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IMPLEMENTATIONOFESSENTIALNEWBORNCARE

EssentialNewbornCare:Implementation

2

INTRODUCTONANDOUTLINE 4

STEP1:SETUPATEAM 7

LEADERSHIPFORTHEPROCESSANDPLANNING 7COREGROUPFORIMPLEMENTATION 8DEVELOPINGAVISIONFORNEWBORNCARE 8ADVOCACYFORACTION 9

STEP2:ASSESSTHESITUATION 10

ADAPTINGNORMSANDSTANDARDS 10DEVELOPTOOLSANDAPROGRAMMETOASSESSTHESITUATION 11COMPILETHEDATAANDUNDERTAKEADVOCACY 14

STEP3:DEVELOPANACTIONPLAN 15

DETERMINEYOUROVERALLAIM 15SETPRIORITIESANDDEVELOPAPHASEDACTIONPLAN 15

STEP4IMPLEMENTACTIONPLAN 18

1.SYSTEMSTRENGTHENING 19COMMUNITYADVOCACY 19WARDSETUPANDPROCESSES 19STAFFAVAILABILITY/ROTATION 20EQUIPMENT 20TRANSFERANDREFERRAL 21SUPPORTSERVICES 212.STRENGTHENSKILLSTOIMPLEMENTSTANDARDGUIDELINESANDPROTOCOLS 212.1REVIEWEXISTINGGUIDELINESANDSTANDINGORDERSWITHKEYUSERS 212.2.ASSESSKEYBARRIERSTOIMPLEMENTATIONOFSTANDARDCARE 212.3ASSESSTRAININGNEEDS 222.4IMPLEMENTTRAINING 25HELPINGBABIESBREATH(HBB) 26LINCTRAINING 27PERINATALEDUCATIONPROGRAMME(PEP) 29NEONATALEXPERIENTIALLEARNING 30NEWBORNICUTRAINING 30IMPLEMENTPRE-SERVICETRAINING 30CLINICALMENTORING 303.MONITORINGANDAUDIT 30SUPPORTIVESUPERVISION 31CLINICALAUDITANDQUALITYOFPATIENTCARE 31PERINATALANDNEONATALMORTALITYANDPERINATALREVIEWMEETINGS 32ABOUTPPIPFROM(WWW.PPIP.CO.ZA) 32NEONATALMORBIDITYANDSERVICES 33

20133

STEP5TRACKPROGRESSANDUNDERTAKEACCREDITATIONASSESSMENTS 34

PROCESSINDICATORS 36OUTPUTINDICATORS 36OUTCOMEINDICATORS 36IMPACTINDICATORS 37ACCREDITATION 38

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INTRODUCTONANDOUTLINE

Improvingnewborncareinyourfacility,districtandprovince,requireschangeagentsandleaderswhohavethevision,dedicationanddeterminationtonurturetheimplementationofessentialnewborncare.Thecommitmentofmanagementisakeyfactorformobilisingthenecessaryresources.

Theintendedpurposeofintroducingessentialnewborncareistoensurethattherearecompetentmaternalandneonatalhealthcareproviderswhoareabletoprovideappropriatenewborncareservicesinawell-functioninghealthsystem.

Onceavisionofthedesiredservicehasbeendevelopedthesituationassessmentwillhelptoidentifywhatneedstobedone.IdentifysmallbutsignificantactivitiesyoucandoNOWwhilstplanningandmobilisingresourcesformediumandlongterminterventions.

FivestepstoachievingessentialnewborncareareoutlinedbelowtogetherwithsuggestionsfromtheexperienceoftheLINCteamandotherswhohavebeenworkingtoimprovenewborncare.Weencourageyoutoadaptthetoolsandideasprovidedordevelopyourownandstartimprovingnewborncare.Wetrustourexperiencewillbeusefultoyou.

Thestepsforimprovementaresummarisedintable1

Step1:Setupateam

Step2:Assessthesituation

Step3:Developanactionplan

Step4:Implementtheactionplanthrough

Strengtheningthehealthcareenvironment

Strengtheninghealthworkercompetencies

Step5:Trackprogressandundertakeaccreditationassessments

20135

LEVELOFIMPLEMENTATION

Singlefacility Districtlevel Provinciallevelandabove

Step1:SetupateamLeadershipforprocessandplanning

Focalperson,toworkwithamedicalornursingmanagementtoleadtheprocessandplanning

District/regionalpaediatricianinplacetoprovideleadership

Provincetoappointaleadpaediatricianandneonatalnursetoleadtheprocess

Coregroupforimplementation

Involvecoreroleplayerstoimplement,nursingandclinicalmanager,responsiblematernityandpaediatricdoctorsandnurses

Regionalpaediatricianandneonatalnursetoworkwithdistrictmanagerstofromcoregroup

Developacoregroupofprovincialpaediatricians,neonatalnurses,managersandexternalexpertstoleadtheprocess.Appointateamofassessorsandaccreditors

Developingavisionfornewborncare

Developavisionforhownewborncareshouldbebysharingideas,visitingothersites

Districttodevelopasharedvision,byworkshops,visits,benchmarking

Developasharedvisionbylisteningtoall,visiting,benchmarking

Advocacyforaction

Sharethevisiontocreateawarenessofneedforchange

Advocatetoallrelevantroleplayersforchange

Advocatetoheadofhealth,hospitalmanagers,etcAdvocateforfinancialandhumanresources

Step2:AssessthesituationAdaptingnormsandstandards

Reviewavailablenationalandprovincialnormsandstandardsandrevisethembasedonvisionfornewborncare

Developtoolsandprocesstoassessthesituation

Toolforself-assessmentandarrangeforexternalassessment

Basedonnormsandstandardsdeveloptoolsandarrangetoassesnewborncareinstages,adaptLINC,

WHOorSNLtools

Currentstatusofbirths,admissionsanddeaths

Birthsinclinics,hospitalandathome,LBWrates,admission,deathsandcauseofdeath

Fordistrictandprovincereviewbirths,LBWrate,admissions,deaths,causeofdeathtohavebaseline

ofsituationandpriorityareasforintervention

Assesstheservicesandfacilities

ServicesandfacilitiesforResuscitation,Routinecareandcareofsickandsmallnewborns

Assessallservicesandfacilitiesandequipmentateachdistrictandprovincialfacility.Reviewcurrentprovincialplansforfacilityimprovementandup-

grading

Assessthestaffingandstaffdevelopment

Assessstaffing,rotationandcompetencies

Assessandcomparestaffingatfacilities.Determineno.ofNeonaalnursesandpaediatriciansrequired.Assesspre-serviceneonataltrainingandadvanced

neonataltrainingAssessthequalityofcareprovided

Doacareauditbasedonstandardguidelines

Arrangearecordrevieworcareassessmentonkeyconditionsonasampleofrecords

Compilethedataandundertakeadvocacy

Compilethedataateachstepandundertakeadvocacyforchange

Compileanddeterminedataandundertakeadvocacyforchange

Steps3:DevelopanactionplanSetprioritiesanddevelopaphasedactionplan

Developanactionplan;prioritiseactivitiestoimmediateactions,mediumandlongtermaction.

Setuppriorities,andputinplaceimmediateactions,andthenaplanformediumandlongtermwork

Determineprioritiesandensuresupportforshorttermplanswhilstworkingonlongtermplanse.gupgradingfacilities

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Steps4:Implementtheactionplan1.Strengtheningthehealthcareenvironment

Wardsetupandprocesses

Re-arrangewardsandfacilitiestocreatesuitableNNU

Mobiliseresourcesforrefurbishmentandestablishmentofregionalhospitalneonatalunits

DrawupplansfortheservicesInpatientnewborn

careunitSetupNNU,withguidelinesandjobaids

Developprovincialrecords,setupprovincialstandardsforNNU

KMCunit Re-arrangeandorganiseKMC

ProvincialstandardforKMC

Attimeofbirth Organiseservice Ensurefacilitiesandequipmentforneonatalresuscitation

Routinecare Putpoliciesinplace Policiesinplaceforroominginandcaringforwellbabies

Staffing,equipment Shiftandretainstaffanddon’trotatestaff

Determinenormsforstaffingandequipmentandmobiliseresourcestoachievenorms.

Referralandtransport

Strengthenneonataltransport

Provincialneonatalambulanceservice

2.Strengthenhealthworkercompetencies

Reviewguidelines Reviewguidelinesandstandingorders

Reviewprovincialguidelinesforroutinecareandcareoftheandsickbabycare

Assesskeybarrierstoimplementation

Assesskeybarrierstoimplementation

Assessbarrierstoimplementation

Teamsfacilitatesremovalofbarriers

Assesstrainingneeds Assessneeds

Assessprovincialtrainingneeds,andidentifyresourcesfortraining

Implementtrainingifneeded

StartwithHBBandin-servicetraining

Developprovincialanddistricttrainingcapacityofin-serviceandpre-servicetraining

Clinicalsupervisionandaudit

Commencesupervision Developsupervisionandaudittools

Onsitefacilitation,mentoring

Workwithonesitefacilitatorsandmentors

RegionalPaediatriciantovisitdistrictfacilities

Putinplacedistrictteams

Step5:Trackprogressandundertakeaccreditationassessments

Inputs Humanandfinancialresources

Districtteaminplace Numberofdistrictteams,regionalandtertiaryhumanresources

Process AdvocacyActionplans

ActionPlansTeamsinplaceVisitstofacilitiesEquipmentandfacilityneedsidentified

EquipmentneedsTransportneedsTrainingneeds

Outputs NormsandstandardsGuidelinesToolsusedNumberofhealthworkerstrained

NormsandstandardsTrainingsconductedReferralandtransportpoliciesNeonatalambulanceinplace

Provincialjobaids

Outcome FacilitiesaccreditedfornewborncareWellequippedandstaffedfacilitiesDateproperlycollected

QualityoftrainingNooffacilitiesaccreditedReferralpatternsAmbulanceresponsetimes

Accreditation

Impact NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates

NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates

NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates

20137

STEP1:SETUPATEAM

Setupateamintheprovince,ineachdistrictandeachfacilitywithresponsibilityfortheimplementationofessentialnewborncare.

