference a copy of the WHO book Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. IN PARTNERSHIP WITH Liverpool School of Tropical Medicine Liverpool Associates in Tropical Health They can also use their copies of the WHO manuals on obstetric and newborn care, which they were asked to bring to the workshop. After 1½ hour the groups present their work and discuss it with other workshop participants, who can give comments or bring up additional points. Next steps This is the last QI workshop. Therefore it is very important to discuss with the participants the next steps for the way forward. This includes a discussion about how to ensure that QI teams continue to function actively in continuously assessing and improving quality of care and evaluating the results of their activities and that QI activities will continue in the health facilities. The issue of regular supportive supervision of the QI teams has to be discussed and who will be responsible for this. It would be useful to have QI teams at LGA and state level, which play a more leadership and supportive role in the QI process. Also the issue of staff transfers has to be raised. If members of the QI team leave the health facility, they should be replaced. Particularly if the chairperson leaves the QI teams must ensure that the QI team continues and QI activities do not stop. Therefore it is good that the QI teams have a vice-chair person and secretary, who will carry on and that in the next meeting a new chair person is elected. Specific next steps should be formulated for the health facility QI teams, the staff at the LGA PHC office, for the state level, including SMOH, SHSMB and SPHCMB, as well as the PRRINN- MNCH programme. Closing Remarks Workshop participants are kindly requested to fill in and return the workshop evaluation form. A representative of PRRINN-MNCH makes the closing remarks, the workshop certificates are handed out and a volunteer closes the workshop with a prayer. 87

89 11. FOLLOW UP & SUPPORTIVE SUPERVISION OF QI TEAMS In order to institutionalise and strengthen the QI teams and QI processes at health facility level and improve quality of care in the PRRINN-MNCH supported health facilities it is essential that after each workshop and also in future the QI teams are followed up and receive regular supportive supervision. For many health care providers QI is a new concept, which is difficult to put into practice. Therefore the QI teams need guidance and support, also in team building. Supportive supervision Improving quality of care is a continuous process in which the health facility QI teams play a crucial instrumental role. However, to help them to play this role effectively the QI teams need regular supportive supervision and from the beginning of the QI training, after each workshop there should be follow up visits of the health facility QI teams in each state, to help them putting into practice what they have learned. They need support in assessing quality of care, identifying and analysing the quality of care problems, planning QI activities and monitoring and evaluating them, as well as in initiating new QI methods such as MDR, PNDR and CBA. The QI teams need also guidance in choosing priorities for QI, focusing more on process aspects and problems which they can solve themselves than on structural problems, which are beyond their capacity and require resources and support from higher authorities. How regular supportive supervision of health facility QI teams is organised, depends on what systems for supportive supervision are already in place at LGA and state level. If there are Integrated Supportive Supervision (ISS) teams at state level it is important that the QI teams and ongoing QI activities are part of the supervision process and that the ISS teams include persons with knowledge, skills and experience in QI, such as the trained trainers in QI. Alternatively, arrangements could be made with the FMCs in the states for FMC consultants to provide technical supportive supervision to the health facility QI teams. Another way to ensure regular supportive supervision of health facility QI teams is, having QI teams at LGA and state level, which provide guidance and support. Health facility management and QI teams are also encouraged to provide internal intra-facility supervision. Supportive supervision has been defined as the provision of monitoring, guidance and feedback on matters of personal, professional, and educational development in the context of the health worker s care of patients (Marquez, 2002). Supportive supervision is about empowerment and not control, emphasizing building of confidence and self esteem through supportive feedback. It is facilitated through an encouraging relationship with individual health care providers. It sets expectations, monitors and assesses performance, identifies problems and opportunities, in which the supervisor remains an intermediary promoting collaboration in problem solving and linking to external resources. Supportive supervision is an enabling and reflective process that allows in-depth reflection on health care practice and helps to achieve quality patient/client focused services. The key characteristics of supportive supervision are presented in the panel on the next page. It is important that the supervisor plays a supportive and facilitative role and avoids playing a punitive role. The supervisor helps health care providers to improve performance and solve problems. On the job training is an integral part of supportive supervision. 88

90 At the end of a supervisory visit the supervisors give constructive feedback to the supervisees and fill in and sign the supervision book. It is good practice to document findings, activities and recommendations and write a supervision report. Key Characteristics of Supportive Supervision The supervisory process has 4 tasks: o To set expectations and standards against which performance can be measured. o To monitor and assess performance. o To identify problems and opportunities. o To take action to resolve problems and improve performance. The external supervisor acts as facilitator, trainer and coach. Health workers participate in supervising themselves and each other. Health care providers are empowered to monitor and improve their own performance. Decision-making is participatory. Supportive supervision of the health facility QI teams could include: Asking about meetings of the QI team and what has been discussed. Reviewing minutes of QI meetings. Reviewing and discussing identified quality of care problems and their root causes. Reviewing and discussing action plans, achievements and challenges. Helping QI teams to focus more on process than structural aspects of quality of care and on problems they can solve themselves. Encouraging QI teams and giving praise for work well-done. Helping to overcome constraints and solve problems. Clarify QI issues which are not clear to the members of the QI teams and provide on the job teaching and training. Giving support and guidance to MDR, PNDR and CBA. Reviewing MDR and PNDR recording forms and resulting action plans. Collecting information on number of MDs and PNDs and numbers reviewed. Quarterly QI cluster meetings The PRRINN-MNCH programme uses a cluster approach in which project interventions are rolled out step by step in so-called MNCH clusters, consisting of 1 CEOC referral hospital and its surrounding health facilities in an administrative area with a population of approximately 500,000. In this MNCH cluster the project supports 4 BEOC facilities and 8 PHC facilities, which are expected to provide 24/7 obstetric services. So far, QI activities have been introduced in the 5 EOC facilities in the clusters. It is recommended that every quarter a QI cluster meeting is organised, in which the QI teams from the 5 EOC facilities meet together at the CEOC hospital, share experiences, discuss problems and review selected cases of MD or PND together. 89

91 12. REFERENCES 1. Adamu YM, Salihu HM, Sathiakumar N, Alexander GR (2003). Maternal mortality in Northern Nigeria: a population-based study. Eur J Ostet Gynecol Reprod Biol; 109: Bouvier-Colle MH, Ouedraogo C, Dumont A, Vangeederhuysen G et al (2001). Maternal mortality in West Africa: rates, causes and substandard care from a prospective study. Acta Obstet Gynecol Scand; 80: Donabedian A (1988). The quality of care: How can it be assessed? JAMA; 260 (12): Gabrysh S, Campbell O (2009). Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy & Childbirth; 9: Graham W, Wagaarachi P, Penney G, et al (2000). Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries. Bulletin of the WHO; 78 (5): Hulton HA, Matthews Z, Stones RW (2000). A framework for the evaluation of quality of care in maternity services. University of Southampton. 7. Kongnyuy, E.J. & van den Broek, N. (2008). Criteria for clinical audit of women friendly care and providers' perception in Malawi. BMC Pregnancy and Childbirth, vol Lawn JE, Cousens S, Zupan J, for The Lancet Neonatal Survial Steering Team. Four million neonatal deaths: When? Where? Why? Lancet (2005); 365: Lawn JE, Yakoob MY, Haws RA, Soomro T, Darmstadt GL, Bhutta ZA (2009). 3.2 million stillbirths: epidemiology and overview of the evidence review. BMC Pregnancy and Childbirth; 9 (supll 1): S Lewis G. (2003) Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. British Medical Bulletin; 67: Marquez L (2002). Making supervision supportive and sustainable: a new approach to old problems. Supplement to Population reports; 30, No. 4; MAQ paper No Mbaruku G, Bergstrom S (1995). Reducing maternal mortality in Kigoma, Tanzania. Health Policy Planning; 10 (1): National Population Commission, ORC Macro (2008). Nigeria Demographic and Health Survey Abuja, National Population Commission Federal Republic of Nigeria. 14. Pattinson R, Kerber K, Waiswa P, Day LT, Mussel F et al (2009). Perinatal mortality audit: counting, accountability and overcoming challenges in scaling up in low- and middle-income countries. Int J Gynaec Obstet; 107: S113 S Pittrof R, Campbell OMR, Filippi VGA (2002). What is quality in maternity care? An international perspective. Acta Obstet Gynecol Scand; 81: Roemer MI, Montoya-Aguilla C (1988). Quality assessment and assurance in primary health care. Offset publication 105. Geneva, WHO. 17. Ronsmans C, Graham W (2006). Maternal mortality: who, where, when and why? Lancet; 368: Thaddeus S, Maine D (1994). Too far to walk: maternal mortality in context. Social Science and Medicine; 38 (8): Wagaarachchi P, Graham WP, Penney GC, McCaw-Bins A et al (2001). Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries. Int J Gynecol Obstet; 74:

92 20. WHO. (2004) Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. Geneva, WHO. 21. WHO (20 ). Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, WHO. 22. WHO (200 ). Managing complications of pregnancy and child birth; a guide for midwives and doctors. Geneva, WHO. 23. WHO (200 ). Managing newborn problems; a guide for doctors, nurses and midwives. Geneva, WHO. 24. Wilson L, Goldsmith P (1995) quality and its measurement. In: Wilson L, Goldsmith P. eds. Quality management in health care. Sydney, McGrw-Hill:

93 ANNEX 1: PROGRAMMES OF THE QI WORKSHOPS Programme 1 st QI Workshop Dates: Venue: PROGRAMME QUALITY IMPROVEMENT FOR MATERNAL AND NEWBORN HEALTH 1st Training Workshop for MNCH Health Care Providers (Indicate PRRINN-MNCH clusters and state) DAY 1: (Fill in day of the week and date) am Registration am Welcoming address am Introductions and purpose of workshop am What is quality and quality in health care? am What is quality in maternal & newborn health care? am Tea break am Importance of quality of care am Models of quality of care am Group exercise: Perceptions of quality pm Prayers and lunch pm Feedback from group exercise pm Photographs: quality in MNH pm Summary of day pm Prayers + tea break 92

94 DAY 2: (Fill in day of the week and date) 8.30 am Registration 8.45 am Recapitulation of day 1 Outline of programme of day am Role plays: Good and bad quality of ANC 9.45pm 10.15am 10.45am 11.30am 12.30pm 12.45am 14.00pm 15.00am 15.45pm 16.30pm Tea break Identifying aspects of good and bad quality of ANC (group work) Presentation of findings from group work How do we improve quality of care? - Approaches - Methods - Tools Group photo Prayers and lunch Group exercise: Quality improvement teams Feedback from group work Next steps: Tasks to be done in next months Next QI workshop Feedback from workshop participants Handing out of certificates 17.0 Pm Closing remarks and prayer 93

