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JULY 2017
This guidance product was prepared by University Research Co., LLC (URC) for review by the United States Agency for
International Development (USAID) and authored by Peter Mutanda, Janice Kangai, Charles Kimani, and Linda Chebet
of URC. It was carried out under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project,
which is made possible by the generous support of the American people through USAID.
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
REPUBLIC OF KENYA
TECHNICAL REPORT
Improving Reproductive, Maternal,
Newborn and Child Health in Kenya
JULY 2017
Peter Mutanda, University Research Co., LLC
Dr Janice Kangai, University Research Co., LLC
Charles Kimani, University Research Co., LLC
Lindah Chebet, University Research Co., LLC
DISCLAIMER
The contents of this report are the sole responsibility of University Research Co., LLC (URC) and do
not necessarily reflect the views of the United States Agency for International Development or the
United States Government.
Acknowledgements
We thank Kenya’s Ministry of Health, health leadership in all participating counties in Kenya and all
the health care facilities and teams across the country who contributed immensely in providing the
platform for testing improvement ideas. We acknowledge the contribution of the USAID supported
health service delivery mechanisms, APHIA plus from (since 2012) and Afyas (from 2016) over the
duration of the ASSIST Project in Kenya for their support at both operational and technical aspects in
actual field activities.
This report was prepared by University Research Co., LLC (URC) under the USAID Applying Science
to Strengthen and Improve Systems (ASSIST) Project, which is funded by the American people
through USAID’s Bureau for Global Health, Office of Health Systems. The project is managed by
URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global
partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T. H. Chan School of Public
Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns
Hopkins Center for Communication Programs; and WI-HER, LLC.
For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or
write [email protected].
Recommended citation
Mutanda P, Kangai J, Kimani C, Chebet L. 2017. Improving Reproductive, Maternal, Child, and
Newborn Health in Kenya. Technical Report. Published by the USAID ASSIST Project. Chevy Chase,
MD: University Research Co., LLC (URC).
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya i
TABLE OF CONTENTS
Acronyms .................................................................................................................................................ii
I. INTRODUCTION ............................................................................................................................. 1
A. Background ..................................................................................................................................... 1
B. Maternal, Newborn and Child health in Kenya ............................................................................... 1
C. Purpose of this document ............................................................................................................... 2
II. QUALITY IMPROVEMENT IN RMNCH ........................................................................................... 2
A. Initial QI set up ................................................................................................................................ 3
B. Improvement teams ........................................................................................................................ 4
C. Experiences from Coaching QI ....................................................................................................... 4
1. Training ................................................................................................................................... 5
2. Supervision versus Coaching.................................................................................................. 5
3. Subject matter expertise versus management roles ............................................................... 5
4. Coach-to-Coach peer support ................................................................................................. 5
5. Operational support ................................................................................................................. 5
6. Incentives for QI at the service delivery level .......................................................................... 6
7. Systems approach .................................................................................................................. 6
D. Learning Sessions .......................................................................................................................... 6
1. Preparation .............................................................................................................................. 6
2. Participation............................................................................................................................. 7
3. Presentations .......................................................................................................................... 7
4. Experience sharing from other counties ................................................................................. 7
E. Results ............................................................................................................................................ 8
F. Transition of QI support .................................................................................................................. 8
III. A closer look: Isiolo County ............................................................................................................. 9
A. Implementation ............................................................................................................................... 9
IV. CONCLUSIONS AND RECOMMENDATIONS ............................................................................. 13
A. CONCLUSION .............................................................................................................................. 13
B. RECOMMENDATIONS ................................................................................................................. 13