LEVELOFIMPLEMENTATION

Singlefacility Districtlevel Provinciallevelandabove

Step1:SetupateamLeadershipfortheprocessandplanning

Focalpersontoworkwithmedicalandnursingmanagementandtoleadtheprocessandplanning

District/regionalpaediatricianinplacetoprovideleadership

Provincetoappointaleadpaediatricianandneonatalnursetoleadtheprocess

Coregroupforimplementation

Engagewithhospitalstaffwhoarekeytoimplementation.Nursingmanagerandclinicalmanager,responsiblematernityandpaediatricdoctorsandnurses

Regionalpaediatricianandneonatalnursetoworkwithdistrictmanagerstoformacoregroupatdistrictlevel

Developacoregroupofprovincialpaediatricians,neonatalnurses,managersandexternalexpertstoleadtheprocess.Appointateamofassessorsandaccreditors

Developingavisionfornewborncare

Developavisionforhownewborncareshouldbeprovidedbysharingideas,visitingothersites

Districttodevelopasharedvision,byworkshops,visits,benchmarking

Developasharedvisionbylisteningtoall,visiting,benchmarking

Advocacyforaction

Sharethevisionwithabroadergroupinthefacilitytocreateawarenessofneedforchange

Advocatetheneedforchangetoallrelevantroleplayers

Advocatetoheadofhealth,hospitalmanagers,etcAdvocateforfinancialandhumanresources

LEADERSHIPFORTHEPROCESSANDPLANNING

Healthsystemsarecomplexandthereareinstitutionalcultures*aswellasindividualculturesandbarrierstonavigateuntiltheinstitutionadoptsacultureofchange.Acultureofchangeexistswhenthekeyplayersintheenvironmentareopentonewpossibilitiestoimprovepatientcare.Peoplebegintothinkmorecreativelyaboutapparentinsurmountablebarriers.(*Acultureistheattitudeandbehaviourthatarecharacteristicofaparticulargroupororganisation.)

Onsitefacilitationbyvisitinghealthworkerscanprovidethenecessaryleadershipandtechnicalexpertisetodistricthospitalsthatdonotusuallyhavespecialistsorspecialistnursesontheirstaffestablishment.Thesefacilitatorsshouldideallybemembersofadistrictspecialistteam,whoarechosentobethedriversofchange.Inadditiontotechnicalexpertiseinneonatalclinicalcareandhealthsystemdevelopmenttheymustshowleadershipskills.Thefacilitatormustinvigoratemomentumandhelptheteamtoattempttomeetthetimelines.Whenprogressisslowandfrustrationordespondencythreatentosetinthefacilitatormustmaintainthemoraleoftheteam.Ideallythefacilitatorshouldidentifyanindividualinmanagement(theCEOorclinicalmanager,ornursingmanager)inmaternityandintheneonatalunitincludingadoctorwhowillsharethisresponsibilityforsustainingenthusiasm.Theseindividualsmaybetermedsiteleaders.

Facilitatorsshouldalsobementors.Training,policies,guidelinesandactionplansalonedon’taddressthemanychallengesthatareassociatedwithimprovementandchangeinservice-delivery.Implementing

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EssentialNewbornCarerequiresalong-termcommitmentandongoingsupportthroughadvice,sharedresponsibility,collectiveaccountabilityandadvocacywithandforthoseintroducingandprovidingit.

Leadershipmaybeprovidedbyanindividualorasmallteam.Theleadershipmusthavecredibilityintermsoftechnicalexpertiseintheareaofessentialneonatalcare.Forthisreasontheleadershipwillusuallybeorincludeaclinicianwithexperienceandinterestinthisfield.

Aprovincialpaediatricianoranyhealthworkerwithtechnicalexpertiseinnewborncareandhealthsystemsimprovementiswellplacedtoleadtheimprovementprocess.Itisveryimportantthattheyreceivesupportandbackingfromtheprovinceorregion.

Adistrictspecialistteam,includingthepaediatricianandpaediatricandneonatalnursecanprovideleadershipinthedistrict.Theywillworkwitheachhospitaltoimprovecareatfacilitylevel.

COREGROUPFORIMPLEMENTATION

Oneofthefirsttaskoftheleaderistoidentifyacoregroupatprovince,districtandfacilityleveltoimplementessentialnewborncare.

IntheprovincethecoregroupmayincludethedirectororManagerofMaternalandChildHealth,apaediatricianorneonatologistfromtheprovince,tertiaryandregionalhospitalsandneonatalnurses.Ifyoudonothavetherequiredexpertise,lookoutsideyourprovinceordistrictforpaediatriciansandneonatalnursestoassistonaparttimebasis.Theimplementationrequiresassessment,ongoingsupport,trainingandaccreditation.Areferencegroupthatincludesextermalmemberswhocandotheassessmentandaccreditationareuseful.

TheLINCteamconsistedoftechnicalexpertswhovisitedadistrictforoneweekamonth,todoassessments,providedtraining,andconductsupportvisits.Theywerekeytotheimprovementofneonatalservicesinfacilities.Theyassitedwithnorms and standards, policies and guidelines.While fulltime staff are ideal, ifyoudon’thavethemmakeaplantogetexternalassistance.

Acoregroupatadistrictincludesthedistrictmaternalandchildhealthteam,MCWH,andpaediatricianandneonatalnursesfromthedistrict.

Athospitalsthecoregroupmayincludetheclinicalandnursingmanagers,adoctorandprofessionalnurseresponsiblefornewborncare.

DEVELOPINGAVISIONFORNEWBORNCARE

Todevelopavisionistoanticipatehowsomethingwillbe,andtosharethatvisionistopaintapictureinpeoplesmindsofwhatyouwanttoachieve.Theprovincialpaediatricianorexpertteammayhelpdevelopthevision.Takeprovincial,districtandfacilitymanagerstovisitotherneonatalunits,andexplorewhattheywouldliketheirservicestolooklike.Theremaybedifferentperceptionsofwhatnewborncareisandshouldbeinaparticulararea.InruralhospitalsstaffinthefacilitiesanddistrictmaynothaveseenaNeonatalICUoraKangaroomothercareunit.

20139

ADVOCACYFORACTION

Shareyourvisionfornewborncareservices,withseniormanagementinordertomobiliseresoucesforthenextimplementationsteps.

TheLINCteamheldaseriesofdistrictworkshopsforkeyroleplayerswherewediscussedtheimportanceofnewborncare,theelementsofnewborncare,andpaintedapictureoftheservicerequired.E.g.WhatisKMCwhyisitsoimportantandeffective.Hospitalswentbackandadvocatedforfurtherservices.Someofthemmobilisedtheircoregrouptogoandbenchmarkatanotherhospitalnearby.Othersrecruitedaneonatalnurseordoctortohelpthemdeveloptheirservice.Advocacyshouldcontinuesuntilallhealthworkersinmaternityknowwhyitisimportanttoimprovenewborncareandwanttogetinvolvedinitthemselves,andmanagementmobiisesresourcesforyoutoact.Resourcesusefulforadvocacyinclude:

1. ImprovingnewborncareinSouthAfrica:lessonslearnedfromtheLINC.ThisUnicefbookletoutlineswhatLINCinLimpopoProvincedidtoimprovenewborncare.Itisespeciallyusefulformanagersatdistrict,provinceandthefacilitiestoseewhatcanbedoneinaruralprovinceandtolearnfromtheexperience.Somofthevignettesfromordinaryhealthworkerswillhelptoinspireotherhealthworkerstoimprovecare.

2. WorkshopsbytheLINCteaminthedistrict.LINCranaseriesof3workshopsineachdistrict.TheprogrammeisintheCDROM.

3. Advocacypresentationsthatcanhelpyouintroducenewborncaretomanagersandhealth

professsionals.

4. HelpingBabiesBreatheisanimportantbasicnewborncareresuscitationprogramme,anadvocacyleafletisattached.

5. KMCadvocacymaterial

6. Breastfeedingadvocacymaterial

TheseresourcesarelocatedintheAppendixandCDROMunder“RESOURCESFORADVOCACY”

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STEP2:ASSESSTHESITUATION

Step2:Assessthesituation

Adaptingnormsandstandards

Reviewavailablenationalandprovincialnormsandstandardsandrevisethembasedonvisionfornewborncare

Developtoolsandaprogrammetoassessthesituation

Toolforself-assessmentandarrangeforexternalassessment

Basedonnormsandstandardsdeveloptoolsandarrangetoassessnewborncareinstages,adapt

LINC,WHOorSNLtools

Currentstatusofbirths,lbw,admissionsanddeaths

Birthsinclinics,hospitalandathome,LBWrates,admission,deathsandcauseofdeath

Fordistrictandprovincereviewbirths,LBWrate,admissions,deathsandcauseofdeathtohavebaselineofsituationandpriorityareasfor

intervention

Assesstheservicesandfacilities

Assessservicesandfacilitiesforresuscitation,routinecareandcareofsickandsmallnewborns

Assessallservicesandfacilitiesandequipmentateachdistrictandprovincialfacility.Reviewcurrentprovincialplansforfacilityimprovementandup-

grading

Assessthestaffingandstaffdevelopmentprogramme

Assessstaffing,rotationandcompetencies

Assessandcomparestaffingatfacilities.Determinethenumberofneonataltrainednursesand

paediatricianstosupportneonatalimprovementandtraining.Assesspre-serviceneonataltrainingand

advancedneonataltraining

Assessthequalityofcareprovided

Doacareauditbasedonstandardguidelines

Arrangearecordrevieworcareassessmentofthemanagementofkeyconditionsforasampleof

records

Compilethedataandundertakeadvocacy

Compilethedataateachstepandundertakeadvocacyforchange

Compileanddeterminedataandundertakeadvocacyforchange

Abaselineassessmentofselectedindicatorsofnewborncareintheprovince,ineachdistrictandfacilitycanbecomparedwiththeagreedvisionforfuturenewborncare.Thiswillformthebasisonwhichanimplementationstrategywillbeplanned.