95 1.2 Programme 2 nd QI Workshop Dates: Venue: QUALITY IMPROVEMENT FOR MATERNAL AND NEWBORN HEALTH 2 nd Training Workshop for MNH Health Care Providers in PRRINN-MNCH supported EOC Facilities (Indicate clusters and state) PROGRAMME DAY 1: (Indicate day of the week and date) am Registration am Welcome address am Opening prayer & introductions and purpose of workshop am Introduction of QI teams from health facilities am Recapitulation of content of 1 st QI workshop am Tea break am Report on activities of QI teams and sharing of experiences (15 minutes per group) pm Prayers + Lunch pm Issues arising from the presentations pm The three delays model Review of case study in small groups (Why did Fatuma die?) pm Presentation of results of group work pm Tea break and closure 94

96 DAY 2: (Indicate day of the week and dates) 08.00am Registration 08.15am Recap of day 1 Programme for day am 09.00am Introduction to maternal death reviews (audit): - What is a MD review? - Why do a MD review? - Advantages and disadvantages My Sister Myself: Film on maternal deaths and questions & discussion 09.30am Maternal death audit process: - Principles of doing audit - Process: steps - Examples from other countries 10.15am 10.30am 11.00pm 12.00am 12.30pm 14.00pm Tea break Experiences with maternal death audit in Nigeria Maternal death audit: demonstrations - Demonstration of poor example by facilitators + discussion - Demonstration of good example by facilitators + discussion Beyond the Numbers: DVD on maternal death audit and discussion Prayers + lunch Introduction to maternal death audit group exercises Maternal death audit: group exercises (case studies) 15.00pm 16.00pm Feedback and discussion of group exercises Tea break Closure 95

97 DAY 3: (Indicate day of the week and date) am Registration am Recap of day 2 Programme for day am Tools for maternal death audit - What tools are needed? - Review of tools developed for Northern states am Small group exercise: filling in the recording form using case studies of previous day am Tea break am Presentation of group work pm What next? pm Closing remarks + handing out certificates m Prayers + lunch 96

98 1.3 Programme 3 rd QI workshop Date: Venue: PROGRAMME QUALITY IMPROVEMENT FOR MATERNAL AND NEWBORN HEALTH 3 rd Quality Improvement Workshop for MNH Health Care Providers in PRRINN-MNCH supported EOC Facilities in Katsina state DAY 1: (Indicate day of week and date) 9.00 am Registration am Welcome address am Opening prayer Introductions and explanation of purpose of workshop am Recapitulation of content of 2 nd QI workshop am Presentations by QI teams on QI activities and sharing of experiences (15 minutes per group) am Tea break am Presentations by QI teams on QI activities and sharing of experiences (15 minutes per group) pm Prayers + Lunch pm Presentations by QI teams on QI activities and sharing of experiences (15 minutes per group) pm Presentation of observations from FMC consultants during supportive supervision and discussion of emerging issues pm Tea break & closing prayer 97

99 DAY 2: (indicate day of week and date) am Registration + opening prayer am Recap of day 1 Programme for day am Presentation and discussion of experiences with MD reviews at the general hospitals am Presentation and discussion of 3 case studies of MD reviews from general hospitals am Tea break am Review of audit cycle, how to measure quality of care and how to evaluate progress of QI activities am Small group work: Review of QI action plans and identification of indicators and methods for evaluation of progress of QI activities am Prayers and lunch pm Presentation of group work (10 minutes per group) am Tea break and closing prayer 98

100 DAY 3: (Indicate day of the week and date) am Registration + opening prayer am Recap of day 1 Programme for day am Introduction to perinatal death reviews: - What is a perinatal death? - Why is perinatal mortality used as an indicator? - Causes and contributing factors of perinatal mortality? - How to reduce perinatal mortality? - What is perinatal death review? - How to do it? am Tea/coffee break am Presentation of tools for peri-natal death reviews am Group work on case studies, using the recording tool (4 groups) pm Presentation of group work pm Prayers and lunch pm Presentation of group work pm Next steps for the way forward pm Closing remarks + handing out of workshop certificates 99

101 1.4 Programme 4 th QI Workshop Date: Venue: QUALITY IMPROVEMENT FOR MATERNAL AND NEWBORN HEALTH 4th Quality Improvement Workshop for MNH Health Care Providers in PRRINN-MNCH supported EOC Facilities PROGRAMME DAY 1: (indicate day of the week and date) 08.00am 08.10am 08.30am 08.45am 09.00am 09.30am Registration Welcome address Opening prayer Introductions and purpose of workshop Recapitulation of content of 3rd QI workshop Report on progress with QI activities of QI teams and sharing of experiences (15 minutes per group) am Tea break am Report on progress with QI and activities of QI teams and sharing of experiences (15 minutes per group) pm Prayers + Lunch pm Report on progress with QI activities of QI teams and sharing of experiences (15 minutes per group) pm Emerging issues and how to address them pm Tea break & closing prayer 100

102 DAY 2: (indicate day of the week and date) am Registration + opening prayer am Recap of day 1 Programme for day am Presentation and discussion of experiences with maternal and perinatal death reviews at the general hospitals am Presentation and discussion of 3 case studies of MD reviews am Tea break am Introduction to criteria-based audit am Group work on identifying topics for audit am Presentation of group work pm Prayers and lunch pm Further introduction to criteria-based audit pm Review of case definitions for obstetric complications pm Steps of the audit process and selection of criteria for audit am Small group work on selection of audit criteria - Care during labour, using the partograph - Women-friendliness of intra-partum care - Antenatal care booking visit - Newborn care in the first 24 hours after birth pm Tea break and closing prayer 101

103 DAY 3: (Indicate day of the week and date) am Registration + opening prayer am Recap of day 2 Programme for day am Presentation of group work from previous day (15 minutes per group) am Group work: Selection of audit criteria for EOC - Primary PPH - Puerperal sepsis - Obstructed labour - Eclampsia - Blood transfusion services in a general hospital am Tea/coffee break am Continuation of group work am Presentation of group work (10 minutes per group) pm Prayers and lunch pm Group work: practical exercise on conducting an audit of the use of the partograph pm Presentation of group work pm Introduction to setting of standards pm Closing payer and tea break 102

104 DAY 4: (indicate day of the week and date) am Registration + opening prayer am Recap of day 3 Programme for day am Group work on setting standards for MNCH service provision am Presentation of group work (group 1) am Tea/coffee break am Presentation of group work (group 2 5) am Next steps pm Closing remarks pm Prayers and lunch 103

105 ANNEX 2: WORKSHOP EVALUATION FORM 1 st (adjust) Quality Improvement Workshop in Maternal and Newborn Health for EOC facilities from MNCH clusters... in...(state) (Indicate workshop venue and dates on this line) EVALUATION FORM What cadre of medical staff are you? Please tick the most appropriate below Nurse/Midwife Community Health Officer PHC coordinator MCH coordinator Medical doctor Specialist medical doctor Others please specify Please give a score for each of the following (encircle the score): 1) Was the workshop interesting? Not extremely 2) Will you find the knowledge and skills acquired useful when you go back to your job? Not useful extremely useful 3) Was it easy to join in the interactive sessions (group work)? Not easy extremely easy 4) Did you feel comfortable and at ease during the workshop? Not comfortable extremely 5) Was the course a good use of your time? not extremely 6) How was the workshop venue (hall)? bad extremely good 104

106 7) What do you think of the workshop facilitators? bad extremely good 8) What do you think of the organization and logistic arrangements of the workshop? bad extremely good 9) What do you think of the meals during the workshop? bad extremely good 10) What do you think of the catering during tea breaks of the workshop? bad extremely good 11) What do you think of the accommodation in the hotel? bad extremely good 12) What do you think of the hotel staff attitudes towards guests? bad extremely good 13) What do you think of availability of water in the guest rooms? bad extremely good 14) What do you think of the amenities in the room (toilet, TV, refrigerator, lighting)? bad extremely good 15) What do you think of the security of the environment? bad extremely good 16) What was most useful of the workshop?

107 17) What was not useful? ) Do you have any other comments on the workshop or suggestions for improvement?..... Thank you 106

108 ANNEX 3: TASKS FOR AFTER THE 1 ST QI WORKSHOP Tasks in the health facilities after the 1st QI workshop 1. Establish a quality improvement team in your facility Select members, chair person and secretary. Decide on roles of QI team. Meetings: how frequently, write minutes, keep minutes on file. Reporting: who and how. Complete task 2 before next workshop 2. Assess perceptions of quality of care in your health facility The purpose of this exercise is to explore perceptions of quality of care amongst women, health care providers and managers in your facility. o Interview at least ten women about their perceptions of quality of care (see pages 2-4) o Interview at least four (hospital) or two to three (PHC) health care workers about their perceptions of quality of care (see pages 4&5) o For the QI team of the General Hospital: Interview at least one manager (medical director, hospital secretary) about his/her perceptions of quality of care (see pages 4&5) Analysis of findings from the interviews: o What is quality from the different perspectives of women, health care providers, managers. o What constitutes good quality care. o What problems are there in the quality of care being provided. o What should be improved Present these findings at your quality improvement team meetings in your facility: o Discuss these findings. o Identify the possible reasons for the quality of care problems. o Develop an action plan based on these findings: what action should be taken (activities), who should do what, dates by which this is done, what do you want to achieve (objectives), how to monitor that these actions have taken place and objectives have been achieved. Prepare a presentation for the next quality improvement workshop of the findings from the interviews after analysis, the quality of care problems identified, the results of the discussion, the action plan, and possible achievements as well as challenges. 3. Give feedback at next quality improvement workshop on what has been done since the 1 st QI workshop (prepare written notes) Who are the members of the QI team and their designation. Number of meetings held and what was discussed. Results of interviews. Quality of care problems identified. Action plan and activities successfully carried out. Achievements and challenges 107

109 Guideline for interviews with women Who do I Interview? Using the interview guide with women, interview at least ten women who have received antenatal, delivery or postnatal care services. When do I interview them? Interview these women as they are leaving the health facility. Where do I interview them? Find a place that is quiet and away from the other patients and staff to ensure privacy. Offer the patient/client somewhere to sit so that she feels comfortable during the interview. Interview tool Use the 2 page interview guide (questionnaire) on the next page. Make 10 photocopies of the questionnaire and use one for each interview or use one questionnaire and the note taker writes the answers for each question on a separate blank sheet of paper for each interview. Who conducts the interviews? Two persons are needed: one to ask the questions, the other to note down the answers. If possible, it is preferable that someone interviews the women who is not directly involved in their care. Interview technique Ask the woman if you may interview her. Explain briefly why you are interviewing her. Read the explanation at the top of the interview guide. One person conducts the interview, and one person takes notes. Ask the questions on the interview guide in a clear way. If they find it difficult to answer the question, then rephrase or explain the question. Try to get as much detailed information as possible and ask to explain the complaints or concerns about the quality of care. Let the client decide on their response. (Remember that it is the client s perception of the service that we are exploring and not what you think their perception is! Do not try to influence the client's answer.) Thank the woman for doing the interview. After the 10 interviews Once you have completed the 10 interviews, then you need to summarise your findings from the interview using your notes and memory. For each question list the responses from the different women. If the same response comes up more than once, write up the response once and between brackets how many times it came up. 108

