Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador

7/28/2019 Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador

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Monitoring data to drive country-

level improvement: lessons

learned in Ecuador and ways

forward

Dr. J orge Hermida

Regional Director, LAC programs

The USAID ASSIST Project, University Research Co., LLC

Global Newborn Health Conference

JOHANNESBURG, SOUTH AFRICA. April 2013


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The place of quality of care indicators in the QI process

We use indicators toidentify deficiencies and

set our aims

We develop indicators toassess if process changes

result in improvements

Indicators help us monitorimprovements over time

and assess sustainability3

How do we improve processes of care?

The Model for Improvement

What are we

trying toaccomplish?

What changescan we make

that will result

in an

improvement?

How will we

know that a

change is an

improvement?

PLAN

DO

STUDY

ACT

1.

2.

3.

PDSA Cycle


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A system to manage EONC quality based on indicators

Provincial MOHMNCH person

County Hospital

Ambulatory care facilities

QI

team

QI

team

QI

team

QIteam

Analyze indicators by provinceSupervision to provincial offices

Analyze EONC indicators byfacilitySupervision following indicatorsAggregate indicators and report to

central MOH

Clinical records audit Analyze EONC indicators Implement PDSAs to improveprocesses

Report indicators to provincialMOH office

National MOHMNCH team

Provincial referralHospital

QI

team


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Quality standards

Indicator

Runchart

Data from sample ofclinical records

Enter data on data base

Analysis and action

Aggregation of datafrom facilities atprovinciallevel

Runchart

Analysis and action

Aggregation of datafrom facilities atnational level

Runchart

Analysis and action

A user-friendly information system for continuous quality

improvement at facility, provincial and central levels, Ecuador

Facility Provincial Central


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NORMS, QUALITY STANDARDS AND DATA SOURCES FOR QUALITY MEASUREMENT


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Indicator1 % Antenatal care in compliance with standard.

2 % deliveries with partograph correctly used

3 % deliveries with an abnormal partograph where adecision was made

4

% deliveries with AMTSL

5 % postpartum care in compliance with standard..

6 % of immediate newborn care in compliance withstandard.

7A % deliveries attended by a doctor or midwife.

7B % of newborns attended by a doctor or midwife

8A % of cases ofpreeclampsia, eclampsia care in

compliance with standard.8B % of cases ofHemorrhage care in compliance with

standard..

8C % de cases of sepsis care in compliance withstandard.

8D % preterm deliveries treated with corticosteroids forfetal lung maturation

8F % premature rupture of membranes care in

compliance with standard.

1

2 y 3

4

5

6

7a 7b

8a y 8b

8d

8f

The perinatal clinical record is the main source of data for quality indicators


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Measuring compliance with standards: auditing records

QI team members meet oncea month and audit records,

following a standard

procedure

QI team: doctors, nurses,auxiliary nurses

QI team enters numeratorsand denominators in an Excel

spreadsheet that produces

runcharts


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Data base for entering numerators and denominators at facili ty, provincial or central levels


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Using indicators to identify deficiencies and to

trigger improvement interventions at the facility

QI teams identify deficientprocesses based on

indicators

Building on their ownexperience, literature and

lessons learned, QI teams

decide to test

interventions.

QI teams assess the impactof the intervention using

indicators

Continuous Quality Improvement teams at work:

WHAT ARE WE TRYING TO ACCOMPLISH ?

HOW WILL WE KNOW A CHANGE MADE AN IMPROVEMENT ?

WHAT SPECIFIC, CONCRETE CHANGES CAN WE MAKE TO THEPROCESS ?

Plan

IMPLEMENT

AND TEST THE

INTERVENTIONDo

Study

Act


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E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D

2008 2009 2010 2011

% 0.0 0.0 0.0 5.0 25. 10. 15. 22. 26. 42. 41. 53. 58. 33. 28. 81. 72. 54. 60. 57. 71. 69. 65. 72. 64. 64. 65. 61. 66. 68. 76. 70. 75. 73. 85. 73. 66. 77. 71. 81. 73. 64. 77. 77. 71. 73. 60. 85.

Num 0 0 0 1 4 14 17 29 33 31 33 22 93 57 67 203 68 68 90 86 105115 88 95 112107115115105 99 125122 88 87 78 84 130108115120119 94 103103 87 79 40 30

Den 18 12 16 20 16 129107129123 73 79 41 159168239 70 94 125150150146165134132175165176187157144163174116146134114195140160148163146133133121107 66 35

0

10

20

30

40

50

60

70

80

90

100

PERCENTAGE

Percentage of Premature Rupture of Membranes (PROM), managed inaccordance to standards, 97 hospitals and health centers. Ecuador, 2008-2011


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Monitoring and reporting indicators from facilities to

provincial MOH offices

Monitoring quality indicators for facilities in a region

through runcharts

QAP, 2004

Reporting made mandatoryby Ministerial decree

One person of QI team in

charge of sending themonthly report

Report sent mostly by emailusing Excel spreadsheet

Supervisory visits tofacilities late in reports

Indicators used in maternaland newborn mortality

audit process


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Aggregated data and analysis at provincial level

J l-03

AgSp Ot NvDc EnFb MrABMyJ n J l AgSpOc NvDc EnFb MrAbMy J n J l AgSp Oc NvDc EnFb MrAbMyJ n J l AgSpOc NvDc

2003 2004 2005 2006

% 25 70 64 54 64 75 70 65 70 68 72 74 78 81 84 89 87 84 74 84 82 83 82 84 86 87 90 86 87 86 84 82 84 88 85 85 88 87 89 93

0

10

20

30

40

50

60

70

80

90

100

PERCENTAG

E

Percentage of deliveries in which the newborn was provided with essential

standardized care (11 standard activities)Fourteen hospitals in 2003, scaled up to 89 hospitals in 2006

1. Weight2. Height

3. Cephalic perimeter4. Apgar score5. Registration of need for HBB/action6. Physical exam7. Vitamin K 1 mg8. Ocular disinfection drops9. Skin-to-skin contact

10. Immediate and exclusivebreastfeeding

11. Baby and mother together in ward


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Using regional indicators at central MOH to monitor

national progress

Antonio Recalde,MOH staff in charge ofnational database

E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D E F M A M J J A S O N D

2008 2009 2010 2011

% 0.0 0.0 0.0 0.0 0.0 10. 32. 30. 47. 64. 63. 81. 64. 63. 71. 84. 89. 86. 75. 72. 82. 85. 84. 85. 82. 83. 85. 76. 89. 87. 93. 92. 91. 92. 90. 95. 81. 90. 90. 93. 88. 92. 92. 92. 90. 90. 92. 97.

Num 0 0 0 0 0 20 45 61 86 65 65 57 159147151 49 137136188191153205200218237222267236273255253247246218151285222331362321252275250213158161 88 83

Den 18 12 16 19 12 189140202181101102 70 247233212177153158248262185 240238254286265314307305291272267269 246238299271367402343286296270230175178 95 85

0

10

20

30

40

50

60

70

80

90

100

PERCENTAGE

Percentage of pr eterm deli veries in w hich dexamethasone wasadmini stered for fetal lung maturation. 97 hosp itals and health

centers, Ecuador, 2008 to 2011


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Challenges ahead

Integrating QI indicators system with regular MOHManagement Information System

Linking QI indicators with MOH system to reimburse

costs for services Developing an ongoing system to monitor quality of

data at provincial and local levels

Introducing mHealth

Stepping-up from a measuring system to amanaging one

Documents

Hermida: Experiences Using Routine Monitoring Data for Quality Improvement of Newborn Health in Ecuador