Change agent or troublemaker – engaging stakeholders and making change.

Implementing Change in northern India.Umass-BostonOct 21, 2014

Robyn Churchill, CNM, MSN

Goals of this presentation:

1. Understand barriers to change2. Learn one framework for building lasting

change3. 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

What is needed for change?

Supportive Environment

Knowledge

Skills

Resources

Motivation

Barriers-Resistance

Initial Response to Resistance

Barriers

Expect Resistance

Barriers

Understand Resistance by Listening

Barriers-Resistance

Outsmart Resistance

Increase Drivers

Decrease 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

Approach to Implementing Change

Make local modifications

Understand processes (map them)Adapt to local policy and standardsConsider resources and barriers

Approach to Implementing Change

Identify team and champions

Who needs to be involvedIdentify early adoptersConsider role for resistorsRecognize and develop championsBuild coaches/on going mentors

Approach to Implementing ChangeCollect and USE data to learn and

iterate

Identify metrics of importanceinputsprocessoutputsoutcomes

Create meaningful and individual reportsregularcustomizedreal-time

Develop system for regular review with front line staffshow what you know (successes, areas for improvement)learn from front line experience

Approach to Implementing Change

Build capacity/plan for sustainability

Identify existing structure to plug intoIdentify owners of processLocate systems for funding, supervision, monitoringCreate policy-facility, regional, national

BetterBirth Safe Childbirth Checklist Implementation

Uttar Pradesh India

Moments of Greatest Risk

Conception

Antenatal period

Admission to birth facility

Delivery

Discharge from birth facility

28 days

42 days

Mat

erna

l & n

eona

tal m

orta

lity

risk

Time

Moments of Greatest Risk

Conception

Antenatal period

Admission to birth facility

Delivery

Discharge from birth facility

28 days

42 days

Mat

erna

l & n

eona

tal m

orta

lity

risk

Time

Check point #1 On admission

Check point #2Just before pushing(or before Cesarean)

Check point #3 Soon after birth (within 1 hour)

Check point #4 Before Discharge

Safe Childbirth Checklist Program

Safe Childbirth Checklist Program

Objective: Measure health worker performanceAdherence 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

After

Before

0 5 10 15 20 25 30

9.8 (9.4, 10.1)

Essential childbirth practices delivered (n=29)

25 (24.6, 25.3)

Gokak Pilot Study

Safe Childbirth ChecklistSingle center pilot, Karnataka, India

Indicator (selection) Baseline Post-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

Stakeholders

Government of Uttar PradeshGovernment of India

World Health OrganizationGates Foundation

Ariadne Labs (BWH/HSPH)Population Services International

Community Empowerment Lab, LucknowJNMC Medical College, Belgaum

Stakeholders

District LeadersFacility LeadersMedical Officers

NursesANMs (Auxiliary Nurse Midwives)

Stakeholders

District LeadersFacility LeadersMedical Officers

NursesANMs (Auxiliary Nurse Midwives)

Ward AyasSweepers

ASHAsWomen

Mothers in law

Stakeholders

Local Modifications

What factors would you consider in making local modifications? Whose input counts?

Team and Champions

Team Leader Coach

• 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

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

Sustainability

What is needed to build sustainability?

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

Digital Data Collection (Apps)

M and EData*

Improvement in implementation

The Goal: for learning and improvementProgram 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

Our intervention team’s two key tasks

• Discovering why she hadn’t 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.

Sustainability

Make it work there: Local adaptation and modification• GoI Checklist• Identify local owners• Identify birth team (official and unofficial)

Sustainability

Don’t reinvent the wheel: Integration into existing systems

• Build on Quality Improvement systems

• Build and support local ownership

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

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

rooms—5 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

What do you do?

a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers

Task ShiftingOr

Task Sharing

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

Stakeholders

Local Modifications

What factors would you consider in making local modifications? Whose input counts?

Team and Champions

How do you select your team (trainers, first trainees, supervisors?)

Data

How do you use it?

Why is it important?

What data do you collect?

Sustainability

What is needed to build sustainability?