110 Interview guide with women Explain the purpose of the interview: We are interested in understanding what users of our health services think about our facilities and services provided. This will help us improve our services to you and future clients. Feel free to give your personal opinion, whether good or bad. We appreciate your honesty and don t blame you for negative criticism. Your answers are strictly confidential. We do not need to know your name. We thank you for your participation and honesty. Type of client/patient:... Date of interview:.. /.. /.; Interview number:.. 1. What services have you received during this visit to this health facility? (encircle) ANC; Delivery care; PNC; FP clinic; Immunisation; Other (specify); Why did you come to this health facility? Do you have any problems, concerns, complaints with regard to the following aspects of the services? Problem/concern: YES or NO Explain: Times of opening Affordability and fees Access of services Transport to get to clinic Waiting time Buildings and space Availability of drugs Availability of equipment and supplies 109

111 Availability of staff Behaviour of staff Skills of staff Care received Understanding of treatment Privacy Cleanliness 4. What is important for you about a good health service for mothers during pregnancy, child birth and the period after child birth? Are there any improvements or changes you would like to see in the way this health facility provides maternal and newborn health services? Not at all Very much 6. Are you happy with the service you get here? (Give a score from 0 5) 6. Is there anything else you would like to say about the services? Many thanks for participating in this interview. This will help us to provide better care. 110

112 Guideline for interviews with health care providers and managers Who do I Interview? Using the interview guide with health care providers, interview at least four health care providers (obstetricians, doctors, midwives, CHEWs) who are providing antenatal, delivery or postnatal care services and at least one manager, e.g. officer in charge of PHC or maternity. When do I interview them? Interview these health care providers and the manager at a convenient time. The interview should only take 10 or 15 minutes. Where do I interview them? Find a place that is quiet and away from patients and other staff to ensure privacy. Offer the health care provider somewhere to sit so that (s)he feel comfortable during the interview. Interview technique Ask the health care provider if you may interview him / her. Explain briefly why you are interviewing him / her. Read the explanation at the top of the interview guide. One person conducts the interview, and one person takes notes. Ask the questions on the interview guide. If they find it difficult to answer the question, then rephrase the question. Try to get as much detailed information as possible. Let the provider decide his/her response. (Remember that it is the person s perception of the service that we are exploring and not what you think their perception is! Do not try to influence the client's answer.) Thank the healthcare provider for participating in the interview. After the interviews Once you have completed the 5 interviews, then you need to summarise your findings from the interview using your notes and memory. For each question list the responses from the different persons. If the same response comes up more than once, write up the response once and between brackets how many times it came up. 111

113 Interview guide with health care providers and managers We are interested in understanding what health care providers and managers think about quality of care, the care being provided in this facility and the problems with providing good quality care. This will help us improve the services provided to women and their families. Your answers are strictly confidential. We do not need to know your name. We thank you for your participation and honesty. Cadre of health care provider:...date:.. /.. /.. Designation:... Interview number:.. 1. What does quality of maternal and newborn health care mean to you? 2. Does your facility provide quality MNH health services? Please give details about aspects of good quality care and services at your health facility What are weaknesses or shortcomings you have observed in the quality of care of MNH services in your health facility? What do you need or has to be done to improve quality of care in your health facility? 5. Is there anything else you would like to add about quality of care? Many thanks for participating in this interview. This will help us to provide better care. 112

114 ANNEX 4: CASE SCENARIO WHY DID FATUMA DIE? CASE SCENARIO: WHY DID FATUMA DIE? This is the story of Fatuma Odeh, a 15 years old schoolgirl from Bonankoro, a rural village in Nigeria, at 12 km from Tsanyawa health centre. Fatuma was learning at the nearby secondary school in form 2. At school she met her boyfriend Mussah. Because she was worried to become pregnant, which would mean the end of her education, she went to Tsanyawa HC to ask for family planning. However, the nurse refused to give her assistance and told her that she was too young for such things and that she should concentrate on school instead of meeting boys. What could she do now? If she refused to have sex with Mussah, he would leave her for another girlfriend and she did not want to loose him as her boyfriend, because he was really nice to her and bought her soap and other things, which she needed for school and her parents were not able to provide. Sometime later Fatuma missed her monthly periods. She also felt nauseated in the mornings and suspected that she was pregnant. She was very upset and tried to hide her pregnancy as long as possible. When she told Mussah about her pregnancy, he denied that it was him who made her pregnant and he ended their relationship. She did not want to attend antenatal clinic, because she felt embarrassed and was afraid of what the nurse would say to her. For sure she would shout at her. When she was about 6 months pregnant her mother noticed that she was pregnant and told her father. Her father was very angry and called her bad names and shouted at her that she had brought shame to the family and threatened to chase her from the house. Her mother tried to cool him down, but because Fatuma was feeling ashamed and afraid of her father, she ran away from home and went to stay with her grandmother. Of course she could not go back to school, because meanwhile the news had already spread. When she was 8 months pregnant she noticed that her feet became swollen and later even her hands became swollen as well. Her grandmother took her to a traditional healer who gave her some herbs, which she had to prepare as a concoction and drink three times a day. There was no improvement. Finally she gathered courage and went to the health centre. It was difficult to walk the long distance with her swollen feet, which were painful and made her feel tired. The midwife told her to rest at home and if there would be no improvement to go to the district hospital, where she would have to stay until she would give birth. But how could she go there and who could go with her to look after her? The hospital is far and she had no money to go there. So she stayed at home. A month later, she woke up one morning with a bad headache and felt dizzy. She told her grandmother that she was not feeling well and could not fetch water that morning. Her grandmother bought her some aspirin, but when she came back from the shop she found Fatuma laying in the house, shaking all over her body. She immediately called the village TBA for help and when Mai Oumou came, the twitchings had subsided, but Fatuma was unconscious. Mai Oumou told Fatuma s grandmother to take her as quick as possible to the hospital. Grandmother sent someone to inform Fatuma s mother, who arrived after an hour. When her mother saw Fatuma she started crying. Meanwhile Fatuma had started having fits again. Fatuma s mother rushed home to tell her husband and ask his permission to take Fatuma to the hospital. Meanwhile, grandmother tried to find transport to take Fatuma to the hospital, but the owner of the only pick-up in the village charged 1,000.= Naira to take her to the hospital. Although Fatuma s father agreed to taking Fatuma to the hospital, he had no money to pay for transport. 113

115 Finally, with the help of some neighbours, they carried Fatuma to the health centre, where she got an injection and the fits stopped for a while. The midwife explained that Fatuma had to go to the big hospital as soon as possible and someone had to go there on bicycle to call for an ambulance, since she has no radio or phone to call the hospital herself. One of the neighbours volunteered and rushed on his bicycle to the district hospital, which was 4 hours cycling away. Fortunately the ambulance was around, but there was no fuel in the tank. The hospital administrator had to be searched for to issue a purchase order to buy fuel and an hour later the ambulance left to collect Fatuma from Tsanyawa health centre. Meanwhile Fatuma was unconscious and was breathing heavily. When they finally arrived in the hospital it was already dark. The midwife examined Fatuma, put her on an IV-drip and told Fatuma s mother that she urgently needed a Caesarean section, but in order to carry out the operation Fatuma s guardians first had to buy the necessary supplies such as gloves, IV fluids, IV canula, anaesthetic drugs. Most pharmacies were already closed and it was difficult and it took time to find a pharmacy. When they finally came back, the doctor on duty was nowhere to be found and it took until after midnight before they found him in one of the nightclubs in town. By the time the operation theatre was ready for the Caesarean section, Fatuma had stopped breathing. Why did Fatuma die? 114

116 ANNEX 5: STEPS IN INTIATING AND CONDUCTING FACILITY- BASED MATERNAL & PERI-NATAL DEATH REVIEWS 1. Set up the facility-based deaths review process. Psychological preparation of health workers to develop commitment and allay fears & anxiety; Identify MDR coordinator (committed champion). Get required authority and support from different levels (e.g.: PMO in charge). Agreement about costs and use of staff to do review. Establish a multidisciplinary review team (e.g.: doctor, midwive(s), administrator, lab technician, pharmacist, chair of health committee) 2. Decide on the scope of the facility-based deaths review: e.g.: in one hospital, at different health facilities, at LGA level with different health facilities together. 3. Develop data collection forms and pilot them. 4. Select collaborators and train data collectors. In one facility, review team alone can conduct the review. Review across several facilities: - Senior person in each facility to gain cooperation. - Staff with at least 3 years experience to be data collectors 5. Identify sources of data and cases of maternal and peri-natal death. Health facility registers: a. Maternity ward admission and discharge registers b. Neonatal special care unit register c. Operating theatre register d. Delivery register e. Mortuary register f. Gynaecological ward register g. Emergency Room register 6. Collect data at the health facility or facilities (and keep them in a special file), and extend data collection in the community if appropriate. Patient case notes, including laboratory forms and medication forms. Antenatal card Nursing reports Interviews with patient s relatives and health care providers who were involved in the case in order to obtain additional information on what happened. 7. Synthesize the data, interpret the results, and draw conclusions. Hold a meeting of the review committee. Present the details of the case and its management. Ensure confidentiality: Do not mention any names. Avoid blaming people for what went wrong! Identify shortcomings in care, avoidable factors and their root causes (ask: why? ) 8. Utilize the findings and prepare after each review an action plan. 9. Communicate the action plan to relevant staff in the health facility and facilitate implementation. 10. Decide how often to have review meetings. 11. Review the previous action plan(s) and their implementation at each MDR meeting. 115