ADAPTINGNORMSANDSTANDARDS

RecommendedstandardsareoutlinedinChapter2.Thesemaybeadaptedtoalignwiththevisionfortheprovince,districtandfacilities.Thenormsandstandardsthathavebeenadoptedwillbeusedtomeasurethecurrentserviceandplanthefutureservice.Thenormsandstandardsshouldbereviewedandadaptedasthenewborncareservicedevelops.

WhenLimpopostartedplanningservicesthenumberoftertiaryandsecondarybeds required seemed unbelievably high, but as the district hospitals havedeveloped their services andbeds there has been an increasing recognitionofbabies inneedof level II and III care to thepoint that level II and III resourceshavebeenoverwhelmed.

201311

DEVELOPTOOLSANDAPROGRAMMETOASSESSTHESITUATION

TheLINCteamfounditusefultoprovidefacilitieswithabasicself-assessmenttooltoconducttheirownassessment.Thisassessmenttoolwasusedbyfacilitiestoidentifyproblemsanddrawupanactionplan.TheLINCteamthenconductedamoredetailedassessment.Thisprovidedamorespecificsecondassessmentthatcouldbeusedtocomparenewbornservicesatdifferentfacilities.

Acomprehensiveassessmenttoolsisattachedforadaptationanduse.(Appendix1)

Thereareanumerouselementstoadetailedassessment.Anassessmentmaytakemorethanadaytocompleteanditmaybenecessarytovisitafacilityrepeatedlytocompleteanassessment.

Anassessmenttoolfordistrictsandprovincesummarisesinformationfromeachfacilitytoaiddistrictandprovincialplanning.(Appendix2)

CURRENTSTATUSOFBIRTHS,LBW,ADMISSIONSANDDEATHS

Thefollowinginformationshouldbecollectedandcomparedwiththeadaptednormsandstandards:

• Thenumberofdeliveriesinthehospital/s,clinicsinthecatchmentarea.Thenumberofbornbeforearrivalsdeliveriesandotherhomebirthsthathavebeenrecordedatthesefacilities.

• Thenumberoflowbirthweightbabiesandtheirdistributionbyweightbands(eg.1000-1499grams).

• Thenumberofbabiesadmittedtotheneonatalunit.

• Thereasonsforadmissiontotheneonatalunit.Aretheseappropriateindications?Aresomeavoidable?

• Thenumberofstillbirthsandthenumberofearlyandlateneonataldeaths.

• Thecausesofthestillbirthsandneonataldeaths.

• Thebirthweightofthebabiesthatdied.

• Theplaceofdeath.

Thefollowingsourcesmaybeconsultedforinformation:

• PPIPdata

• DHISdata

• CheckthatthedataonPIPandDHIShavebeenaccuratelyrecordedandarecongruous

• Maternityrecordsmaybeusedtocrosscheckthisdata

• Theneonataladmissionbook

• Thepaediatricadmissionbook.Wereanyneonates(<28days)admittedtothepaediatricward?Ifsowhatwasthereasonfortheadmissionandtheoutcomeoftheadmission?

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ASSESSTHESERVICESANDFACILITIES

Theservicesandinfrastructureavailablefornewbornsintheprovinceandateachfacilityshouldbeassessed.

Atfacilitylevel

Assesstheroutinecare.

• Readinessoflabourwardandtheatreforbasicandadvancedneonatalresuscitation

• Babiesarekeptskintoskinwiththeirmotherandbreastfeedinginitiatedwithin30minutes.

• Wellbabiesroominwiththeirmothersandreceiveandsupportisprovidedforbreastfeeding

• Routinepreventivecareisprovidedanddocumentedinthematernitycarechartandroadtohealthbooklet

• PMTCTisprovidedtothemotherandbaby.

• Whenmedicallyindicatedformulaissafelypreparedanddiscretelyadministered.

Theneonatalunitserviceandthefacilitiesandequipmentshouldbeassessed.

• Thenormsareprovided.Assesswhethertheservicesandinfrastructureareappropriateforthelevelofcarethatisrequired.

• Isthereoxygenandmedicalairintheneonatalunit?ForunitsthatprovideorwillprovideCPAPtheoxygenandmedicalairsourcesmustbeabletoprovidetherequiredpressurefortheCPAPdevice.

• Assessthecareprovidedintheneonatalunit.Aclinicalauditformandrecordreviewarepartoftheassessmenttool.

Thecomprehensivefacilitysituationassessmenttoolwillguidethisprocess.

Atprovinciallevel

• Collatetheinformationfromfacilities

• Assesswhatthedistrictandprovincialplansareforinfrastructuredevelopmentandhospitalrevitalisation.

Aretherefacilitiesthatrequireimprovementorarescheduledforimprovements?Havetherequirementsoftheneonatalservicesbeenadequatelyaddressedintheplans?Dotheymeettheagreednormsandstandards?

• Assessthetertiaryandregionalneonatalservices.Arethereenoughbedsandgoodcare.

• Assesstheneonataltransferandtransportintheprovince.

Theprovincialnewbornassessmenttoolcanbeadaptedforthispurpose.

201313

ASSESSTHESTAFFINGANDSTAFFDEVELOPMENTPROGRAMME

Atfacilitylevelassessthestaffnumbersandbackgroundtrainingandexperienceinnewborncare.

• Dostaffrotateregularlyoraretheyallocatedonlyintheneonatalunit?

• Whatplanisinplaceforstaffdevelopmentateachfacility?

• Dostaffmembershavethecoreneonatalcompetencies?

Atprovinciallevelassesstheprovincialstaffingfornewborncareatthetertiaryservice,theregionalservices,thehospitalandmaternityservices.

Intheprovincialoffice:

• Whoisresponsiblefornewborncare?

• Doesthispersonhaveauthoritytoact?

• Whoprovidestechnicalassistance?

TertiaryandRegionalcare

• Howmanyneonatologistsarethere?

• Howmanypaediatricians?

• Howmanyneonatalnurses?

• Whatistheplantoattractandretainpaediatriciansandneonatologists?

• Whatistheplantotrainneonatalnurses?

• Whattrainingtakesplaceintheprovince?

• Isthissufficientfortheneedsoftheprovince?

ASSESSTHEQUALITYOFCAREPROVIDED

Assesswhatguidelinesandpoliciesareinplacetomanagenewbornsatfacilitiesandintheprovince.

Intheprovince:

• Whatguidelinesareinplacefortheprovince?

• HastherebeenaprocessofdevelopingprovincialguidelinesbasedontheNationalstandardtreatmentguidelines?

• Arepoliciesinplacefor

o BabyFriendlyHospitalInitiative(BFHI)

o Roominginofbabieswithmothers

o Lodgermotherfacilities

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o Referral

o Transportofnewborns

Atfacilities

• Aretheneonatalguidelinesinplace?

• Aretheyuptodateandused?

Conductaclinicalauditoftheimplementationoftheguidelines.Theclinicalaudittoolispartoftheassessment.Thismaybeusedtodetermineifguidelinesarebeingfollowed.Apersonconversantwiththestandardclinicalguidelinesshouldconducttheaudit.

TheLINCteamhasdevelopedarecordaudittoassessthequalityofclinicalcare.Foreachmajorclinicalconditionthereisanassessmentwhichgivesascoreforthecareprovidedagainstthestandardcarerequiredforthatcondition.Ascoreof>80%isregardedasgoodcare,60–80%acceptablecare,and<60%unacceptablecare.Thepersonconductingtheassessmentshouldbeconversantwiththestandardcareandwouldusuallybeapaediatricianorexperienceddoctororneonatalnurse.Thesetoolsareattached.Teamsareencouragedtolearnfromsiteswithexperienceoftheassessmentprocess.

COMPILETHEDATAANDUNDERTAKEADVOCACY

Compilethecollecteddataandwriteareport.Ensurethatmanagersandhealthworkersreceivethereport.Focusfirstonthestrengthsandthenoutlinewhatneedstobedone.

Conductadvocacyaroundtheissuesthatneedtobedealtwith,forexample:

• Visitafacilitywhereacertainaspectofcareisgood,e.gtheKMC.

• Haveadiscussionaboutacontentiousnewborncaretopic

• Inviteanoutsidespeakertotalkaboutanaspectofnewborncare

201315

STEP3:DEVELOPANACTIONPLAN

Steps3:DevelopanactionplanDetermineyourgoalforimprovementinneonatalmortality

Determineagoalfortheperinatalandneonataloutcomesinyourfacility

Determineagoalforneonataloutcomesinhospitalsineachdistrict

Setprioritiesanddevelopaphasedactionplan

Developanactionplan;prioritiseactivitiesforimmediateaction,mediumandlongtermaction.

Setuppriorities,andputinplaceimmediateinterventions,thenplanformediumandlong-termactivities.

Determineprioritiesandensuresupportforshortermplanswhilstworkingonlongtermplanse.gupgradingfacilities.

DETERMINEYOUROVERALLAIM

Basedontheperinatalandneonataldatayoucollecteddetermineagoalfortheimprovementofperinatalandneonataloutcomes.Theseshouldbeshorttermsgoals(1year)andlongtermgoalsnext3–10years.

e.g

Currentlevel

Targetfornextyear

Targetfor3years

Targetfor10years

NNMR 18 12 10 NNMR>1000g 14 10 8 ENMR 15 12 10 LNMR 3 2 2 NNMR(BW>2500g) 6 5 4 NNMR(BW2000g–2499g) 40 25 20 NNMR(BW1500g–1999g) 200 120 50 NNMR(BW1000g–1499g) 500 300 150 NNMR(BW<1000g) 800 600 400 %admissionstoneonatalunit 10% 15% 15% Forregionalhospital%admissionsfromDH

2% 5%

Fordistricthospitals%transferouts

5%

SETPRIORITIESANDDEVELOPAPHASEDACTIONPLAN

Identifytheissuesthatrequireaction.Prioritisethembyimportance.Categoriseplannedresponsestoeachissueintoimmediate,mediumandlong-terminterventions.Issuesthatmayneedinterventionsinclude:

• Advocacy

• Protocolsandpolicies

• Labourwardresuscitation

• Postnatalwardcare

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• MedicalStaffing

• NursingStaffing

• Staffdevelopment

• Neonatalunitfacility

• Equipmentandsupplies

• Infectioncontrol

• Qualityofneonatalcare

• Neonatalreferralandtransport

Planimmediate,mediumandlong-terminterventionsforeachproblem.Considerusingthefollowingformat:

• Problem

• Intervention/srequired

• Stepstobetaken

• Personresponsible

• Timeframe

• Resourcesrequired

• Personresponsibleformonitoringintervention

Atfacilitylevelbeginwithchangesthatcanbemadeimmediatelyanddonotrequiresignificantadditionalresources.Forexampleunderfacility,theproblemmaybeinadequatespace.Rearrangingthenurserylayoutandremovingunnecessaryfurnitureandequipmentmayhelp.Whilewaitingforprovincialprotocolsotherguidelinesmaybetemporarilyadapted.