APPENDICES ....................................................................................................................................... 14
Appendix I: QI Action Plan .................................................................................................................... 14
Appendix II: QI team maturity index ...................................................................................................... 15
Appendix III: Team journal .................................................................................................................... 18
Appendix IV: Data collection guides ..................................................................................................... 22
Appendix V: Changes rating table ........................................................................................................ 24
Appendix VI: Detailed change package from Isiolo County .................................................................. 25
Appendix VII: CASE STUDY ................................................................................................................. 30
ii Improving Maternal, Newborn, and Child Health in Kenya
Acronyms
APHIA AIDS Population and Health Integrated Assistance
ASSIST USAID Applying Science to Strengthen and Improve Systems Project
CHMT County Health Management Team
FBO Faith-based organization
FP Family planning
HCI USAID Health Care Improvement Project
HR Human resources
IP Implementing partner
KDHS Kenya Demographic and Health Survey
KQMH Kenya Quality Model for Health
M&E Monitoring and evaluation
MDG Millennium development goals
MLEAC&SS Ministry of Labor, East African Community and Social Security
MNCH Maternal, newborn, and child health
MOH Ministry of Health
NASCOP National AIDS and Sexually Transmitted Infection Control Program
NHIF National Health Insurance Fund
OVC Orphans and vulnerable children
QI Quality improvement
QIT Quality improvement team
RMNCH Reproductive, maternal, newborn and child health
SDG Sustainable development goal
TFR Total Fertility Rate
URC University Research Co., LLC
USG United States Government
USAID US Agency for International Department
WHO World Health Organization
WIT Work improvement team
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 1
I. INTRODUCTION
A. Background
The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project began working in
Kenya in October 2012, building on the work of the USAID Health Care Improvement Project (HCI). In
Kenya, ASSIST supported the Ministry of Health (MOH); the Ministry of Labor, East African
Community and Social Security (MLEAC&SS); the National AIDS and Sexually Transmitted Infection
Control Program (NASCOP); United States Government (USG) implementing partners (IPs); and
county governments to design, develop, and implement strategies to enhance the quality of health
service delivery. From 2012-2017, ASSIST worked to improve programs and services related to:
reproductive, maternal, newborn, and child health (RMNCH) to reduce maternal and neonatal deaths;
malaria to improve case management and strengthen the national program; HIV care and treatment;
and the care of orphans and vulnerable children (OVC).
ASSIST’s work in Kenya was purposefully designed to institutionalize the capacity for continuous
improvement in national, county, and health facility structures for health care delivery. ASSIST worked
closely with all relevant MOH units to ensure that the project’s support for facility-level improvement
work and engagement with county and sub-county structures is fully aligned with national policies and
strategies.
ASSIST sought to enhance the capacity of county governments and other USG partners to apply QI
techniques to improve and strengthen RMNCH services in Kenya. This was accomplished through: a)
building the capacity of the county governments to have effective improvement management
structures; and b) direct support for low-cost evidence based interventions while applying effective
improvement approaches at the facility level. The main focal areas for this activity were: tracking of
process and outcomes in the provision of quality essential and obstetric services; tracking of process
and outcomes in essential neonatal care services; provision of family planning (FP) services at the
facilities to reduce the service gap in FP uptake; and tracking the capacity of QI teams in maintaining
the QI initiative while scaling up good practices to other departments the same facility or to other
facilities.
B. Maternal, Newborn and Child health in Kenya
Kenya has made remarkable progress in improving RMNCAH outcomes in the last decade. Child
mortality has declined by over 20 percent since 2008 and the country achieved a total fertility rate
(TFR) of less than four. Stunting, which remained stubbornly high over the past two decades, has
started to decline. Six out of ten pregnant women now receive skilled care at childbirth and over half
get postnatal care. However, in Kenya today, many women, neonates, children, and adolescents
continue to suffer or die from conditions, which are preventable or treatable. Access to quality
RMNCAH services remains a challenge across all levels of care, while geographic, population sub-
groups, and economic inequities persist due to supply and demand side. (Kenya RMNCH Investment
Framework 2016).
Improving coverage for RMNCH services is a priority for the Government of Kenya as is reflected in
its Vision 2030, the Constitution of 2010 and the Health Sector Strategic and Investment Plan 2014-
18. The Government has introduced new policies as well as initiatives such as Free Maternity
Services which is now enshrined in the Health Act 2017 as a right, Elimination of User Fee for Primary
Care and the Beyond Zero campaign to address the critical barriers.
While global, regional, and national policies and strategies exist to improve RMNCH; and
interventions to prevent maternal, neonatal and child deaths are available in Kenya, RMNCH indices
remain poor. Progress has been hindered by poor policy implementation and weak health systems,
which do not engage with, or respond to, community needs (Kenya RMNCAH Investment Framework
Jan 2016). The country’s maternal mortality rate remains at a high level: 362 deaths per 100,000 live
births (Kenya Demographic and Health Survey 2014).