117 ANNEX 6a: DEMONSTRATION OF POOR APPROACH TO MDR Scene In a district hospital, a midwife Florence is having a conversation with another midwife about conducting a maternal death review. Florence: I have been asked by the manager to look at all the maternal deaths in the hospital over the last month. What a waste of time. I have more important things to do, but I suppose I have to do this. I have looked at the delivery register and found one death. Midwife 2: I thought there were some more than that do you remember that lady who had a fit? Florence: Oh well, there is only one in the register, so I am just going to look at that one. Midwife 2: How are you going to do that? Florence: Well, I have got the notes here and I am just going to go through them and see what is written and then make some conclusions from that. I think I will speak with Gertrude she is the midwife who looked after this woman she made a lot of mistakes, you know. I don t know what she was doing. Midwife 2: Were there no other staff involved? Florence: I don t think so it s just Gertrude s name in the notes. I will let you know how my conversation with Gertrude goes. Later Florence interviews Gertrude about the maternal death. This is on the ward, where other patients and staff can hear. Florence: Sit down, Gertrude I want to talk to you about when Mrs Beatrice died. Well, I can see from the notes of Mrs Beatrice that you looked after her when she died. Gertrude: Yes, I did, but also the doctor was there. Florence: I am just interested in what you did. So Mrs Beatrice came in at 10am, but you didn t call for the doctor until 12am I can t understand what you were doing. Couldn t you tell that she was in danger? Didn t you know what to do? Gertrude: I was trying to... (Florence interrupts) Florence: Well, it is clear from the notes that you didn t call the doctor in time, and that you did not even put up an infusion. (Florence looks briefly at notes and then casts them aside). Gertrude: I tried to put up an infusion but I could not... (Florence interrupts). Florence: I am not interested in your excuses. I just want to know what you did. In this hospital we don t work like that. Gertrude: I tried to... (Florence interrupts). Florence: Anyway it seems that because of you, this woman died. This is very sad for the family you know. Gertrude: Yes, I know it s very sad. I m sorry if I did anything wrong. I did call the doctor straightaway, but he was in the operating theatre and the other doctor was on holiday. Florence: It s no use trying to blame other people. Did you not have any training about how to deal with a haemorrhage? This is basic midwifery care. Gertrude: (She starts to cry). I don t know what I did wrong. I tried to help. I am useless. Florence: Yes, you let Beatrice down. I will have to report this all to the manager. (She writes a few things down on loose piece of paper). Gertrude is still crying and Florence walks off. The other staff and patients just look at Gertrude. 116

118 On the following day, there is a hospital meeting with the manager, Florence, Gertrude and the rest of the staff. Florence: I would like to present to you the maternal death case of Mrs Beatrice. She died on 8 March from a postpartum haemorrhage. When she came in she was looked after by Sister Gertrude. She did not call the doctor or put an intravenous infusion up. She didn t seem to know what she was doing. It is clear that she received substandard care. Subsequently, Mrs Beatrice died. Manager: Yes, this is a clear case of substandard care. What Gertrude did was just not good enough. Gertrude, you should have done better than this. Gertrude: Looks very upset and is unable to speak. Other staff looked frightened. Manager: So we must stop these sad events happening. We must not let this happen again. 117

119 ANNEX 6b: DEMONSTRATION OF GOOD APPROACH TO MDR Scene In a district hospital, the QI committee is holding a meeting in the meeting room to discuss maternal death reviews. The QI committee consists of head midwife, head obstetrician, anaesthetist, hospital manager, senior midwife and obstetrician. There are no other people in the meeting room and the doors and windows are closed. Head midwife: First of all we need to identify all the maternal deaths that have occurred in the last month. I have looked at the delivery register, the admission register, the gynae ward book and the mortuary records. I have found 3 maternal deaths. Doctor: did you look at the operating theatre book? Sometimes they are put in there. Head midwife: yes, I did. There were no deaths recorded in there. Cecelia, David and I have been looking at the three cases. We have looked at the inpatient notes, the antenatal records and the registers to gather some information about the circumstances surrounding the deaths. We have also identified the people we would like to interview. So for case 1 we would like to interview the two midwives who were on duty at that time, the doctor, the anaesthetist and the laboratory technician. Doctor: what about the other doctors on duty? Head midwife: At the moment I don t think we need to. But following these initial interviews we may need to interview some more people. Doctor: Good. Any other comments?... that seems to be fine. So let s meet next week to discuss the cases in detail. THE HEAD MIDWIFE AND GLORIA ARE IN THE HEAD MIDWIFE S OFFICE. THEY ARE SITTING SIDE BY SIDE AND ARE HAVING A CUP OF TEA. Head midwife: thank you for coming this afternoon, Gloria. I appreciate you taking the time to come her. As I mentioned before, the QI team are looking at all the maternal deaths that have happened in the hospital in the last month. As I am sure you know, we can learn a lot from these sad cases. We can look at what we do and see if we can do anything better, so as to avoid these deaths from happening. I know you were involved in looking after Mrs Delia earlier this month, so I would like to ask you a few questions. We are also speaking with the other midwives and doctors involved. So the process is that we look at all the records, talk with the midwives and doctors who were involved in Mrs Delia s care, discuss and identify what care could have been different, and then identify what we can do in the hospital. Is this alright with you? Do you have any questions? Gloria: I am a little bit frightened about this. I have never been involved in anything like this. Head midwife: Please do not worry. The aim of this is to try and improve the care we provide in this hospital so that these deaths do not happen again. It is good for us all to reflect on what we do and think about how we can do anything better. i will be making some notes as we speak as these will help us when we are analysing the case. Gloria: OK. Head midwife: So in your own words, can you tell me about the day Mrs Delia came to the hospital. Gloria: Well it was on the Tuesday early morning at about 8am that she came in. Mrs Delia, she was in a terrible state. She was bleeding a lot and was moaning. Her mother was with her and she was very distressed. I tried to do put an intravenous infusion in but this was impossible. I couldn t find a vein. So then I called the doctor but he didn t come for a while. (Pauses). Head midwife: OK. What happened next? Gloria: I tried to mop up the blood. I wasn t sure if the placenta had been delivered. The baby was born but I am not sure when I couldn t get any sense from her mother. Head Midwife: did you try to examine Delia and see if the placenta was delivered? 118

120 Gloria: I had a look but I couldn t see the placenta. I don t really know what to do if the placenta hasn t delivered. The doctor eventually came and then he decided to take Delia to theatre. I don t think he tried to deliver the placenta. He gave her some IV fluids. Head midwife: (looks at the inpatient records) Were you able to give any drugs? Gloria: I looked in the cupboard for some oxytocin, but there was none there. I think it had all been used up. I told the mother to go and buy some from the pharmacy but she refused to leave her daughter. Head Midwife: Do you have any more things to add? Gloria: I don t think so. Head Midwife: Thank you Gloria. You have been very helpful with this. MEETING SCENE: QI COMMITTEE Doctor: So how did you get on with the first case, Mrs Delia. Head Midwife: Well, here are the inpatient notes, the antenatal record, and the registers. Cecelia and I talked with the midwives involved in the case and also the doctors, anaesthetist and laboratory technician. Let s have a look at the notes and our findings from the interviews all together. All committee members look at notes. Doctor: So what do you think the cause of death is? Midwife: Postpartum haemorrhage. It looks like she had a home delivery with a TBA and then she had d retained placenta which had partially separated and she haemorrhaged. Doctor: So when did she come into the hospital? Midwife: It seems like she came several hours after the delivery. I think there may be some issues that we need to explore about Delia having a home delivery, and her transfer to the hospital. Perhaps we should try to interview the TBA and her relatives? Head midwife: Yes, that may be a good idea, but we will have to do that very sensitively. Doctor: So let s have a look at what happened when she did arrive at the hospital? What are the avoidable factors? Midwife: It looks like she came in at about 2pm and was seen by the midwife. The midwife was unable to get an intravenous line in her arms. The doctor came at 4pm and was able to get a line in, and they gave some intravenous fluids it looks like 1 litre was given. They tried to get some blood but they were unable to contact the laboratory staff. She was still bleeding vaginally and they were preparing to take her to theatre, but she died before this was done. Head midwife: I think there are several points here to consider. Firstly, that the midwife was unable to get an intravenous line. Secondly, there was a delay in the doctor arriving. Thirdly, they were unable to contact the laboratory staff. Doctor: Also the amount of IV fluids given. Did anyone say about what methods they used to stop the bleeding? Or was this recorded anywhere? Midwife: Nothing was recorded or discussed in the interviews. Doctor: So I think we have come up with the avoidable factors here. Let s think why these things happened, so that we can think of ways so that they will not happen again. Midwife: The midwife said that she had heard about venous cut down, but she had not been taught this and felt she could not do this. So perhaps this could be part of our in service training. Doctor: Yes, that s a good idea. I think that the doctor was away from the hospital having his break at this time. Perhaps we need to think about ensuring that there is always a doctor on the hospital premises. We need to think about some ways to make sure that this happens. Head midwife: About the amount of IV fluids given. We have plenty of IV fluids here, so that is not the problem. Having discussed this with the midwives and doctors, I think it seems that staff do not know how much and how quickly to give fluids in a case like this. Perhaps we need to develop a clinical protocol for managing haemorrhage and do some training with all the staff. Midwife: we could put the protocol on the wall of the labour room so we can all see it. We could also have a protocol and training on 119

121 Doctor: Good. There may be some protocols in the city hospital. We should contact them and ask if we could have a copy. Now, let s consider the problem about the laboratory. This woman clearly needed some blood, but the laboratory staff could not be contacted. So we need to make sure that we can contact the lab technician day and night. Let s discuss this with the lab staff and see if we can post their mobile numbers in the labour room. Head midwife: let s write all this up in an action plan with clear timelines and responsibilities. And lest review how we have got on next month. 120

122 ANNEX 7: RECORDING & REPORTING FORMS FOR FACILITY- BASED MATERNAL DEATH REVIEWS 7a: Maternal Death Review Form (MDR 1) 7b: Maternal Death Notification Form (MDR 2) 7c: Maternal Death Follow Up Form (MDR 3) 7d: Facility staff interview record 121

123 YOBE STATE MINISTRY OF HEALTH MATERNAL DEATH REVIEW FORM (MDR 1) GENERAL INSTRUCTIONS This form must be completed for all maternal deaths (including indirect deaths, abortions, molar and ectopic gestation) occurring up to 42 days following delivery / termination of pregnancy. The Health Facility Maternal Death Review Committee must complete the form within 1 month and make a follow up on the implementation of the action plan within 3 months. The original form should stay at health facility level and a copy submitted to the LGA MCH coordinator, who will report to the LGA M&E officer and the MCH coordinator of the State Ministry of Health (SMOH). Federal and central teaching hospitals should submit copies of the form to the LGA MCH coordinator of the PHC office and the MCH coordinator of the SMOH. The code must be the same code as that on the notification form, MDR DETAILS OF DECEASED 1.1 MD Case Number: / / / 1.2 File No.: (First 4 characters of name of HF / Month / Year / Case no.) 1.3 Age (years): (if unknown: estimate) 1.4 Physical Address or locality where patient lived: (LGA, Name of village/town/ area) 1.5 Marital status: Married Single Divorced Widowed Separated 1.6 Educational level (completed): None Primary Secondary Higher Other (specify); 1.7 Condition at the time of death: Undelivered: Gravida Para Gestation (weeks) Delivered: Para Days since delivery Gestation at delivery (weeks) 122