Belowisanexampleofaninitialactionplanfromadistricthospital.

201317

Problem Activityrequired Stepstobefollowed

Person/sresponsible

Timeline Newresourcesrequired

1. Lack of information about neonatal care in community and hospital

Advoacy meeting with maternity staff, doctors and management Advocacy meeting with clinic nurses and IMCI HHCC groups

Plan meetings with management

N.S 1 month Catering for community meeting

2. Inadequate numbers of professional nurses

Need dedicated staff 2AMW + 4 Prof. Nurses

-Discuss rescheduling of allocation -Draw training schedule & present it to supervisor

T. N Matron T M R. M T. N

3 August

3. Lack of policies on referral

Develop referral policy to and from clinics and to regional hospital

-Discuss with unit manager -Meet with regional hospital -Meet with PHC -Draw up policy -Meet with all role players to implement plociy

T. N

3 July

None

3. Protocols Get appropriate written policies. Distribution & implementation of policies

-Discuss with unit Manager -Meeting with all staff nurses & doctors . -Discussion & formulation of protocols -Proper filing of protocols

N. T N. J

LINC charts Standard treatment guidelines PEP manual Notes on newborn care

AnexampleofablankactionplanispartoftheSituationAssessmenttool

Atprovinciallevelsetprioritiesandsettargetsforimmediate,mediumandlong-termactivities;

1. ForProvincialcoordinationandsupport

2. ForProvincialpoliciesandprotocols

3. ForProvincialtoolsandjobaids

4. ForTertiaryservices

5. FordevelopmentofRegionalservices

6. Fortraining

7. Forequipmentandsupplies

8. Foraccreditationandmonitoring

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STEP4IMPLEMENTACTIONPLAN

Steps4:Implementactionplan1.Systemstrengthening

Wardsetupandprocesses

Re-arrangewardsandfacilitiestocreatesuitableNNU

MobiliseresourcesforrefurbishmentandestablishmentofregionalhospitalneonatalunitsDrawupplansfortheservices

Inpatientnewborncareunit

Setupnewborncareunits,withguidelinesandjobaids

Developprovincialrecords,setupprovincialstandardsforNNU

KMCunit Re-arrangeandorganiseKMC

ProvincialstandardforKMC

Attimeofbirth Organiseservice Ensurefacilitiesandequipmentforneonatalresuscitation

Routinecare Putpoliciesinplace Policiesinplaceforroominginandcaringforwellbabies

Staffingandequipment

Determinestandardsandshiftandretainstaff

Determinestandardsforstaffingandequipmentandmobiliseresourcestoachievestandards.

Referralandtransport

Strengthentransportforneonatesfromclinicsandtoreferralhospital

Provincialneonatalambulanceservice

2.Strengthenskillstoimplementstandardguidelinesandprotocols

Reviewguidelines Reviewprovincialguidelinesandstandingordersforfacility.

Reviewprovincialguidelinesforroutinecareandcareoftheandsickbabycare

Assesskeybarrierstoimplementation

Assesskeybarrierstoimplementation

Assessbarrierstoimplementation

Teamfacilitatesremovalofbarriers

Assesstrainingneeds Assessneeds

Assessprovincialtrainingneeds,andidentifyresourcesfortraining

Implementtrainingifneeded

StartwithHBBandin-servicetraining

Developprovincialanddistricttrainingcapacityofin-serviceandpre-servicetraining

Clinicalsupervisionandaudit

Commencesupervision Developsupervisionandaudittools

Onsitefacilitation,mentoring

Workwithonsitefacilitatorsandmentors

Regionalpaediatriciantovisitdistrictfacilities

Putinplacedistrictteams

Implementationmustbeapproachedwiththeunderstandingthatimprovementofaserviceisacontinuousprocessthatmustcontinueforthelifetimeofthatservice.Becauseitrequiresacollectiveandunifiedeffortthedegreetowhicheffectiveimplementationoccurswilldependonskilfulleadershipandthewillingnessofallrole-playerstorespondpositivelytothechallengescreated.Persistence,compromise,adaptationandenthusiasmareamongthecharacteristicsthattheteamwillneedtodisplay.

Havingcompletedtheassessmentandactionplantheprocessofimplementationneedstobesetinmotion.Althoughatimelineformspartoftheactionplanitislikelythatdeadlinesandtargetswillbereviseddependingoncircumstancesattheparticularfacility.

Thefrequencyofon-sitefacilitationwilldependontheneed,theavailabilityoftheteamandtheresources.Ideallymonthlyvisitsallowforon-sitefacilitationaswellasin-servicetrainingandindividualclinicalmentoring.Ifpossible,thefacilitatorshouldattendtheperinatalreviewmeetings,andshouldplantodosobyarrangingvisitsonthedayswhenthemeetingsarebeingheld.Thisformspartoftheclinicalteachingandauditprocess.

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1.SYSTEMSTRENGTHENING

Thesystemistheenvironmentinwhichthehealthcareworkerprovidescareforthenewborn.Theimportanceofanefficientandergonomicsystemisoftenoverlookedtotheseriousdetrimentofstaffproductivityandsatisfaction.Carefulattentionshouldbegiventothefacilityintermsofspace,lighting,workflowandphysiologicalneedsofthestaff.Theequipmentshouldbeproperlymaintainedandadheretotheagreedstandards.Staffingshouldbeadequateandthereshouldbeanappropriateambulanceserviceinsupport.

Inadditionitisimportantthateverynewbornintheserviceareashouldbeabletoaccesstherangeofservicesavailable.Thisentailsplanningforalldeliveriesnotonlythosethatoccuratfacilities.Thereisaneedforcommunityengagement.

Afacilitatorormentorfromadistrictteammayprovidesupportforimplementation,otherwisetheresourcesthatareavailableinthispackageorelsewheremaybeuseful.

COMMUNITYADVOCACY

Communicatewiththecommunityaboutessentialnewborncareservice,whatisimportant,importantmessagestokeepnewbornshealthy,howtousetheservice.Identifyproblemsthecommunityhaswiththeservice,culturalbeliefsandpracticesthataregoodorpossiblyharmful.Communitybuyinisvitaltomaximizingtheimpactofthenewbornservice.Ensureanon-goingcommunicationchannelwiththecommunity.

WARDSETUPANDPROCESSES

Standardsforaneonatalwardhavebeenprovided.Iftheexistingwarddoesnotmeettherecommendedstandardsconsiderinnovationsthatimproveefficiencywhilemotivatingforanewwardoralterations.Cantheincubatorsbere-arranged,orthenursingstationre-positioned?Arethereproblemswithinfectioncontrol?Aretheresmallstructuralchangesthatcanbemadeatminimalcost?Isthereanalternativespacewhereequipmentmaybestoredwhenitisnotinuse?

INPATIENTNEWBORNUNIT

Provinciallevel:Setupprovincialstandardsforinpatientnewborncareunits.Developaplantoensureappropriateneonatalunitsatalllevelsoftheservice.

Identifyjobaidsandtoolsrequiredintheprovince,forexamplenewbornadmissionbook,newbornrecordsandobservationcharts,dischargeandtransferforms,posters.AttachedareexamplesofjobaidsfromLimpopoandotherprovinces.Thesemaybeusedtoassistwiththedevelopmentofprovincialjobaids.

Atfacilityleveladoptstandardsandensurethatthereareappropriatedailyroutinesintheneonatalward.Theprovincialnewbornadmissionbook,newbornpatientrecord,observationchartsandstandardguidelinesforcareshouldbeavailableinthefacility.

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KMCUNIT

EstablishstandardsforKMCunitsandworktowardsimplementingtheseateachhospital.IfnoKMCfacilityexistsidentifyaspace(albeittemporary)forKMC.MostdistricthospitalsinLimpopohaveusedacubicleinthepostnatalward.

SetuptheKMCunitandmakeitashomelyaspossible.Recruithelptomakeduvetcovers.Requestreadingmaterials,motivateforaTV,DVD.MakebabywrapsfortheKMCmothers.Involvethestaffandthecommunity.

SeveraloftheLimpopoKMCunitshavesewingprojects,onemakesdolls,anotherduvetcovers.Thiskeepsthemothersandstaffoccupiedandmotivated.

ATTHETIMEOFBIRTH

Thelabourwardmustbeadequatelypreparedtoreceivethebaby.Thisincludesprovidingforthepossibilityofneonatalresuscitation.Awarmdrysurfaceorresuscitairemustbeavailableinthebirthingareaandanadvancedresuscitationtrolleyshouldbeonsiteornearby.Suction,oxygenandabag,valve,maskdeviceshouldbeon-handandregularlychecked,preferablybeforeeachdelivery.Aclockwithanalarmsetat1minute,5minutes,10and30minutes,ifpossible,willpromoteaccuratemonitoringofthenewbornbaby.

Thereshouldbeappropriatejobaidstosupportcareatbirthsuchasbasicneonatalresuscitationcharts,apgarchart,hand-washingchartsandbreastfeedingcharts.

