StepWise Approach To Quality In Health Service Delivery-SafeCare IHI Africa Forum February 2018
Quality of care in resource-restricted settings Gaps and challenges Licensing not enforced due to limited capacity of the government Facilities do not meet standard compliance due to lack of basic infrastructure, equipment and shortage in HR and supplies ISQua-based accreditation systems such as implemented by COHSASA and JCI are difficult to achieve As a result, few facilities are accredited Quality of care is unknown and benchmarking not possible Often standards are lowered instead of improving healthcare quality How to help improve this A quality system for resource-restricted settings should: Focus on progression Be a specified, recognizable product, independently awarded Be solutions-based with achievable goals Have data widely available Be sustainable Standards accredited by ISQua February 2017 1
Activity highlights: quality standards SafeCare standards ensure objective measurement (transparency) and rating (benchmarking) of the level of quality of basic healthcare facilities in Africa. For the benefit of patients, governments, insurers, banks etc. They form the basis of tailor made quality improvement plans. 2011 -Developed with JCI (USA) and COHSASA (South Africa) to suit the vast majority of clinics in Africa well below accreditation level Stepwise quality improvement plans that address clinical and organizational management systems to optimize outcomes and position facilities as viable businesses Local government commitment: used as a basis for government regulation and enforcement in Kenya, Nigeria, and Tanzania 2
Clinical Support Management SafeCare : International standards, local solutions Governance & Management Primary Healthcare (Outpatient) Services Human Resource Management In-patient Care Patient and Family Rights & Access to Care Surgery & Anesthesia Services Clinical Management of Information Risk Management Laboratory Services Diagnostic Imaging Services Facility Management Services Support Services Ancillary Medication Management
The SafeCare cycle of quality improvement 4
Impact: Safe healthcare processes and visible quality improvement for patients and staff Pharmacy Before After Waste management Before After 5
Scope of SafeCare, February 2018 1000 800 Number of active facilities per country Ghana Nigeria Kenya Tanzania 600 400 200 0 Ghana Kenya Nigeria Tanzania Uganda >1900 active clinics 4420 Assessments 835 Training 3.3 mln patient visits per month
percentage of facilities Percentage of facilities versus score improvement Results: Improved SafeCare scores : 35% 30% 25% 20% 15% 10% 5% 17% 83% 28% 24% 22% 12% 7% 4% 1% 1% 0% 0% -30-20 -10 0 10 20 30 40 50 60 score improvement SafeCare February 2018 7
CASE STUDY: Jacaranda Health s Journey to SafeCare Level 5 GAPS IN QUALITY CARE Hospital systems and processes Nurse/midwife capacity and knowledge SOLUTIONS Respectful care of patients Replicable quality improvement tools and systems Professional development to to empower nurses/midwives Patient-centered design to improve respectful care 8
TEAM #WE Team #WE Steer away from top down approaches ad cultivate growing a multidisciplinary team Open Door Policy Increase lines of two way communication-meetings, emails etc Increase avenues to report risk/incident reporting RESPOND!!! to build TRUST! Staff Satisfaction-Who Cares?
Human resources: Enhancing Capabilities and Performance Interview and Onboarding: Cultural Fit-Shadow Day Orientation: curricula, theory and didactic sessions, observation/demonstration to validate and sign off competency Leadership and empowerment: We train our team to lead and manage at all levels manager, nurse in-charge, champions, leads in each department-drive accountability Recognition and Incentives: incentives for retention, career ladder to promote professional development, recognition programs( employee of the month, email bday), team building Continuing education: staff clinical educator, case reviews, grand rounds, annual competencies Auditing medical records, assess knowledge gaps and design interventions to improve in these areas. Performance Management: Annual performance reviews-meet org and personal goals and expectations Task Shifting and Task Sharing Task shifting and task sharing can help ensure that clinical expertise falls in the right hands and our human resources are allocated optimally. Promote Nurses/Midwives to work within their license Patient care assistants (nurse aides) provide all nonclinical care, while community health workers (CHWs) facilitate home visits and education.
Systems and Processes Organogram: > Accountability, Transparency, Eliminate role confusion: Job description: role definition reporting structure, accountability, performance measurement How do we do what we do and how do we monitor adherence: Documentation audits Case reviews Root Cause Analysis Review and Update of protocols as needed or every 2 years
Quality Improvement: Using Data to Drive Practice WEEK 1 Monday Tuesday Wednesday Thursday Friday Case review (7:45am) Nurse Lead Meetings (8:00am) Front Office Meeting (4:00pm) M and M (Review of patient outcomes and RCA) 8-9a (As need be) Quality and Practice (8:00am) Auxiliary Staff (4:00pm) ALL STAFF MEETING (Quarterly) (8:00am) Clinical Meeting (Monthly) (8:00am) WEEK 2 Case review (7:45am) Theater team Meeting (8-9am) Monthly HR Connect (Bi-Monthly) (8:30am) WEEK 3 Case review (7:45am) Programs Meeting (3-4pm) Nurse Lead Meetings (8:00am) Front Office Meeting (4:00pm) Doctor s meeting (8 am) (Monthly) (Breakfast Meeting) Clinical Operations Meeting (8:00a) Auxiliary Staff (4:00pm) WEEK 4 Case review (7:45am) HR Connect (Bi-Monthly) (8:30am) Programs Meeting (3-4pm) Management Bi-Weekly HTC & Pharm and Therapeutics Time: (8-9a) Quarterly Breakfast with Faith (8:00am)
Voice Of The Customer One of the top reasons women do not deliver in facilities is that they are not treated with respect and kindness. Design services with the help of your customer to create truly patientcentered environment Interviews and focus groups in communities across Nairobi Human Centered Design approach; Iterate
Results Interventions SafeCare score Impact: Jacaranda Maternity Hospitals Birthing Center RMNCAH 63/100 90/100 Facility with Dec 2013 Jul 2014 Operating Level 2 Level 3 Theater Level 5 Aug 2012 Licensure Infrastructure Documentation Basic SOP Case Reviews Progressive Improvement Referral System Documentation audits Data collection Grand Rounds Performance Review Advanced SOPs Sep 2014 Feb 2015 Plug and Play 94/100 Jan 2017 Budget for QI and SafeCare Hires: QI Lead, Clinical Educator, Clinical QI Lead Updated Protocols/documentation Dashboard ( Facility and practice audit) Committees and Structured Agenda QI Team with Frontline Champions Departmental Quality Checklists Annual Competencies 100 2000 Patient visits per month 30 150 Deliveries per month 99% Maternal Survival 98% Client Referral 1
15
16
Independent Validation: International Standards World Class Care Can be delivered at The Community Level Thank You!