124 2. ADMISSION AT INSTITUTION WHERE DEATH OCCURRED 2.1 Date of admission to facility: / / (dd/mm/yy) 2.2 Time: : am/pm 2.3 Admitted from: Another facility TBA Home Other (Specify) Name of referring facility (if applicable): 2.4 Reason for admission ( appropriate boxes): 1. Ante partum Haemorrhage 8. Ectopic pregnancy 2. Post partum Haemorrhage 9. Malaria 3. Obstructed/prolonged labour 10. HIV/AIDS 4. Ruptured uterus 11. Anaemia 5. Sepsis 12. TB 6. Pre-eclampsia/eclampsia 13. Hepatitis 7. Complications of abortion 14. Others (specify) 2.5 Condition on admission: 1. Stable 2. Critically ill 3. Dead on arrival (DOA) 2.6 Date of death: / / (dd/mm/yr) 2.7 Time of death: : AM/PM 2.8 Pregnancy stage at moment of death: 1. Antenatal 2. Intra partum 3. Postpartum 3. ANTENATAL CARE 3.1 Did she receive antenatal care? Yes No (skip to section 4) 3.2 If Yes, total number of visits: 3.3 Any danger sign(s) identified: Yes No 3.4 If Yes specify: 3.5 Any action taken on identified danger signs? Yes No 3.6 If Yes tick all that apply: 1. Referred 3. Ferro/folic acid 5. VCT 2. Anti-malarial 4. BP recorded 6. Other (specify): 123

125 4. DELIVERY AND PUERPERIUM 4.1 Did delivery occur? Yes No (If no, skip to section 5) If "Yes", 4.2 Date of rupture of membranes: / / (dd/mm/yy) 4.3 Date of delivery: / / (dd/mm/yy) 4.4 Time: : AM / PM 4.5 Was a partograph used? Yes No 4.6 Locality where labour started: ( one box) Level of facility: 1. Tertiary Teaching Hospital 6. TBA 2. Federal Medical Centre 7. Home 3. General Hospital 8. On the way before arrival at HF 4. Primary Health Centre 9. Other (specify) 5. Stand alone Maternity Unit 4.6 Duration of labour (hours:min): 1. First stage 2. Second stage hrs min hrs min 3. Third stage hrs min Total: hrs min 4.7 Mode of Delivery: ( appropriate boxes ) 1. SVD 3. Vacuum 5. Caesarean Section 7. Other 2. Breech 4. Forceps 6. Destructive operation (specify) 4.8 Delivered by: ( one box) 1. Midwife 4. Specialist Obs&gyn 7. CHEW 2. CHO 3. Medical Officer 5. TBA 6. Nurse 8. Other (specify) 124

126 5. CAUSE OF DEATH (use back of page if necessary) 5.1 Direct obstetric causes Primary (immediate) cause of death Specific cause of death A. Early pregnancy death 1. Septic abortion 2. Haemorrhage and abortion 3. Haemorrhage and ectopic pregnancy B. Haemorrhage 1. Placenta praevia 2. Abruptio placenta 3. Postpartum (atonic uterus) 4. Ruptured uterus 5. Other: C. Sepsis 1. Prolonged rupture of membranes 2. Obstructed labour 3. Retained placenta 4. Puerperal 5. Other: D. Hypertensive disorders 1. Eclampsia 2. Cerebro Vascular Accident 3. Organ failure 4. Coagulopathy 5. Other: E. Obstructed labour 1. Malpresentation/malposition 2. Cephalo Pelvic Disproportion 3. Others: F. Thrombosis/Embolism 1. Pulmonary Embolism 2. Amniotic Embolism 3. Deep vein thrombosis 4. Other: G. Operative Complications 1. Anaesthesia related 2. Surgery related 3. Other: H. Unknown 5.2 Indirect obstetric causes Malaria Heart disease Diabetes Anaemia Infective hepatitis HIV Other (specify): 125

127 6. ASSOCIATED FACTORS THAT CONTRIBUTED TO DEATH ( appropriate boxes, to be extracted as far as possible from records) Factors Causes Yes No Remarks (use back of page if necessary) 6.1 Health worker factors Lack of training in midwifery/obstetric skills Delay in deciding to refer Initial assessment incomplete Inadequate resuscitation Wrong diagnosis Wrong treatment No treatment Delay in starting treatment Inadequate monitoring Prolonged abnormal observations without action Lack of obstetric life saving skills 6.2 Admin. factors Communication problem between health facilities Transport problem between health facilities Lack of qualified staff Lack of essential obstetric drugs Lack of essential equipment, incl. resuscitation Lack of laboratory facilities Non availability of blood Absence of trained staff on duty 126

128 6.3 Patient/ Family Factors Delay in reporting to health facility Lack of transport from home to health facility Unsafe traditional/cultural practice Use of traditional medicine Unsafe medical treatment Refusal of treatment Delay in decision making Financial constraints 6.4 TBA, community factors Failure to recognise danger signs Failure to accept limitations Use of traditional medicine Lack of transport Delay in deciding to refer 6.5 Other factors (specify) 127

129 7. NEONATAL INFORMATION 7.1 Was the baby weighed after delivery? Yes No 7.2 If Yes, Birth weight: grams 7.3 Was the Apgar score determined after delivery? Yes No 7.4 If yes, 5 min Apgar score: 7.5 Outcome for newborn: ( one box): Alive Fresh SB Macerated SB Neonatal Death (NND) If NND: 7.6 Time of death: : am/pm 7.7 Date of death: / / (dd/mm/yy) 7.8 Cause of Death ( appropriate boxes): Preterm baby Neonatal tetanus Low birth weight Asphyxia Hypothermia Diarrhoea Birth defect Others (specify) Sepsis ASSESSMENT OF THE MATERNAL DEATH BY FACILITY MATERNAL DEATH REVIEW COMMITTEE 1. CASE SUMMARY (supply a short summary of the events surrounding the death including quality of care at all levels. Use back of page if necessary) 128

130 9. FACILITY MATERNAL DEATH REVIEW COMMITTEE ACTION PLAN TO IMPROVE FUTURE CARE (use back of form if more space is needed) Level of Care Proposed Activities Proposed Time Frame Responsible Person Hospital Health Centre TBA Family/ Community 10. FORM COMPLETED BY: 10.1 Name: 10.2 Designation: 10.3 Telephone: Date: / / (dd/mm/yy) 10.6 Signature: 10.7 Name Chair Person Review Committee: 10.8 Designation: 10.9 Date: / / (dd/mm/yy) Signature: (Chairperson of Review Committee) 129

131 YOBE STATE MINISTRY OF HEALTH MATERNAL DEATH NOTIFICATION FORM (MDR 2) GENERAL INSTRUCTIONS This form must be completed for all maternal deaths (including indirect deaths, abortions, molar and ectopic gestation) occurring up to 42 days following delivery / termination of pregnancy). This form must be completed immediately after death by the last person who attended to the patient. A copy should be submitted to the LGA MCH coordinator, who will report to the LGA M&E officer and the MCH coordinator of the State Ministry of Health (SMOH). Coding must be done at hospital level with code of HF (first 4 letters), LGA and state and MD individual code number for each deceased. DETAILS OF THE DECEASED 1. MD Case Number: / / / 2. File Number (health facility): 3. Physical Address or locality where patient lived (LGA, Name of village, Code): LGA: Health Facility: 4 Age (years): (estimate if age is unknown) 5 Locality where death occurred: LGA: health Facility: 6. Place where death occurred: ( one box) 1. Tertiary Teaching Hospital 6. TBA 2. Federal Medical Centre 7. Home 3. General Hospital 8. On the way/before arrival at H/F 4. Primary Health Care Centre 5. Stand alone Maternity Unit 7. Ownership of health facility: ( one box) 9. Other (specify) 1. Federal MOH 3. Private 5. Faith-based 2. State MOH 4. LGA 6. Other 8. Suspected cause of death( one box): 1. Haemorrhage 5. (Pre-) eclampsia 2. Obstructed labour 6. Complications of abortion 3. Ruptured uterus 7. Ectopic pregnancy 4. Puerperal sepsis 8. Other (specify) 9. Condition at the time of death ( one box): Delivered Undelivered 10. Date of / / 11. Date of / / Admission: Death: 12. Outcome for newborn ( one box): Alive Fresh SB Macerated SB Neonatal Death (NND) 13. Name: 14. Designation: 15. Date: / / 16. Signature: 130

132 YOBE STATE MINISTRY OF HEALTH MATERNAL DEATH FOLLOW UP FORM (MDR 3) GENERAL INSTRUCTIONS; This form must be completed by the Facility Maternal Death Review Committee The code must be the same as the code on the MDR1 and the MDR 2 forms. 1. MD Case Number: / / / (First 4 characters of name of HF / Month / Year / Case no.) 2. Admission Number: 3. Date reviewed by Facility MD Review Committee: / / 4. LGA: 6. State: 7. Facility: 5. Primary (Immediate) Cause of Death: 6. Secondary (Specific) Cause of Death: 7 Principal avoidable factors: 11. Action points: Proposed activities Activities done / Remarks Hospital level PHC level 131

133 TBA Family/Community 12. If proposed activities not done, indicate reason(s): 13. Remarks of chair of the Facility MD Review Committee: 14. Signature: 15. Name: 16. Designation: 17. Date: 132

134 YOBE STATE MINISTRY OF HEALTH FACILITY STAFF INTERVIEW RECORD Introduce yourself and thank the respondent/s for helping the Maternal Death Review Committee by agreeing to be interviewed. Offer to answer any questions about the purpose and methods of the MDR before beginning. Use codes to note the person giving response. If there are staff present who would not have written in the notes (e.g. orderlies) but who cared for the woman, give them a code too. The checklist is to be used as a memory prompt; the sample questions given here are illustrative and should be adapted for local use. Name of woman... Checklist Details Verbatim report Can you tell me what happened from the time (name) arrived at (name of facility) until she died? Respondents knowledge Were you with (name) when she died? If no, how long before her death did you see her? Who told you about her death? Was this person with (name) when she died? About how long after her death, did you hear about it? 133