ROUTINECAREINPOSTNATALWARDORWELLBABYCARE

Mostbabiesroominwiththeirmothersinthepostnatalward.Theyrequiremonitoringandcareasdoesthemother.Ifneededmakechangestothepostnatalwardtoaccommodatethebabywiththemother.Reviewthepolicy,practicesandprocedures.Communalbathingandpracticesthatkeepbabiesseparatefromtheirmothersshouldbestopped.Besidesthebenefitstothemotherandbaby,thiswillfreeupmorespace.Thebabyshouldbeattendedtotogetherwiththemother.Helpthemothertoestablishbreastfeeding,torecognisethatthebabyiswellandtoidentifyearlysignsofpossibleillness.

STAFFAVAILABILITY/ROTATION

Exploreproblemsrelatedtofrequentstaffrotation.Isittheresultofamanagementdecision,pressurefromtheunionordomidwivesnotwanttostayintheneonatalunitormaternity?Identifytherootcauseandworkonfindingandretainingstaffthatwanttoprovidenewborncare.

Isthestaffestablishmentinsufficientandaretherevacantposts?Addresstheseproblemswithmanagement.

EQUIPMENT

Equipmentnormsandstandards,andspecificationsareattached.Ensurethatthereisanequipmentbookintheneonatalunittokeeptrackofallequipmentpurchasedandhowitisfunctioning.Buyingrobustequipmentandteachinghealthworkershowtocorrectlyusetheequipmentwillextenditslife.Someequipmentrequiresdedicatedconsumablesandthesupplyandaffordabilityoftheseshouldbeassessedbeforemakinganequipmentpurchase.

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TRANSFERANDREFERRAL

Agreeonreferralpoliciesfortheclinicsandbetweenhospitalsintheprovince.Theseshouldbecommunicatedtoalltogetherwithasystemforreportingandmonitoringdisagreementsorconfusion.Setupandprioritiseneonataltransportintheprovincesothatbabiescanbecompetentlytransportedtotheappropriatelevelofcare.

SUPPORTSERVICES

Workwiththelaboratory,radiology,dieticians,audiologists,physiotherapistandothersupportservicesonaspectsofcarethatneedimprovement.

2.STRENGTHENSKILLSTOIMPLEMENTSTANDARDGUIDELINESANDPROTOCOLS

Thecarenewbornsreceiveisdependentontheexperience,knowledgeandskillsofthehealthworkers.Inthisregardthehealthworkersactasateamandthereshouldbeabalancedspreadofabilitiesacrossthewholestaffcomplement.

2.1REVIEWEXISTINGGUIDELINESANDSTANDINGORDERSWITHKEYUSERS

Reviewtheguidelinesandprotocolsthatareinuseatfacilitiesinthedistrictandprovince.

SomeguidelinesthatmaybeadaptedforusearelistedbelowandmaybefoundontheattachedCDROM.Facilityprotocolsarenotessentialifanacceptablestandardnationalguidelinehasbeenadopted.Theguidelineshouldbeacceptabletoallthekeyroleplayersatfacilitiesandintheprovincesothatmutualunderstandingandconsensusisachieved.

• PaediatricEssentialDrugListandStandardTreatmentGuidelines(SouthAfrica)

• LINCNewbornCareCharts:RoutineCare

• LINCNewbornCareCharts:CareoftheSickandSmallNewborn

• LINCNewbornCareGuidelines

• Mosttertiaryhospitalshavetheirownguidelinesforexample

o NotesonNewbornCareUCT

o Stellenboschguidelines

2.2.ASSESSKEYBARRIERSTOIMPLEMENTATIONOFSTANDARDCARE

Thekeybarrierstotheimplementationofguidelinesshouldbeassessedbeforeinitiatingatrainingprogramme.Theadvocacyworkshopsandsituationassessmentwillhaveidentifiedanumberofkeybarrierstoimplementation.ASWOT(strength,weaknesses,opportunities,threats)analysiswillhelptodeterminethebarriersandopportunitiesforimplementation.

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Helpfultoachievingobjective

Harmfultoachievingobjective

Attrib

utes

oft

he

orga

nisa

tion Strengths Weaknesses

Attrib

utes

oft

he

enviro

nmen

t Opportunities Threats

SomeofthebarriersidentifiedbytheLINCteamwere:

v Rotationofstaffinmaternity,andintheneonatalunit.Somehospitalsrotatestafffrequentlymakingitdifficultforstafftobemotivated,tolearnguidelinesandpolicies.Maternalandnewborncarebenefitswhenstaffarepermanentlyplacedinthematernityorneonatalunit.Studentsandnewstaffmayrotatethroughtheunit.Thisisanopportunitytoinstitutionalisegoodpractice.

v Lackofavailabilityofguidelines.Guidelinesnotdisplayedoravailableincasualty,maternityandneonatalunit.

v Lackofbuyintotheprotocols.Evenwhenusingprovincialornationalprotocolstheseshouldbediscussedwithallthestaff.Explaintherationalefortheguidelinesandwherenecessarydrawupanadaptedlocalprotocolthatwillassistwithimplementationoftheguidelines

v Guidelinesmaynotbecommunicatedtoalldoctors,includingsessionalandnewdoctors.Somedoctorsonlylookafternewbornswhentheyareoncall,andarenotawareoftheguidelines.Insmallhospitals,standingordersforcareofnewbornsbythenurses,withclearinstructionsforthedoctorscanfacilitateimplementationoftheguidelines.

v Theremaybeinadequatestaff,equipmentandfacilitiesbutthisshouldnotbecomeanabsolutebarriertoimplementation.

v Thelackofcontinuouson-sitesupporttopromotetheimplementationofanewguidelinecanallowareversiontooldpractises.Thisisparticularlythecasewhentheoldpractiseisentrenchedintheinstitutionalculture.

2.3ASSESSTRAININGNEEDS

Ensuringthatdoctorsandnurseshavethecompetenciestoprovideessentialnewborncarecanbeaddressedthroughthetrainingofmotivatedpermanentstaff.Newborncarecompetencyrequirements

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shouldfirstbeevaluated.Acompetencyisablendofskills,abilities,andknowledgeneededtoperformaspecifictask.

Identifythecompetenciesrequiredbydifferenthealthworkers,andplantrainingandlearningtoensurethattheyaremet.Acquiringandmaintainingthecompetencyrequirestheuseofdifferentteachingstylesandreinforcementthroughpracticeandfollowup.Aprogrammeofmentoringandsupportshouldparallelanytrainingprogramme.

Basicneonatalresuscitationisacorecompetencyforallhealthworkersinmaternityandneonatal.HelpingBabiesBreathe©isrecommendedasacourseforallhealthworkers.Wherepossibledoctors,advancedmidwivesandneonatalnursesshouldattendanadvancedneonatalresuscitationcourse.

TheLINCchartsandvariousLINCtrainingpackagesweredevelopedtoaddressthecompetenciesrequiredtoprovideessentialnewborncare.Thesearebasiccompetenciesfornewborncarethatallstaffworkinginmaternityandtheneonatalunitneedtohave.ThereareadditionalcompetenciesthatmaybeneededandothertrainingpackagessuchasthePerinatalEducationProgrammearealternativesthatcanbuildonthebasiccompetencies.

AtregionalandlargedistricthospitalsthatprovideCPAPandhighcare,someofthenursesshouldhavetraininginneonatalintensivecare.Sometertiarycentresofferthisasa1-yeartrainingtrainingcourseatintervals.

DoctorsinpaediatricwardsareencouragedtoobtainaDiplomainChildHealth.Thiswillprovidevocationalgrowthandimprovethelocalskillsandknowledgeinpaediatricandnewborncare.

Someimportanttrainingandupdatesmaybeavailableasshortcoursesorintegratedintoothercourses.Forexample:

v PMTCTv Breastfeedingv EPIv Genetics

ThelistbelowidentifiesthecompetenciesaddressedbytheLINCtrainingpackage.Italsoliststhecompetenciesrequiredfordifferentcategoriesofstaff.Ablankchartisincludedintheappendixandeachfacilityisencouragedtodrawupasimilarlist.

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COMPETENCIESREQUIREDINNEWBORNCARECompetency Subcompetency

MO

Paed

iatricM

O

Adv

ance

midwife

Neo

natalP

N

Mid-w

ife

Neo

natalE

N/ENA

MSS

Nm

odulean

dlesson

nu

mbe

r

Othermaterial

Resuscitatethenewbornatbirth

Basicresuscitation ü ü ü ü ü ü HelpingBabiesBreathe

ProvideAdvancedresuscitation

ü ü ü ü NRPAPLSPALSSAMA/FM

Provideroutinecaretonewbornsatbirth

Provideroutinecareandtriageinlabourward

ü ü ü ü M0

Assessthenewbornafterbirth

ü ü ü ü ü M0 PEP

Provideroutinecareinpostnatalward

ü ü ü ü ü M0 PEP

Dischargeandmakeafollowupplan

ü ü ü ü ü ü M0

Assessandsupportbreastfeeding

ü ü ü ü ü ü M0 IMCI,Lactationmanagement

Assessandclassifythesickandsmallnewborn

AssessandClassifyneedforemergencycare

ü ü ü ü ü M1,L2

AssessandClassifyprioritysignsinnewborns

ü ü ü ü ü M1,L2

Assessabnormalities ü ü ü ü M1,L3

PEP

Assesslocalinfections ü ü ü ü M1,L3

PEP

Assessriskfactors ü ü ü ü ü ü M1,L4

PEP

Providesupportivecaretonewborntomaintainhomeostasis

Monitor,prevent,andmanagehypothermia

ü ü ü ü ü ü M2,L5

PEP

Monitor,prevent,andmanagehypoglycaemia

ü ü ü ü ü ü M2,L7

PEP

ProvidesafeKangarooMotherCare

ü ü ü ü ü ü M2,L5

Providesafeoxygentherapy

ü ü ü ü ü ü M2,L6

PEP

Providesafefeedsandfluidstobabies

ü ü ü ü ü ü M2,L8

PEP

Safelytransferbabies ü ü ü ü ü ü M2,L10

Diagnoseandmanagecommonspecificnewbornproblem

Managebabieswithrespiratorydistress

ü ü ü ü M2,L11

PEP

ManagebabiesonCPAP ü ü ü ü AdditionalLessons

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Managelowbirthweightbabies

ü ü ü ü ü M2,L12

PEP

Managebabieswithinfections

ü ü ü ü M2,L13

PEP

Preventandmanageneonatalencephalopathy

ü ü ü ü M2,L15

PEP

Preventandmanageneonataljaundice

ü ü ü ü ü ü M2,L16

PEP

Managecongenitalabnormalities

ü ü ü ü M2,L17

PEP,

ManageexposuretoHIV,Tbandsyphilis

ü ü ü ü ü ü M2,L18

PMTCT

Counselmothertocareforhernewborn

Assessfeedingandgrowthandcounselonfeeding

ü ü ü ü ü ü M3,L19L20,L21

IMCILactationmanagement

Counselmotheroncare,whentoreturn

ü ü ü ü ü ü M3,L22

Ensureaclean,safeandfriendlynewbornenvironment

ü ü ü ü ü ü M2,L9

Abbreviations PEP: Perinatal education Programme IMCI: Integrated Management of Childhood Illness PMTCT: NRP: Neonatal Resuscitation Programme HBB: Helping Babies Breathe MSSN: Management of Sick and Small Newborns