2 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
C. Purpose of this document
This report provides an overview of the USAID ASSIST Project’s experience applying quality
improvement (QI) to improve RMNCH services and reduce maternal and newborn mortality in Kenya
and offers practical guidance to county-level supervisors and implementing partners on leading QI
initiatives in the country. The report also offers as appendices, tools used by improvement teams to
carry out QI activities; a change package with recommended changes based on the experience of
health facilities’ achievements in improving quality in maternal and newborn care; and a case study
telling the experience of one site’s QI journey.
II. QUALITY IMPROVEMENT IN RMNCH
ASSIST aimed to support effective, sustainable QI approaches that could address the challenges
raised above and in recognition that newborn and maternal health and survival are closely linked.
ASSIST’s strategy was to apply a system approach to QI by providing technical assistance to county
governments to improve and strengthen RMNCH services in Kenya.
In Kenya, the strategy focused on a sample of counties with a spectrum of facilities selected and
developed as centers of learning through which QI was applied to generate change ideas that can be
scaled up across the system. Although with different levels of interactions over the implementation
period, the counties involved directly in the RMNCH work beyond a QI training were Nairobi, Nakuru,
Meru, Isiolo, Kakamega, Kilifi, Kitui, Kwale, Migori, Taita Taveta and Turkana.
The complete scale of reach may not be fully available in this report because of ASSIST’s mandate to
directly support select facilities while ensuring that county systems and direct service implementing
partners scale-up QI across the system. At scale, ASSIST’s support has influenced QI in the following
different ways over the project’s life span;
- Direct support – At least 45 facilities annually receiving direct QI technical guidance with
different improvement initiatives in RMNCH.
- Indirect Support - All the USAID-supported health service delivery mechanism received direct
support from ASSIST.
- Systems support – 35 counties either trained or sensitized on QI under the Kenya Quality
Model for Health.
- Systems monitoring – Revision of monitoring tools to include RMNCH process of care
indicators at both national and county level.
To provide guidance to the counties and improvement team, ASSIST shared improvement aims and
indicators sheet containing 14 indicators. Counties and facilities were free to select from this list or
come up with any other process indicators based on their respective priority. This document later
highlights some of the process improvement from various counties. Table 1 shows a summary of
ASSIST implementation schedule for QI in RMNCH from 2013 to 2017.
Table 1: Summary of ASSIST’s Implementation Schedule 2013-2017
Year County and Number of facilities receiving direct continuous QI support by ASSIST
Comments
2013 Kwale (16 facilities) Isiolo (8 facilities) Kitui (12 facilities) Nairobi (10 facilities) Migori (15 facilities) Meru (15 facilities) Nakuru (10 facilities)
Training conducted for the seven counties and initial setting up of improvement teams. All facilities would focus on either/or HIV/AIDS and RMNCH programs.
2014 Minimal facility level support, focused more on national scale-up.
Scale up of QI through joint, multi-agency trainings and orientation to 35 counties across the country.
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 3
2015 Kitui (12 facilities) Kakamega (10 facilities) Taita Taveta (8 facilities) Isiolo (8 facilities) Nairobi (10 facilities)
Focused narrowed to MNCH program areas/indicators, Nairobi QI activity support handed over to the USAID service delivery mechanism.
2016 Turkana (10 facilities) Taita Taveta (10 facilities) Kakamega (8 facilities) Migori (8 facilities) Kitui (10 facilities)
Focus narrowed to USAID’s RMNCH focus counties, Isiolo, Taita Taveta and Nairobi replaced with Migori, Turkana and Kilifi.
2017 Turkana (10 facilities) Kilifi (7 facilities) Kakamega (9 facilities) Migori (8 facilities) Kitui (13 facilities)
Transition period and further support in setting up county QI structures and USAID’s service delivery mechanisms.
A. Initial QI set up
Quality improvement work in Kenya started with trainings on the Kenya Quality Model for Health
(KQMH) by the Ministry of Health’s Department of Standards and Quality Assurance and ASSIST.