135 Checklist Details Treatment at the facility Who (level of staff) admitted (name)? or who was looking after (name) when her death occurred? What did you make of her condition when you first commenced her care? Did you feel confident in your diagnosis? What was your plan of care, (including referral to medical staff)? Were there any obstacles to/delays in implementing your plan? What were these? Were you able to stay with (name) at this time or not? If not, Why not, and did anyone (incl. relative)? Action taken About how long after you felt something was seriously wrong did you decide to act? What did you do (including referral to medical staff/facility if asking at satellite clinic)? Did you feel confident in carrying out these actions, did you have enough support? Did you have the appropriate equipment/drugs? If not, do you know why not? 134

136 Checklist Details Symptoms before death Close to the time of death, did (name) have any of the following problems: - convulsions/fits - bleeding from the vagina (flooding with blood) - long labour (longer than 12 hours) - high fever - yellow skin or eyes - severe abdominal pain - severe chest pain - extremely short of breath - coughing up blood Relevant factors before arrival at facility Were there any factors before arrival at the facility which affected the woman s condition? - treatment from TBA/traditional healer - mode of transport 135

137 Checklist Details Antenatal care Did (name) ever go for antenatal care during her last pregnancy? Did she go more than once? Were these visits because she had a problem or just to check on the pregnancy? General health Before (name) became pregnant for the last time, was she generally well? Did she have any long-standing medical problems? Avoidable factors Do you think anything could have been done to avoid her death? - availability of equipment (e.g. vacuum aspirator) - availability of drugs & supplies (e.g. blood, drugs) - delays in receiving appropriate care at facility - delays before arrival at facility (eg. no transport) - contributing circumstances and events in the community (eg. untrained TBA attended delivery) - woman s characteristics (eg. previous obstetric history) 136

138 Summary of avoidable factors Importance of factor ( ) Type of factor ( ) Definitely would have avoided death Possibly would have avoided death Staff oversight Staff misguided action Staff incompetence Service inadequacy Events and circumstances in the community Woman factors If more space is required, use another form and attach forms together Name of data collector : Date of completion : 137

139 ANNEX 8: RECORDING & REPORTING FORMS FOR FACILITY- BASED PERI-NATAL DEATH REVIEWS GENERAL INSTRUCTIONS KATSINA STATE MINISTRY OF HEALTH PERINATAL DEATH REVIEW FORM (PNDR 1) This form must be completed for all perinatal deaths (including stillbirths and early neonatal deaths, which are neonatal deaths within first 7 days after birth). The Health Facility Maternal and Perinatal Death Review Committee must complete the form within 1 month and make a follow up on the implementation of the action plan within 3 months. The original form should stay at health facility level and a copy submitted to the LGA MCH coordinator, who will report to the LGA M&E officer and the MCH coordinator of the State Ministry of Health (SMOH). Federal and central teaching hospitals should submit copies of the form to the LGA MCH coordinator of the PHC office and the MCH coordinator of the SMOH. The code must be the same code as that on the notification form, PND 2 and in case mother has died as well the same as on MDR 1 and MDR 2. PND Case Number: / / / (First 4 characters of name of HF / Month / Year / Case no.) 1. DETAILS OF MOTHER 1.2 File No.: (Hospital file of mother) 1.3 Age of mother (years): (if unknown: estimate) 1.4 Physical Address or locality where mother lives: (LGA, Name of village/town/ area) 1.5 Marital status of mother: Married Single Divorced Widowed Separated 1.6 Educational level (completed): None Primary Secondary Higher Other (specify): Ethnic group Haussa Fulani Kanuri Other (specify): Pregnancy condition at time of death: Gravida Para Gestation at delivery (weeks) 138

140 2. ADMISSION AT FACILITY WHERE DEATH OCCURRED 2.1 Date of admission of mother to facility: / / (dd/mm/yy) 2.2 Time: : am/pm 2.3 Date of admission of newborn from home: / / (dd/mm/yy) 2.4 Time: : am/pm 2.5 Admitted from: Another facility TBA Home Other (specify): Name of referring facility (if applicable): 2.6 Foetal Heart Rate on admission: Absent Normal Abnormal (>180 or < 100) 2.7 Condition of mother on admission: Stable Critically ill Dead on arrival (DOA) 2.8 Date of death: / / (dd/mm/yr) 2.9 Time of death: : AM/PM 2.10 Pregnancy stage at moment of death: Before onset of labour Intra partum Postpartum 3. ANTENATAL CARE 3.1 Did she receive antenatal care? Yes No (skip to section 4) 3.2 If Yes, total number of visits: 3.3 Any danger sign(s) identified: Yes No 3.4 If "Yes" specify:. 3.5 Any action taken on identified danger signs? Yes No 3.6 If "Yes", tick all that apply: Referred Anaemia treatment Treatment of hypertension Malaria treatment Treatment of PROM Treatment of syphilis (VDRL +) PMTC of HIV Treatment of infection Tetanus vaccination of mother Other (specify):. 139

141 4. DELIVERY AND PUERPERIUM 4.1 Date of rupture of membranes: / / (dd/mm/yy) 4.2 Aspect of liquor: Clear Meconium-stained Blood-stained 4.3 Date of delivery: / / (dd/mm/yy) 4.4 Time of delivery: : AM/PM 4.5 Was a partograph used during labour? Yes No 4.6 Locality where patient delivered (level of facility): ( one box) Home MCH PHC / CHC General Hospital FMC/Teaching hosp On the way before arrival at facility Other (specify): 4.7 Duration of labour (hours:min): 1. First stage 2. Second stage 3. Third stage hrs min hrs min hrs min Total hrs min 4.8 Mode of Delivery: ( appropriate boxes ) SVD Vacuum Forceps Caesarean section Breech Destructive delivery Other (specify): 4.9 Delivered by: ( one box) Specialist (Obs&Gyn) Medical officer Midwife Nurse S CHEW J CHEW CHO Health Ass. TBA Other (specify): 4.10 Was the baby weighed after delivery? Yes No 4.11 If Yes, Birth weight: grams 4.12 Was the Apgar score determined after delivery? Yes No 4.13 If yes : 1 min Apgar score: 5 min Apgar score: 4.14 Newborn resuscitation done with bag and mask? Yes No 4.15 Outcome for newborn: ( one box): Fresh SB Macerated SB Early Neonatal Death (ENND) If NND: 4.15 Time of death: : am/pm 4.16 Date of death: / / (dd/mm/yy) 140

142 5. CAUSE OF DEATH 5.1 Final Cause of Death ( appropriate boxes): Preterm baby Small for gestational age (SGA) Birth asphyxia Birth trauma Sepsis Other (specify): Neonatal tetanus Dehydration due to diarrhoea Congenital abnormality Hypothermia Intra-uterine death with unknown reason 5.2 Primary Cause of Death ( appropriate boxes): Spontaneous premature birth Intrapartum asphyxia Congenital abnormality Maternal infection Shoulder dystocia Prolonged or obstructed labour Hypertensive disorders / (pre)-eclampsia Antepartum haemorrhage Pre-existing maternal disease Breech delivery Cord problems (prolapse, knot, entanglement) Other (specify); 6. ASSOCIATED FACTORS THAT CONTRIBUTED TO DEATH ( appropriate boxes, to be extracted as far as possible from records) Factors Causes Yes No Remarks (use back of page if necessary) 6.1 Health Lack of necessary midwifery/obstetric/nc skills worker Delay in deciding to refer / consult senior staff factors Partograph not used during labour Prolonged labour with no/ delayed intervention Inadequate monitoring of FHR during labour Inadequate newborn resuscitation Inadequate monitoring of newborn after birth Prolonged abnormal observations without action Inadequate response to maternal disease/complic No response to positive syphilis test during ANC No or inadequate response to PROM Inadequate management of premature labour Wrong or missed diagnosis No or inadequate treatment Delay in starting treatment Other (specify) 141

143 6.2 Admin. Factors 6.3 Patient/ Family Factors 6.4 TBA, Community factors 6.5 Other factors (specify) Communication problem between health facilities Transport problem between health facilities Lack of qualified staff Absence of skilled staff on duty Lack of essential drugs Lack of essential equipment, incl. resuscitation Lack of laboratory facilities Non availability of blood No antenatal care (ANC) Late booking of ANC or infrequent visits Failure to recognise danger signs Delay in decision making or getting permission Preference for care at home or by TBA Unsafe traditional/cultural practice Use of traditional medicine Unsafe medical treatment Refusal of treatment non-compliance to advice Inappropriate response to rupture of membranes Inappropriate response to poor foetal movements Transport problem from home to health facility Financial constraints Failure to recognise danger signs Failure to accept limitations Use of traditional medicine Transport problems Delay in deciding to refer CASE SUMMARY AFTER ASSESSMENT OF PERINATAL DEATH BY REVIEW COMMITTEE (supply a short summary of the events surrounding the death including quality of care at all levels of care and at different times (antenatal care, intra-partum care, newborn care). Use back of page if necessary. 142

144 8. FACILITY MATERNAL & PERINATAL DEATH REVIEW COMMITTEE ACTION PLAN TO IMPROVE FUTURE CARE (use back of form if more space is needed) Level of Care Proposed Activities Proposed Time Frame Responsible Person Hospital Health Centre TBA Family/ Community 9. FORM COMPLETED BY: 9.1 Name: 9.2 Designation: 9.3 Telephone: Date: / / (dd/mm/yy) 9.6 Signature: 10.7 Name Chair Person Review Committee: 10.8 Designation: 10.9 Date: / / (dd/mm/yy) Signature: (Chairperson of Review Committee) 143

145 KATSINA STATE MINISTRY OF HEALTH PERINATAL DEATH FOLLOW UP FORM (PNDR 3) GENERAL INSTRUCTIONS This form must be completed by the Facility Maternal and Perinatal Death Review Committee The code must be the same as the code on the PNDR1 and the PNDR 2 forms. 1. PND Case Number: / / / (First 4 characters of name of HF / Month / Year / Case no.) 2. Admission Number: 3. Date of Notification: / / (dd/mm/yy) 4. date reviewed by Facility review committee: / / 5. LGA: ; 6. State; ; 7. Facility: 8. Primary Cause of Death: 9. Final Cause of Death: Action points Proposed activities Activities done / Remarks Hospital level PHC level 144

146 TBA Family/Community level 12. If proposed activities not done, indicate reason(s): 13. Remarks of chair of the Facility MD Review Committee: 14. Signature: 15. Name: 16. Designation: 17. Date: 145