2.4IMPLEMENTTRAINING SuggestedtrainingandlearningfordifferentcategoriesofhealthworkersDoctors:

• DiplomaChildHealth• 2dayLINCtrainingcourse• MotherandInfantHIVcourse• PMTCTtrainingandupdates• SelfstudywithNeonatalPEP

ProfessionalNurses

• DiplomainAdvancedMidwifery• DiplomainNeonatalNursing• LINCtrainingforProfessionalnurses• PMTCTtrainingandupdates• MotherandInfantHIVcourse• Lactationmanagement/BFHIcourse• NeonatalPEPcourse

Enrollednurses

• LINCtrainingcourse• Lactationmanagement/BFHIcourse

Belowaresomerecommendedtrainingcoursesorprogrammes:

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RESUSCITATION

HELPINGBABIESBREATH(HBB)

HBBisabasicneonatalresuscitationtrainingprogramme.Itishighlyrecommendedforallhealthworkersinmaternityandneonatalcare.Theskillslearnedshouldbereinforcedthroughregularupdatessessionsordrillsateachfacility.

“HelpingBabiesBreathe®(HBB)aimstohelpmeetMillenniumDevelopmentGoal4targetsforreductionofchildmortalitybyaddressingoneofthemostimportantcausesofneonataldeath:intrapartum-relatedevents(birthasphyxia).HBBisanevidence-basededucationalprogrammethatteachesaneffectivestepwiseapproachforsuccessfulresuscitationofthemajorityofinfantsnotbreathingatbirth.

HelpingBabiesBreatheisdesignedtobecoordinatedwithotherinterventionsinapackageselectedtoimproveneonatalandmaternalhealth.HBBcanbeusedastheresuscitationcomponentincoursesteachingEssentialNewbornCareandcoursesinmidwiferyskills.HBBcanbeusedatalllevelsinthehealthsystem.Itenablestheextensionofresuscitationtrainingtofirst-levelhealthfacilitiesandhealthworkersinresource-limitedsettings,wheretheseskillsaremostlacking.Italsocanbeusedinhigher-levelhealthfacilities,includingtertiaryfacilities,whereitcomplements,butdoesnotreplace,comprehensiveresuscitationprogramssuchastheNeonatalResuscitationProgram(NRP).BothHBBandNRPteachthesamefirststepsinresuscitation,butNRPalsoincludestheuseofsupplementaloxygen,chestcompressions,intubation,andmedications.

HBBusesalearner-centerededucationalmethodologywithemphasisonmasteryofkeyskills.Pictorial,color-codedprintmaterialsandalow-cost,high-fidelityneonatalsimulatorengagelearnersandempowerthemtocontinuelearningintheworkplace.HBBencouragesfrequentpractice,usingjobaids,simulators,andmannequinsavailableintheworkplacetomaintainskills.

Asanintegralelementofmaternalandneonatalcare,HBBcanactasacatalystforbroaderimprovementsintheseservices,particularlyattheperipheryofthehealthsystem.

FurtheradvocacyandinformationaboutHBB,thetrainingmethods,andanimplementationpackageareintheResourcesectionandCDROM.

Itisrecommendedthatthereshouldbe2HelpingBabiesBreathefacilitatorsateachdistricthospital.Thesefacilitatorscanrunregularcoursesformaternityandprimaryhealthcarestaff.4–6participantscanbetrainedinonedaybyafacilitator.

ADVANCEDNEONATALRESUSCITATION

Ensurethatalladvancedmidwives,andseniordoctorsaretrainedinadvancedneonatalresuscitation,andmaintaintheirskillandaccreditationforresuscitation.SeveralaccreditedcoursesareofferedthroughoutthecountryandincludetheAmericanAcademyofPaediatricscoursestheNeonatalResuscitationProgram(NRP),andtheBritishPaediatricAssociationCourse,AdvancedPaediatricLifeSupport(APLS)coursethatincludesneonatalresuscitation.ESMOEEincludesamoduleonneonatalresuscitation.

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ROUTINECARE

Allmaternitystaffprovideroutinecaretonewborns.Thisincludesidentifyingriskfactorsandillness,supportingbreastfeedingandprovidingroutinepreventivecare.Thecaregivenisdocumentedandinformationisprovidedtothemother.RoutinecareincludeslactationmanagementandPMTCT.

Trainingcanbeprovidedaspartofin-servicetrainingoronanintegrated1–3daytrainingcoursethatincorporatesalltheaspectsofcareincludingHBB.

AseparatePMTCTandlactationmanagementcoursemaybeofferedinthedistrictorprovince.

LINCprovideschartsonroutinecareofnewbornswithalearnermoduleandtrainingthatcanaccompanythecharts.Trainingmaybeprovidedaspartofacourseorasanin-servicetrainingmoduleorasself–learning.

ThePerinatalEducationProgrammehasamoduleonPrimaryNewbornCarethatcoversroutinecareofthenewborn.

LINCTRAINING

TheLINCtrainingisbasedontheprinciplethattherearedifferentstylesanddomainsoflearninganddifferentmethodsengagedifferentlearners.

Adultlearnersbringpriorknowledgeandexperiencetothelearningsituationandnewknowledgeshouldbepresentedinafashionthatfacilitatesassimilationandintegration.Differentlearnerslearnindifferentwaysandtrainingprogrammesneedtoincludevisual,auditoryandinteractivemethods.

Adultlearnersaremotivatedbytasksperceivedasmeaningful.Theyaredecisionmakersandself–directedlearners.Presentedwithnewinformationtheybenefitfromopportunitiestoputitintopracticethroughcarryingoutnewtasksandcompetencies.Thiscanbethroughsimulationsorappropriateworkplaceexposurewiththeoversightofamentorifnecessary.

LINCtrainingincorporates:

• Aneedsassessment

• Pre-readingandadditionalreading

• Presentations

• Smallgrouplearningtoallowforsharingofideas,discussionandrefocusingthelearningonexpressedlearnerneeds.

• Visualdemonstrationsandpracticalsessionsfortherehearsalofnewskills.

TheLINCNewbornCareChartsaredesignedaspersonalaidstoguidethehealthworkerinmaternityandtheneonatalunitinprovidingcarefornewborns.Thetrainingmaterialsrefertothecharts,andlearners

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areencouragedtohavethemopenatalltimesduringthecourse.Thisdevelopsfamiliaritywiththechartsandprovidesacontextfortheguidelines.

Readinglearnermanual

Thelearnermanualexplainsthechartsandprovidesbackgroundinformation.Themanualisreadbeforethecourse,andsummarizedinclassbythegroup.Itcanalsobeusedforself-study.Sectionscanbereadbeforecomingtoclass,orindividuallyfordistance-basedlearning.

IntroductiontoToolsfornewborncare

Themanualintroducesanumberoftoolsthatareusedtofacilitatethecarethatisprovidedtonewborns.Theseinclude:

• Newbornrecordaspartofthematernitychart• Observationchartfornewbornaspartofmaternitychart• NewbornAdmissionRecordforsickandsmallnewborns• Initialassessmentformforsicknewborns• Admission/Dischargesummary• Weight,feedingandtreatmentsummary• Ballardscore• Fetal-infantgrowthchartforpreterminfants• Bilirubincharts• KMCscorechart• HIEscorechart• Healthworkernotes• NewbornObservationChart

LINCtrainingusesthechartsdevelopedforuseinLimpopo.Ifdifferentsuitablechartsareinusethesemaybeusedinstead.TheLimpopochartsareprovidedforadaptation.

Writtencasebasedexercises

Writtenexercisesareinterspersedinthemanual.Thewrittenexercisesusuallyrefertoaclinicalcaseandareusedtoreinforcethelearninginthemodulesbytheoreticalapplicationoftheinformationtotheassessmentandcareofanewborn.Aseparateexercisebookisgiventoeachparticipant.Facilitatorshavetheanswerstotheexercisesintheirlessonplans.

Role-plays

Role-playsareusedtoexplorecounselingandinteractionsbetweenhealthworkers.

Visuallearning

Powerpointpresentationsorslideshowsareusedtodemonstrateclinicalsignsandcare.Thisreinforceslearningsuchastherecognitionofclinicalsigns.Anumberofvideosareindevelopmentasanalternativetothepowerpointpresentation.Thiswillenableeasierself-learningandaidfacilitiesthatdonohaveexperiencedfacilitators.

ClinicalSession

Theclinicalsessionsareconductedintheclinicalarea(NeonatalUnitandPostnatalWard)andensurethattheparticipantsseeandpracticeclinicalandproceduralskills.

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LINCCDROM

TheCDROMcontainsthefollowing

• LINCCourseDirectorGuide

• LINCfacilitatorGuideandLessonPlans

• LINCManagementofSickandSmallNewbornLearnerManualandWorkbook

• LINCRoutineCareLearnerManualandWorkbook

• LINCPowerPointPresentationfortraining

• LINCtoolsforuseintraining

• LINCCPAPguidelineandworkshop

• LINCPPIPguidelineandworkshop

PERINATALEDUCATIONPROGRAMME(PEP)

Thisisaself-study,distanceeducationprogramme.Itdoesnotrequiretutors,andtheonlycostisthepurchaseofthemanuals.Therearetworelevantmanualsfornewborncare:PrimaryNewbornCare,andNewbornCare.ThePrimaryNewbornCaremanualissuitableforstaffworkinginClinics,HealthCentresandMidwifeObstetricUnits.TheNewbornCaremanualisforstaffworkinginhospitals.

