Change agent or troublemaker – engaging stakeholders and making change. Implementing Change in...
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Change agent or troublemaker – engaging stakeholders and making change. Implementing Change in northern India. Umass-Boston Oct 21, 2014 Robyn Churchill,
Change agent or troublemaker engaging stakeholders and making
change. Implementing Change in northern India. Umass-Boston Oct 21,
2014 Robyn Churchill, CNM, MSN
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Goals of this presentation: 1.Understand barriers to change
2.Learn one framework for building lasting change 3.Draw lessons
learned from India and apply to case study Plan for today: Using 5
element framework for implementing systems change: 1.Review
experience of BetterBirth project in northern India 2.Use lessons
learned to address implementation plan for case study
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What is needed for change? Supportive Environment Knowledge
Skills Resources Motivation
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Barriers-Resistance Initial Response to Resistance
Framework for Implementing Change Engage Stakeholders Make
local modifications Identify team and champions Collect and USE
data to learn and iterate Build capacity/plan for
sustainability
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Approach to Implementing Change Make local modifications
Understand processes (map them) Adapt to local policy and standards
Consider resources and barriers
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Approach to Implementing Change Identify team and champions Who
needs to be involved Identify early adopters Consider role for
resistors Recognize and develop champions Build coaches/on going
mentors
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Approach to Implementing Change Collect and USE data to learn
and iterate Identify metrics of importance inputs process outputs
outcomes Create meaningful and individual reports regular
customized real-time Develop system for regular review with front
line staff show what you know (successes, areas for improvement)
learn from front line experience
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Approach to Implementing Change Build capacity/plan for
sustainability Identify existing structure to plug into Identify
owners of process Locate systems for funding, supervision,
monitoring Create policy-facility, regional, national
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BetterBirth Safe Childbirth Checklist Implementation Uttar
Pradesh India
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WHO Safe Childbirth Checklist Developed Safe Childbirth
Checklist-a 4 stage, 29 item checklist Initial usability testing in
19 sites across 10 countries Essential practices--hand hygiene,
oxytocin use, sterile blade use, and early initiation of breast
feedingimproved after implementing the checklist. Maternal 350,000
Neonatal 3.1m Fetal 1.2m
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Moments of Greatest Risk Conception Antenatal period Admission
to birth facility Delivery Discharge from birth facility 28 days 42
days Maternal & neonatal mortality risk Time
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Moments of Greatest Risk Conception Antenatal period Admission
to birth facility Delivery Discharge from birth facility 28 days 42
days Maternal & neonatal mortality risk Time 24.6% 27.7% 35.6%
12.1% Timing of Maternal Mortality ?
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Moments of Greatest Risk Conception Antenatal period Admission
to birth facility Delivery Discharge from birth facility 28 days 42
days Maternal & neonatal mortality risk Time Check point #1 On
admission Check point #2 Just before pushing (or before Cesarean)
Check point #3 Soon after birth (within 1 hour) Check point #4
Before Discharge
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Safe Childbirth Checklist Program
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Objective: Measure health worker performance Adherence to 29
essential processes linked with improved maternal, fetal, and
neonatal health outcomes Intervention: Introduction of checklist
supported by coaching Methods: Prospective, pre-post-intervention
study over 6 months in single sub-district level hospital in south
India using observations by independent data collectors Gokak Pilot
Study
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Safe Childbirth Checklist Single center pilot, Karnataka, India
Indicator (selection)BaselinePost-Intervention Hand washing and
gloving 1.3%97.8% Breastfeeding initiation within one hour of birth
50.4%90.6% Routine administration of Oxytocin within 1 minute after
birth 8.4%68.9% PLoS One 2012;7(4):e35151
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Stakeholders Government of Uttar Pradesh Government of India
World Health Organization Gates Foundation Ariadne Labs (BWH/HSPH)
Population Services International Community Empowerment Lab,
Lucknow JNMC Medical College, Belgaum
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Stakeholders District Leaders Facility Leaders Medical Officers
Nurses ANMs (Auxiliary Nurse Midwives)
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Stakeholders District Leaders Facility Leaders Medical Officers
Nurses ANMs (Auxiliary Nurse Midwives) Ward Ayas Sweepers ASHAs
Women Mothers in law
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Stakeholders
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Local Modifications What factors would you consider in making
local modifications? Whose input counts?
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Team and Champions Team LeaderCoach Building relationships is
key to getting buy-in and making changes Leader to Leader Coach to
Health Care Worker Many staff contribute to checklist adoption
Ayas, ASHAs Sweepers
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Study Measures Outcome measures (7 days postpartum) Call center
Home visits Practice behaviors Observers Monitoring and Evaluation
Implementation team Implementation processes Facility adoption
Process observation Facility champion-Childbirth Quality Leader
Data
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Sustainability What is needed to build sustainability?
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Coaching + Checklist Champion ENGAGE LAUNCH SUPPORT District
Facility 2 day orientation Approach: E-L-S
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Measurement Study Measures Outcome measures (7 days postpartum)
Call center Home visits Practice behaviors Observers Monitoring and
Evaluation Implementation team Facility champion-Childbirth Quality
Leader
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Digital Data Collection (Apps)
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M and E Data* Improvement in implementation The Goal: for
learning and improvement Program management Implementation of
intervention and of research activities *M and E data include
inputs, activities, outputs and selected short term outcomes from
routine program data
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Our intervention teams two key tasks Discovering why she hadnt
followed a given practice (e.g., skin-to-skin). Had the knowledge.
Effect seems invisible. No thermometer. Requires skill in
persuading mothers. Using consistent methods to persuade her and
others to change. Required multiple visits. But after a
relationship with the coach was created, she changed.
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Sustainability Make it work there: Local adaptation and
modification GoI Checklist Identify local owners Identify birth
team (official and unofficial)
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Sustainability Dont reinvent the wheel: Integration into
existing systems Build on Quality Improvement systems Build and
support local ownership
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Coordinating with GoI QA: Childbirth Quality Improvement
Structure NRHM GoI NRHM GoUP (State QA Comm) CMO/DHO (forms
District QA Comm) Nodal officer/nurse mentor MOIC (forms internal
QA Comm) LMO, Childbirth Quality Nurse = Sr. Nurse Nurse/ANM/Other
staff BetterBirth Team (PSI/HSPH) supplies quality/progress data BB
(COP/DCOP/HSPH) supplies data/support for problem- solving in study
sites Q3mo. BB (DCOP/TLs/DQA/HSPH M&E) supplies data/support
for problem-solving Q1mo. BB (TLs/Nurse Coaches) supplies
data/support for problem solving Q weekly
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The MOH of Odyssia has invited you in to direct implementation
of an immunization program in an urban slum Population unknown but
estimated at ~1m souls. Overall vaccination coverage is estimated
at ~50%. Literacy rates: ~80% men and ~60% women. Local health
facility has 50 beds in 4 rooms5 nurses, 1 radiologist, 1
anesthetist, 1 traditional healer/doctor Questions: 1.What other
information would be useful? 2. Who do you talk with first?
3.Identify the first 3 steps you would take
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What do you do?
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a process of delegation whereby tasks are moved, where
appropriate, to less specialized health workers Task Shifting Or
Task Sharing
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Framework for Implementing Change Engage Stakeholders Make
local modifications Identify team and champions Collect and USE
data to learn and iterate Build capacity/plan for
sustainability
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Stakeholders
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Local Modifications What factors would you consider in making
local modifications? Whose input counts?
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Team and Champions How do you select your team (trainers, first
trainees, supervisors?)
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Data How do you use it? Why is it important? What data do you
collect?
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Sustainability What is needed to build sustainability?