147 KATSINA STATE MINISTRY OF HEALTH PERINATAL DEATH NOTIFICATION FORM (PNDR 2) GENERAL INSTRUCTIONS This form must be completed for all perinatal deaths (including stillbirths and early neonatal deaths). This form must be completed immediately after death by the last person who attended to the patient. A copy should be submitted to the LGA MCH coordinator, who will report to the LGA M&E officer and the MCH coordinator of the State Ministry of Health (SMOH). Coding must be done at hospital level with code of HF (first 4 letters), LGA and state and MD individual code number for each deceased. DETAILS OF THE DECEASED AND MOTHER 1. PND Case Number: / / / 2. File Number (health facility): 3. Physical Address or locality where mother lived: (LGA, Name of village, Code) 5. Age of mother (years): (estimate if age is unknown) 6. Locality where death occurred: LGA: State: 7. Place where death occurred: ( one box) 1. Tertiary Teaching Hospital 6. TBA 2. Federal Medical Centre 7. Home 3. General Hospital 8. On the way/before arrival at H/F 4. Primary Health Care Centre 5. Stand alone Maternity Unit 9. Other (specify) 8. Ownership of health facility: ( one box) 1. Federal MOH 3. Private 5. Faith-based 2. State MOH 4. LGA 6. Other 9. Name of Health Facility: 10. Primary cause of death: 11. Final cause of death: 12. Modifiable contributing factors: 13. Classification of perinatal death ( one box): Neonatal death Fresh stillbirth macerated stillbirth 14. Birth weight: grams 15. Gestation at birth: weeks 16. Date of / / 17. Date of / / Admission: Death 14. Name: 15. Designation: 16. Date: / / 17. Signature: 146

148 ANNEX 9: PERINATAL MORTALITY CASE STUDIES CASE STUDY 1 Zeinab Mohammed married 1 year ago and is a 17 year old primigravida from Korobo. Her husband Hassan is a rich businessman and she is his 3rd wife. When she was 20 weeks pregnant she noticed some offensive vaginal discharge and went to the antenatal clinic at the nearby hospital. It was her 1 st AN visit. At the booking visit the midwife took her full history and filled in a card, measured her weight and blood pressure, checked her blood for anaemia and palpated her abdomen, listened to the heart sounds of the foetus and told her everything was fine with her and the child. She gave her a tetanus injection, prescribed her iron and folic acid tablets and she had to take 3 anti-malarial tablets at the clinic. When Zeinab mentioned her discharge, the midwife did not examine her but told her that that was normal during pregnancy and that she should not worry. She went one more time to the antenatal clinic when she was 34 weeks pregnant, got the same treatment and went home. When she was 38 weeks she got labour pains and was taken by her mother in-law to the maternity ward in the hospital. On admission she had moderate contractions, the fundul height was term, the child was laying in longitudinal lie and cephalic presentation, the head was 4/5 above the pelvis. The foetal heart was 130/min. On VE she was 4 cm dilated, the membranes were intact. The midwife recorded the findings on the partograph. She was taken to the labour suite. Four hours later her membranes ruptured spontaneously. The liquor was slightly meconium-stained. The head was now 3/5 above the brim of the pelvis. Cervical dilatation was that time 6 cm. FH: 120/min. Four hours later the contractions were strong, 4 in 10 minutes, the foetal head 2/5 above the brim, the cervix was 8 cm dilated. The foetal heart rate was 124/min. Zeinab was becoming tired and the contractions were very painful. Finally after 3 more hours she was fully dilated. The midwife told her to push with each contraction. After pushing for more than 1 hour she delivered a male infant of 3.8 kg. The baby was pale and did not immediately cry after birth and was breathing irregular. The midwife sucked out the nose and mouth and slapped the baby on its back. There was no ambu bag and mask in the labour ward. After some time the baby improved, but was still grunting a bit while breathing. The Apgar score was 3 after 1 minute and 7 after 5 minutes. The midwife wiped the baby dry and wrapped it in a cloth. Then she administered 10 U Oxytocin to the mother and delivered the placenta by controlled cord traction. Blood loss during delivery was 300 ml. The perineum was intact. Later that day the baby had improved and was able to suck the breast, but he was still grunting a bit when breathing. The next day the baby got fever 38.8 o C. The midwife called the doctor and he prescribed antimalarials and ordered tepid sponging and 6 hourly monitoring of the temperature. However, the temperature was only recorded twice a day. The next day there was still fever and the baby was a bit greyish in colour and slightly jaundiced and had a convulsion, which lasted for 2 minutes and responded well to 1 mg diazepam rectally. The doctor ordered a FBC and prescribed ampiclox syrup 8 hourly. The next day the condition of the baby was worse. He was unable to suck, looked lethargic, had a vacant look in his eyes and had slight twitchings. The midwife inserted a nasogastric tube and expressed breastmilk was given 3 hourly. The doctor reviewed the baby during ward round and prescribed phenobarbitone 5mg/kg, given in 12 hourly doses. The evening of the same day the baby suddenly stopped breathing and passed away. 147

149 After a week the case was reviewed at the perinatal death review meeting. 1. What is the most likely primary cause of death? 2. What factors may have contributed to the death and which are modifiable? 3. What missed opportunities for good care or sub-standard care can you identify? 4. What recommendations you have for the action plan to improve quality of care? 148

150 CASE STUDY 2 Aisha Tukur is 21 year old gravida 3, para 2+2. Her last two pregnancies ended in miscarriage. At 16 weeks gestation she started antenatal care at the nearest CHC clinic, which was 1 hour away by minibus. At the booking visit the midwife took her full history and filled in a card, measured her weight and blood pressure, palpated her abdomen, listened to the heart sounds of the foetus and told her everything was fine with her and the child. She gave her a tetanus injection, prescribed her iron and folic acid tablets and she had to take 3 anti-malarial tablets at the clinic. Then she was send to the laboratory for testing of Hb, VDRL and urine for glucose and albumen. The Hb was 11gr% The results of the VDRL would be out at the next antenatal visit. After 4 weeks she went again to the clinic. The JCHEW who received her checked her weight and blood pressure and recoded the findings on her antennal card. He also checked the register for the results of the VDRL test, which was ++ and recoded the findings on the card. Next Aisha was referred to the MSS midwife, who examined her and told her everything was fine. She was counselled on danger signs of pregnancy and birth and emergency preparedness. She got her 2 nd dose of Fansidar and was given ferro/folic acid tablets for 4 weeks. At 34 weeks she had the impression that the foetal movements were less. She went to the antenatal clinic at the CHC and was told by the jchew to come back after 3 days because on that day there was no antenatal clinic, but only childhood immunisations. Disappointed and worried about the condition of the child, she returned home. Three days later her husband was not around so she had no money for transport and had to wait until the next week to go to the antenatal clinic. When she finally went back to the antenatal clinic she could not feel foetal movements since 3 days. The midwife examined her and could not hear the foetal heart. She was referred to the general hospital 3 hours away by bus and was given a referral letter. She cried, went home and told her husband. The next day they went together to the hospital. She was examined by the midwife, who also could not hear the foetal heart, not even with the Sonicaid. She was referred to the doctor, who confirmed the intra uterine death. After admission labour was induced with an IV drip with 2 U oxytocin, of which the drip rate was gradually increased half hourly. After two infusions she delivered a macerated stillbirth, with a weight of 2.2 kg. The placenta looked somehow abnormal and was bulky. Blood loss was 250 ml. Some tests were carried out in the hospital and she received two injections before discharge. The case was reviewed at the next perinatal death review meeting. 1. What is the most likely primary cause of death? 2. What factors may have contributed to the death and which are modifiable? 3. What missed opportunities for good care or sub-standard care can you identify? 4. What recommendations you have for the action plan to improve quality of care? 149

151 CASE STUDY 3 Funmi Okintade was a 17 year old schoolgirl, who accidentally got pregnant from her boyfriend Mussah, who was her classmate in form 1. They had had occasional sex since 3 months but never used contraceptives. When the pregnancy became obvious she was expelled from school. Her father was very angry and told her she had brought shame on the family. To hide the situation Funmi was sent to her grandmother in her mother s native village. She helped her grandmother in the garden and with household chorus, but did not go to antenatal clinic because she felt embarrassed. After she was 32 weeks pregnant her feet gradually became swollen and later even her fingers. Her grandmother took her to the nearby MCH clinic, where she was seen by the midwife at the antenatal clinic. The female CHEW was not very nice to her and condemned her pregnancy as a result of her immoral behaviour. Apart from an elevated blood pressure of 130/90 nothing abnormal was found. No any laboratory tests were carried out since the MCH had neither laboratory nor dipsticks to test her urine. Funmi was advised to rest at home and to come back after a week. However, Funmi decided not to go back to the antenatal clinic because she did not like the judgemental attitude of the CHEW and her moralistic talks. When she was 36 weeks pregnant, suddenly she got abdominal pain, which persisted. Later the same day she started bleeding and felt weak. Her grandmother called the local TBA, who examined her and told her something was wrong with the pregnancy and that she had to go to the hospital. Her grandmother took her in a minibus to the hospital in town, which was 1 hour away. On admission she was examined by the midwife in the maternity. Her pulse rate was 100/min, BP: 160/110, Temp: 37 o C. She looked slightly pale and had edema of hands and feet while her face also looked slightly puffy. The fundus was at term, the uterus felt hard and the foetus was difficult to palpate, but was in cephalic presentation. The FH was 120/min. There was slight vaginal bleeding. The cervix was soft and closed. She was admitted and reviewed by the doctor, who prescribed an injection of 5 gr magnesium sulphate in each buttock and an iv injection of 5mg hydralazine, which treatment was repeated after 4 hours. Later that day the BP had gone down to 130/90. Her condition remained stable. On her patient notes no information was recorded on the foetal heart rate since admission. The afternoon of the next day she went into labour and at 11pm she delivered a fresh female stillbirth with a weight of 2.5 kg. The placenta was delivered by controlled cord traction 15 minutes after delivery of the fetus, together with a large blood clot. Total blood loss was estimated at 500 ml. Magnesium sulphate was continued until 24 hours after delivery. The edema gradually subsided and the BP returned to normal. Three days after delivery she was discharged in good condition. The case was reviewed at the next perinatal death review meeting. 1. What is the most likely primary cause of death? 2. What factors may have contributed to the death and which are potentially modifiable? 3. What missed opportunities for good care or sub-standard care can you identify? 4. What recommendations you have for the action plan to improve quality of care? 150