Thequalityofhealthcareprovidedbynursesanddoctorsdependslargelyontheirabilitytoaccessahighstandardofbothbasicandcontinuingtraining.Thisisparticularlyimportantforhealthcareworkersinunder-resourced,ruralareaswhereeducationalsupportandopportunitiesforin-servicelearningareverylimited.Traditionalmethodsofcentralisedteachingwithformaltutorsandsmallclassesoftencannotbeprovidedtomeettheirneedastheyareexpensive,dependonadequatenumbersofcompetenttrainersandrequireparticipantstoleavetheirplaceofemployment.Allthesefactorsaremajorobstaclestoimprovingthequalityofpatientcareinmanyunder-servedareasofSouthAfrica.

Inordertoaddressthechallengesofbetterprevention,diagnosisandmanagementofcommonandimportantmedicalconditions,apackageofcost-effectiveandpracticaltrainingmethodsisneeded.Thisshouldincludeasystemofself-studyandco-operative,grouplearningtoenablehealthcareworkerstotakepartialresponsibilityfortheirowneducationandprofessionalgrowth.Itisparticularlyimportanttoprovideagoodbackgroundknowledgeandunderstandingoftheessentialstepsusedinaprotocol-drivenapproachtotrainingandhealthcare.Unlessaparticipantknowswhyastepinmanagementisimportant,theyareunlikelytoincorporatewhattheylearnintotheirclinicalpractice.

Awell-balancedprogrammeoffacilitatedtrainingshouldhavecomponentsofbothindividualstudyandgrouplearningaswellastutoredexercisesinclinicalskills.Inthiswayalimitednumberoftrainerscanmanagemanyparticipantsaseachgrouponlyneedslimitedface-to-faceteaching.Withtheemphasisonlearningratherthanteaching,traditionaltrainersbecomefacilitatorswhoencouragethedevelopmentofself-confidenceandcompetence.

ThePerinatalEducationProgrammehaspresentedappropriatelearningmaterialinmaternalandnewborncareforthepast20yearsandhasenabledbothnursesanddoctors,aswellasmedicalandnursingstudents,toplayanactiveroleintheirownlearningprocess.Coursebooksuseaproblem-basedapproachtoaddressawiderangeoftopicsandarehelpfulforbothself-studyandgroupdiscussions.Usinga

30

question-and-answerformat,togetherwithcasestudiesandmanagementprotocols,theyprovidealogicalapproachandclearunderstandingofallstepsinpatientcare.Multiplechoicetestsbeforeandaftereachchapterenablesparticipantstomonitortheirownprogress.Recentlythelearningmaterialhasalsobeenmadeavailableontheinternetforeasyaccess.Anumberofprospectivestudieshavedocumentedthesignificantimprovementinknowledge,clinicalskills,attitudesandpatientcarepracticeswhenmidwivesandneonatalnursesusethisself-helplearningmethodtomanagetheirowntrainingprogrammes.ThecontentofthePerinatalEducationCarebookshasbeenincorporatedintootherpartsoftheNewbornCarepackage.Itisstronglyrecommendedthatthisbecomesanessentialpartofneonataleducation,especiallyinunder-resourcedsettings.

MoreinformationonPEPisincludedintheImplementationToolXonTraininginthenextsection.

NEONATALEXPERIENTIALLEARNING

NeonatalExperientialLearningisansupportivecomprehensivelearningprogrammebasedonclinicalgovernancestructure.NELSutilisestheNewbornCarePEPmanualduringa2weekcontactsession.MoreinformationonNELSisprovidedintheadditionalresourcessectionChapter4.

NEWBORNICUTRAINING

FewuniversitiescurrentlyofferNeonatalICUtrainingastheNursingCouncildoesnotcurrentlyregisterthecourse.Theskillsprovidedinthiscoursewillbenefitnursesatlevel2and3facilitiesanditishopedthatthecouncilwillsoonregisterNICUtraining.

IMPLEMENTPRE-SERVICETRAINING

Newborncareisrequiredtobepartofpre-servicenursingandmedicaltraining.Provinceneedtoensurethatthisishappeningandthattheyareuptodate.

CLINICALMENTORING

Clinicalmentoringasmentionedpreviouslyisanimportantpartoflearningandhelpinghealthworkerswhohavebeentrainedimplementwhattheyhavelearned.

3.MONITORINGANDAUDIT

Asystemofmonitoringandauditshouldbeestablishedateachfacility.Thiswillinclude

1. Supportivesupervision

2. ClinicalAudit

3. PerinatalAudit

4. Monitoringkeynewbornindicators

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SUPPORTIVESUPERVISION

Everybodywhohassomeroleinoverseeinghealthcareisresponsibleforsupervisingatleastsomepartofthesystem.Theclinicalmanagerisresponsibleforclinicalcareinthehospital.He/sheneedstobeclearaboutwhattherequirementsfornewborncareare,toassesstheseandtomakethenecessarychangestoensurethattheunitisabletofunctionoptimally.He/she,particularly,shouldbethechairpersonoftheperinatalreviewmeetings,andtakeresponsibilityforcheckingthattheactionplansarebeingimplemented.

Thenursemanagerensuresthatthereareadequatenursingstaffandthatthestaffhavetheappropriateknowledgeandskillstobeabletoprovideahighqualityofcare.He/sheneedstotakeresponsibility,withthemedicalmanagerandotherstaff,forclinicalauditofrecordsandforassessingqualityofcareintheward.

ThefacilityCEOhasoverallresponsibilityforensuringthatalltherequirementsforprovidingqualitycareareprovided.He/sheneedstobeadvisedbytheclinicalmanagersandcliniciansonwhatisneededandwhattheoutcomeofevaluationsare,sothatappropriateactioncanbetaken.

Thedoctorisresponsibleforthepatientcareonadaytodaybasis.He/sheneedstoevaluatecarefullyclinicaloutcomes–morbidityandmortality,lookingspecificallyforavoidablefactors/substandardcare.He/sheneedstoactinanadvisorycapacityforotherclinicalmanagers,particularlyinmatterswhichaffectthedaytodaypatientcareandtherunningoftheward.

Allhealthworkerswithasupervisoryfunctionshouldstriveto:

• Demonstratetherightwaytoperformtasksratherthanpointingouterrors

• Provideanenablingenvironmentinwhichtheirjuniorcolleaguesfeelfreetousetheirowninitiativeratherthancreatingacontrollingenvironmentthat,throughtheexcessiveuseofdirectives,stiflesinitiative

• Promotetheprofessionaldevelopmentofstaffundertheirsupervision

• Assumeasmuchresponsibilityandaccountabilityasisjustifiable

CLINICALAUDITANDQUALITYOFPATIENTCARE

Clinicalauditreviewshowguidelinesareimplemented.Thereareanumberofwaystoperformclinicalaudits.

1. Apaediatricianconductingwardroundswillreviewallaspectsofthepatient’scareandimmediatelyidentifygoodandbadclinicalpracticesanddiscussthesewiththemedicalandnursingteam.Thisauditrequiresanexperiencedclinicianavailableforwardrounds.

2. Clinicalauditform.Achecklistofgoodpractice,whichcanbeappliedtoanumberofpatientsatintervalstomonitorcompliancewithguidelines.Thismaybeusefulfortheclinicalmanagerwhomaynotbeanexpertinnewborncareasanaidtoidentifyingcompliancewithguidelines.

3. Recordreview.TheLINCsituationassessmentandaccreditationutilisesarecordreviewofpatientswhohavebeencaredforintheneonatalunit.Thecareforeachconditionisscoredagainststandardcareforthatcondition.Thescoresaretotalledandapercentageforstandard

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careforeachconditionisachieved.Therecordreviewmustbeconductedbyskilledcliniciansoftenfromoutsidethefacility.

PERINATALANDNEONATALMORTALITYANDPERINATALREVIEWMEETINGS

ThePerinatalProblemIdentificationProgramme(PPIP)isagoodtoolforperinatalaudit,andoneendorsedforusebytheDepartmentofHealth.Itprovidestoolstoassistincollectingbaselinedataandauditingthecauseofperinataldeaths.

Perinatalreviewmeetingsshouldbeheldeverymonthineachfacility.Thecauseofaperinataldeathmustbeassessedwithin24hoursofthedeath.

ABOUTPPIPFROM(WWW.PPIP.CO.ZA)

PPIPWILLTAKECAREOFTHENUMBERS,WHILEYOUTAKECAREOFMOTHERSANDTHEIRBABIES

ThePerinatalProblemIdentificationProgram(PPIP)isatooltomakeyourperinatalandmaternaldeathauditeasier.Itdoesnotdotheauditforyou,butittakesthetediouspaperworkoutoftheprocess.Themomentyouenterthebasicdata,youcaninstantlydoextensivedataanalysis,andevenpresentyourdataingraphsandprintreports-allwiththepressofabutton.

Lettherebenodoubt:medicalaudit(andcertainlyperinatalandmaternaldeathaudit)isnotaprocessthathappenswithoutdedicatedindividualsspendingtimeandefforttomakeithappen.Furthermore,auditisafutileprocessifitdoesn't'closetheloop'bychangingthepracticeitisauditing.Thepurposeofauditisnottheaudit,orthefigures,orthereportsitgenerates,buttheimprovementofpractice.Ifyoudonotintendtochangethewayyoucareformothersandtheirbabies,PPIPwilldonothingforyou.If,ontheotherhand,youwantthequalityofyourcaretobeweighedandmeasuredbecauseyouwanttodobetter,PPIPwillprovideyouwithaninstrumenttomakesenseofyourdatawithoutspendinghoursgoingthroughdatasheets.