152 CASE STUDY 4 Nura Abubakar, who is married to Ishmael Mohammed, is 21 years and gravida 2, para 1. At 20 weeks gestation she started antenatal clinic at the nearby MCH clinic. No any abnormalities were found. At 28 and 32 weeks she attended again. At gestation 33 weeks her membranes ruptured and she started draining liquor, but there were no contractions. She realised that the foetus was still quite small to be born. When her husband came home from work at 4pm she informed him and the next day he arranged transport and took her to the general hospital. At the hospital she was admitted in the maternity with a diagnosis of threatening premature labour and put on complete bed rest, with 4 hourly monitoring of vital signs, contractions and foetal heart rate. The draining of liquor diminished, but after 4 days she got slight contractions. She was prescribed a salbutamol intravenous infusion of 10 mg / 1 litre normal saline, but despite this she went into labour the next day. During admission her vital signs and the FHR were only recorded 12 hourly. On the day she went into labour a temperature of 38 o C was recorded in the morning. At 3pm Nura gave birth to a premature male infant of 1.8 gr with an Apgar score of 6 after 1 minute and 9 after 5 minutes. The cord was clamped after 3 minutes, the baby was wiped dry and wrapped in a cloth, received 1 mg Vitamin K1 im and was put on the mother s chest. After Nura received 10 U oxytocin, the placenta was delivered by controlled cord traction. The baby was treated with Kangaroo Mother Care and initially did well apart from occasional apnoe attacks, which responded well to tactile stimulation. However, the 2 nd day the baby developed more severe breathing difficulties, had an increased respiration rate of 60/min and had chest-indrawing and looked slightly cyanotic. The newborn was unable to suck and was put on 3 hourly nasogastric tube feedings of expressed breast milk and received ampicillin 100 mg bd and gentamycin 5 mg od. Unfortunately the maternity had run out of oxygen cylinders so oxygen could not be given. At night the baby stopped breathing. The case was reviewed at the next perinatal death review meeting. 1. What is the most likely primary cause of death? 2. What factors may have contributed to the death and which are potentially modifiable? 3. What missed opportunities for good care or sub-standard care can you identify? 4. What recommendations you have for the action plan to improve quality of care? 151

153 ANNEX 10: CASE DEFINITIONS FOR CRITERION-BASED AUDIT OF MANAGEMENT OF OBSTETRIC COMPLICATIONS Complication Essential features Additional features Abortion-related haemorrhage Gestation < 28 weeks. At least one of the following: Vaginal blood loss > 500 ml Any blood loss with clinical signs of shock (syst BP < 90; Pulse > 100). Ruptured ectopic pregnancy Primary Post Partum Haemorrhage (PPH) Pregnancy outside uterine cavity with blood in abdominal cavity, diagnosed by abdominal centesis, ultrasound or laparotomy Genital tract bleeding within 24 hours of delivery Secondary Post Partum Haemorrhage Genital tract bleeding > 24 hours of delivery, but within 42 days. Gestation of foetus =/> 28 weeks. Antepartum Haemorrhage Gestation =/> 28 weeks. Clinically observed vaginal bleeding. Eclampsia Generalised fits in an obstetric patient without previous history of epilepsy. Obstructed labour Prolonged labour > 12 hours with adequate contractions. Caput and/or moulding. Uterine rupture Puerperal sepsis Rupture of uterus before or during labour with confirmation at laparotomy. Temperature =/> 37.5 o C within 42 days of delivery Septic abortion Gestation < 28 weeks. Temperature =/> 37.5 o C. History of vaginal bleeding or clinically observed bleeding. Chorioamnionitis Evidence of prolonged ruptured membranes (> 24 hrs) by draining of liquor. Maternal tachycardia (P > 100) The following may be present: Missed monthly period(s) and lower abdominal pain. Clinical signs of shock At least one of the following: Significant vaginal blood loss. Clinical signs of shock. At least one of the following: Vaginal blood loss > 500 ml Soft non-involuted uterus May have abdominal pain Uterus feels woody hard in abruption placenta Presenting part not engaged or abnormal in placenta praevia Amount of bleeding irrelevant Confirmation: placenta praevia with scan or at operation abruption retroplacental clot Elevated BP Proteinuria At least one of the following: Uterine tetany Offensive vaginal discharge Bandl s ring Uterine rupture Temperature =/> 37.5 o C Haematuria Clinical signs of shock Bleeding per vagina Easily palpable foetal parts Clinical signs of shock At least one of the following: Odorous vaginal discharge Tender non-involuted uterus Clinical signs of shock At least one of the following: Abdominal pain/tenderness Injury to genital tract Odorous vaginal discharge Tender fornices Open cervix with products of conception At least one of the following: Temperature > 37.5 o C Odorous vaginal discharge Tender uterus Adapted from Graham et al (2000), Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries. Bulletin of the WHO; 78 (5):

154 ANNEX 11: CRITERIA FOR AUDIT OF MANAGEMENT OF OBSTETRIC COMPLICATIONS (SOURCE: IMMPACT) I Common criteria for optimal management of any obstetric complication 1 Patient s history should be documented in case notes on admission (age, parity, complications in current and previous pregnancies) 2 General clinical state on admission should be recorded (pulse, blood pressure) II Common criteria for optimal management of obstetric haemorrhage 1 Experienced medical staff should be involved in the management of obstetric haemorrhage within 10 min of the diagnosis Ghana: experienced = medical officer with 2 years training or a practising midwife with 5 years experience Jamaica: experienced = senior registrar or consultant obstetrician 2 Intravenous access should be achieved 3 Patient s haematocrit or haemoglobin should be established 4 Typing and cross-matching of blood should be performed 5 Coagulation tests should be performed if indicated (clotting time, bleeding time, platelet count) 6 Crystalloids and/or colloids should be infused until cross-matched blood is available 7 In the face of continuing haemorrhage, after infusing up to 3 L fluids, blood must be given (cross-matched if possible) 8 Clinical monitoring to detect early deterioration should be done at least every 15 min for 2 h (pulse, blood pressure) 9 Urine output should be measured hourly 10 Oxytocics should be used in the treatment of postpartum haemorrhage 11 Genital tract exploration should be performed in cases of continuing postpartum haemorrhage 12 Women with antepartum haemorrhage should not have a vaginal examination unless placenta praevia has been excluded by ultrasonography or vaginal examination is conducted where emergency operative delivery is possible 153

155 III Criteria for optimal management of eclampsia 1 Senior medical staff should take responsibility for formulating a management plan for the patient Ghana: senior = medical officer Jamaica: senior = senior registrar or consultant 2 Anti-hypertensive treatment should be given to patients with severe hypertension 3 The treatment and prophylaxis of seizures should be by magnesium sulfate 4 Respiratory rate and tendon reflexes should be monitored when magnesium sulfate is used 5 Ante/intrapartum fluid balance chart should be maintained 6 Haematological and renal investigations should be done at least once (bleeding time, clotting time, platelet count, urine albumin test) 7 Ghana: delivery should be achieved within 24 h of the first convulsion Jamaica: delivery should be achieved within 12 h of the first convulsion 8 Monitoring of blood pressure and urine output should continue for at least 48 h after delivery IV Criteria for optimal management of obstructed labour 1 Ghana: prompt delivery of the fetus should occur within 3 h of diagnosis Jamaica: prompt delivery of the fetus should occur within 2 h of diagnosis 2 Urinary bladder should be drained 3 An observation chart should be maintained (urine output, pulse, blood pressure, temperature) 4 Intravenous access and hydration should be achieved 5 Broad spectrum antibiotics should be given in obstructed labour 6 Typing and cross-matching of blood should be carried out V Criteria for optimal management of uterine rupture 1 In suspected or diagnosed uterine rupture, emergency surgery should be performed Ghana: within 2 h Jamaica: within 1 h 2 Urinary bladder should be drained 3 An observation chart should be maintained (urine output, pulse, blood pressure, temperature) 154

156 VI Criteria for optimal management of genital tract sepsis associated with pregnancy 1 Delivery should be expedited in chorioamnionitis irrespective of the gestation 2 Blood should be taken for culture 3 Treatment of genital tract sepsis should be with broad-spectrum antibiotics 4 Metronidazole should be included in the antibiotic regimen 5 An observation chart should be maintained (urine output, pulse, blood pressure, temperature) 6 Exploration and evacuation of uterus should be performed if retained products are suspected 155

157 ANNEX 12: CRITERION-BASED AUDIT DATA EXTRACTION SHEET Identify a topic for criteria based audit Develop criteria to measure practice, considering Structure, Process and Outcomes List the criteria in the first column Identify 10 cases which comply to the case definition Review 10 cases, one at a time, and check whether criteria are met Write Y (for yes) in the column if criterion is met an N (for no) if it is not met Topic: Total Cases no Y Criteria for criteria-based audit /10 156

158 ANNEX 13: CRITERION-BASED AUDIT DATA EXTRACTION SHEET EXAMPLE OF PPH Identify a topic for criteria based audit Develop criteria to measure practice, considering Structure, Process and Outcomes List the criteria in the first column Identify 10 cases which comply to the case definition Review 10 cases, one at a time, and check whether criteria are met Write Y (for yes) in the column if criterion is met an N (for no) if it is not met Topic: PPH Total Cases no Y Criteria for criteria-based audit /10 Two intravenous lines put up with normal saline or ringers lactate Uterus massage done to make uterus contract and clots expelled Indwelling urine catheter inserted and bladder emptied 10 Units oxytocin given im stat or 20 Units oxytocin given in 1 litre IVI at 60 drops/min Placenta inspected (completeness) Vital signs monitored and recorded ¼ hourly Estimated blood loss recorded Oxytocin available in maternity ward Standard treatment protocol for PPH available in labour ward 157

159 ANNEX 14: CRITERION-BASED AUDIT DATA EXTRACTION SHEET USE OF PARTOGRAPH Identify a topic for criteria based audit Develop criteria to measure practice, considering Structure, Process and Outcomes List the criteria in the first column Identify 10 cases which comply to the case definition Review 10 cases, one at a time, and check whether criteria are met Write Y (for yes) in the column if criterion is met an N (for no) if it is not met Topic: Management of woman in labour, using the partograph Cases Total no Y Criteria for criteria-based audit Past and present obstetric history taken and recorded on partograph /10 Foetal heart rate recorded at least hourly Contractions assessed and recorded at least hourly Maternal blood pressure measured and recorded 4 hourly Cervical dilatation assessed through VE and recorded 4 hourly Commencement and duration of 2 nd stage of labour recorded Oxytocin 10 Units given im immediately after birth of baby Placenta inspected for completeness and findings recorded Vital signs (BP, pulse), bleeding and fundal height assessed and recorded after delivery ½ hourly for 2 hours 158

160 ANNEX 15: TEMPLATE FOR PRRINN-MNCH REPORTS Report to [organization/s] Title of the Report (Usually similar to the title of the ToRs) Number of the assignment (from the ToRs) Consultants Name(s) Month / Year Mallam Bakatsine Street Nassarawa GRA, Kano Kano State Nigeria 159