AUDITSUPPORTPROVIDEDBYPPIP

Medicalauditincludesanumberofactions.PPIPmakessenseofthisprocessbyprovidingyouwiththree'levels'ofdataentry:

DOINGTHENUMBERS

PPIPallowsyoutocollectnumbersofdeliveries,stillbirths,earlyandlateneonataldeathsandmaternaldeaths.Thisallowsthecalculationofdifferentrates(e.g.aperinatalmortalityrate)andisusedasdenominatorinvariouscalculations.Aselectionof'miscellaneous'datafieldsallowsentryandanalysisofspecificdetail,e.g.modeofdelivery.

IDENTIFYINGCAUSES

Eachperinatal,neonatalandmaternaldeathisenteredinmoredetail.PPIPallowsentryofbasicdemographicdata,afterwhichaprimaryobstetriccauseofdeathandafinalcauseofdeathmustbeidentified.Obviouslythesecausescanthenbeanalyzedindetail.

AVOIDABLE?

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Lastly,PPIPallowsfortheidentificationofspecificavoidablefactors.Theseareincidentsrelatedtotheactionsofthemotherorhealthcarepersonnel,orthehealthcaresystem,whichmayhavealteredtheoutcomeofthespecificcasehaditbeenmanageddifferently.Again,theseavoidablefactorscanbeincludedindataanalysis.

FurtherinformationaboutPPIPcanbefoundontheirwebsitewww.ppip.co.za

NEONATALMORBIDITYANDSERVICES

Additionaldataandinformationisrequiredtomonitortheneonatalservice.Thisincludes

• Thenumberandpercentageofadmissionstotheneonatalunitandthereasonsfortheadmission

• Thetrendsinadmissions

• Transfersinandoutoftheneonatalunitandoutcomefromtransfers

• Neonataltransportresponsetimesandoutcomes

• Numberandnatureofbirthabnormalities

• Outcomeofspecificconditions

SeetheattachedtoolsinAppendix3,Neonatalregistersandsummarydata

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STEP5TRACKPROGRESSANDUNDERTAKEACCREDITATIONASSESSMENTS

Step5:TrackprogressandundertakeaccreditationassessmentsInput Humanandfinancial

resourcesDistrictteaminplace Numberofdistrict

teams,regionalandtertiaryhumanresources

Process AdvocacyActionplans

ActionPlansTeamsinplaceVisitstofacilitiesEquipmentandfacilityneedsidentified

EquipmentneedsTransportneedsTrainingneeds

Output NormsandstandardsGuidelinesToolsusedNumberofhealthworkerstrained

NormsandstandardsTrainingsconductedReferralandtransportpoliciesNeonatalambulanceinplace

Provincialjobaids

Outcome FacilitiesaccreditedfornewborncareWellequippedandstaffedfacilitiesDateproperlycollected

QualityoftrainingNooffacilitiesaccreditedReferralpatternsAmbulanceresponsetimes

Accreditation

Impact NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates

NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates

NeonatalmortalityratesPerinatalmortalityratesAdmissionspercentagesandcasefatalityrates

Progressshouldbemonitoredatfacility,districtandprovinciallevel.Thechoiceofindicatorswillvaryaccordingtothepointofmonitoringanduniquecircumstances.Itisusefultoaggregateindicatorsintothe5categoriesshowninthetableabove.Thiswillprovideforacontinuumofmonitoringduringimplementation.Anexampleofthisprocessisprovidedinthetableandsubsequentdiscussionbelow.

AnAccreditationSystemformspartoftheLINCprogrammeinLimpopo.ItenablestheimplementationoftheNewbornCareInitiativetopbetrackedandprovidesanincentiveforparticipatingfacilities.Thisisdescribedatthecloseofthischapter.

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Input Process Output Outcome Impact

FacilityLevel HumanandFinancialResources

Teaminplaceatfacilitywithchangeagent

Actionplansaredrawnupinfacility

Advocacyworkshops

Community

Healthworkers

Normsandstandardsfornewborncareidentified

Guidelinesinplace

Jobaidsinplaceandbeingused

Numberofhealthworkerstrained

Facilitiesaccreditedforexcellentnewborncare

Wellequippedfacilities

Improvementinnewborncarenotedonrecordreviews

Neonatalmortalityrates

Perinatalmortalityrates

Admissionratesandcasefatalityrates

National,ProvinicalandDistrictlevel

Teaminplaceinxnumberofdistricts

Advocacyprogramme

Actionplansinplace

Numberofteamsinplace

Numberofvisitstofacilities

NormsandstandardsandGuidelinesinplace

Trainingsconducted

Appropriatetransferpolicies

Neonatalambulancesinplace

Nooffunctionalregionalhospitals

Nooffacilitiesaccreditedforexcellentnewborncare

Responsetimes

Qualityoftraining

Improvedreferralpatterns

Neonatalmortalityrates

Perinatalmortalityrates

Admissionratesandcasefatalityrates

Meansofverification

Numberofteamsinplace

Visitreports

Trainingreports

Recordreviews

ClinicalAudit

Accreditationvisits

Equipmentaudits

PPIPdata

DHISData

StatsSAData

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INPUTINDICATORS

MonitorthebudgetandhumanresourcesforEssentialCare.Haveprovincesandfacilitiesallocatedadequateresourcesforessentialnewborncareatprovince,district,regionalanddistricthospitallevel?

• Hasthehospitalrevitalisationprogrammeincludedneonatalunits?

• Hastheprovinceidentifiedstaffforneonatalimprovement?

• Havethefacilitiesidentifiedstafftoprovidenewborncare?

• Hastheprovinceidentifieddistrictsupportteamsorexternalfacilitatorsandmentors?

PROCESSINDICATORS

Thiswilldependontheplanthatwasdrawnupbutmayincludethefollowing:

• Isthesituationassessmentcomplete,andcommunicatedtorelevantstakeholders?

• Hastherebeenadvocacyatcommunity,healthworkerandmanagementlevel?

• Haveactionplansbeendevelopedateachfacilityforimmediateaction,mediumandlongtermactivities?

OUTPUTINDICATORS

Whataretheresultsofactionplansrelatedtofacilities,staffing,training?

• Howmanytrainingcourseswereconductedandpeopletrained?

• Havethenormsandstandardsbeencompletedandadoptedbyfacilities?

• Areprovincialguidelinesinplace?

• Isthereareferralguidelineandtransportpolicy?

• Areotherprovincialjobaidsinplaceforexample,admissionbook,newbornrecord,monitoringcharts?

OUTCOMEINDICATORS

Outcomeindicatorsassesstheoutcomeofactionsintermsofquality.

• Whatisthequalityofthetrainingprovided?

• Whatisthequalityofpatientcare,isstandardclinicalcarebeingprovidedatfacilities?

• Whatistheresponsetimeoftheneonatalambulance?

• Arereferralpatternsappropriate?

Thiscanbeassessedbyclinicalaudit,andcommunitysatisfaction.TheaccreditationsystemdevelopedbyLINCincludesanassessmentofthequalityoftheserviceprovided.

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IMPACTINDICATORS

Theimpactindicatorsmeasurewhethertheservicehashadanimpactandachieveditsobjectives.Iftheobjectivewastodecreaseneonatalmortalitytrendsintheneonatalmortalityratesmustbemeasured.

Impactindicatorswillnotshowthedesiredimprovementifaprojecthasnotbeenimplementedtoscale,orifaspectsoftheimplementationhavebeenincomplete.

Theimpactmeasuresforessentialnewborncareinclude:

• Neonatalmortalityrate

• Intrapartumasphyxiarates(SBrates)

• Causespecificmortalityrates

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ACCREDITATION

TheaccreditationprocessinLimpopowassetuptomotivate,monitorandrewardhospitalsforachievingthesetnormsandstandardsforneonatalservices,andasetclinicalstandardfornewborncare.Theaccreditationsystemincludesanumberofcomponents

Accreditationassessesallaspectsofnewborncare.

InLimpopoHospitalsapplyforaccreditationoncetheyareready.Ateamconsistingofexternalandinternalmembersvisitandassessfacilities,services,staffingandnewborncare.Thelatterisassessedbyrecordreviewandclinicalaudit.

Hospitalsthathaveachievedaccreditationdidsomostlybecauseofgoodclinicalcareprovidedtonewborns.Thosethatdidnotoftenhadfacilitiesandequipmentinplacebutfailedtoprovideanadequatelevelofclinicalcare.

InthefirstroundofaccreditationfacilitiesachievedSilver,GoldandPlatinumrankingsaccordingtothesystemdescribedbelow.Theintentionisthatthesewillbeadjustedforthenextroundofaccreditation.

Accreditationisvalidforaperiodof2–5years.

Theaccreditationutilisesthecomprehensivesituationassessmenttoolstoassessfacilities.

SILVER

EachoftheitemsintheHospitalVisitcheck-listmustbeinplacewithascoreof65%plus

Criteriaareasthatarenon-negotiableare:

• Checklistscored65%plus

• 12stepstoKMCimplemented

• Admissionrecordsused

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• Observationrecordsused

• Oxygenmonitoring

• Statisticsavailableinthe1000–1999gbirthweight

• Evidencethattheneonatalmortalityrateinthisweightgroupisimproving

• LevelIIfacilitiesmusthaveCPAP

• Patientrecords(qualityofcare)scoremorethan60%

GOLD

AllthecriteriaasforSliver

Additionalitemswhichareessential:

• Check-listscores75%plus

• CPAPavailableandbeingusedappropriately

• Multi-parametermonitoring

• Infusionpumps

• Decreasedmortalityratein1500–1999gbirthweightgrouptolessthan50/1000

• Abilitytointerprettheperinatalstatistics

o ● Patientrecords(qualityofcare)scoremorethan70%

PLATINUM

AllofthecriteriaforSilverandGold

Additionalessentialitemsare:

• Check-listscores85%plus

• In-servicetrainingforstaffinthehospital

• Out-reachtotheDistrict–clinics

- hospitals

- training

- perinatalauditmeetings

Patientrecords(qualityofcare)scoremorethan80

ThisworkislicensedunderaCCBY4.0InternationalLicense.

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