Seven counties were initially trained in 2013, although there wasn’t a focus on RMNCH at the time,
but general health care improvement. The purpose was to introduce QI concepts at a general service
delivery level. In the seven counties, there was a mix in the selection criteria for facilities to be
provided with direct support on QI. The concept of selecting the ‘Centers of Excellence’ was agreed
upon discussions with USAID’s regional health service delivery mechanisms, AIDS Population and
Health Integrated Assistance or APHIAs.
Uptake of implementation of QI in facilities largely depended on the respective APHIAs’ readiness to
adopt to the QI framework and the county’s will and support. ASSIST embedded QI advisors in
selected counties where operational support would be provided by the regional APHIA Plus office.
The initial stations for the ASSIST staff were Isiolo (for APHIA Plus Imarisha), Nairobi and Kilifi
(APHIA Plus Nairobi/Coast), Kisumu (for APHIA Plus Western), Meru (APHIA Plus Kamili) and
Nakuru (APHIA Plus Nuru Ya Bonde). ASSIST technical staff would join the APHIA staff in joint field
visits as agreed upon in the work plan. In some instances, it was difficult to fit new QI initiatives into
an already approved APHIA work plan thereby slowing the implementation process.
As part of establishing uniformity in the application of QI across the country, the first step was to adopt
the Model for Improvement as adapted under KQMH that is simple, applicable and explains the steps
in improvement through three simple questions (see Figure 1). In past years, many agencies,
particularly non-governmental organizations (NGO’s) had ‘brand’ models which would really mean the
same thing but in more complicated jargon.
Another key approach that ASSIST advocated for was the collaborative approach, based on ‘all learn,
all teach, and all benefit’ principle. Here, facilities were clustered by their common characteristics e.g.
– geographical (facilities from one sub-county or one facility drawn from each sub-country), level of
care (high volume or referral facilities), services offered (facilities offering maternity or child care
services).
In 2014, there was re-direction of the project to focus mainly on scaling up QI to as many counties
through sensitizations and trainings. This was a joint effort by all USG service delivery partners,
national and county governments’ health departments. A total of 35 counties were trained by different
multi-agency teams. Many of the trained county and facility team didn’t have a post training follow-up
mechanism, and thus neither did they start any QI initiative or offered any guidance through coaching.
In 2015, ASSIST re-organized its QI support with a clear technical area mandate, to have HIV/AIDS
focus counties and MNCH focus counties. In MNCH, ASSIST focused their direct support to Isiolo,
Kitui, Taita Taveta, Kakamega, and Nairobi counties. Some of the gains made in 2014 had been lost
and in almost all counties, teams were to be re-established. Refresher trainings were conducted since
4 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
there had been a lot of human resource
restructuring as result of devolution. From the
lessons learned in 2013 and 2014, it was
important then that the project focuses on
supporting service level QI while supporting
the counties have supporting structures. At the
end of the project year, ASSIST handed over
its support for Nairobi County to USAID-
supported Afya Jijini Project.
There were changes in the MNCH focus
counties in 2016 with the exclusion of Nairobi
and the dropping of Taita Taveta. Two new
counties, Kilifi and Migori, were added to the
support counties.
ASSIST worked with the supported counties to
establish county QI support structures
including; a County QI Office (although
referred to by different names in each county),
include QI as part of the county health
strategic and investment plans, and coordinate
QI in RMNCH services through the county
Technical Working Groups (TWG).
B. Improvement teams
The ideal administrative strategy for QI is to have a County QI team (QIT), led by the County Quality
Improvement Officer or coordinator. Members include a few representatives of the County Health
Management Team (CHMT), members of the sub-county health management team, and coaches. All
the supported counties have active QIT with a designated point person to coordinate all quality
initiatives in the county. This is followed by a sub-county QIT, which includes members of the Sub-
County Health Management Team and coaches. This is followed by facility QITs in the smaller
facilities (i.e. health centers and dispensaries) and in large facilities, departmental work improvement
team (WITs).
ASSIST aligned its assistance to the national KQMH which underlines different responsibilities for QI.
QITs mainly provide stewardship, advocate for resources, and provide technical guidance to the
WITs. The WITs mainly comprise frontline health workers who look at process improvement in their
respective departments. This was done with on-site coaching on use of common QI tools in work area
improvement (using 5-S principles), problem identification (priority matrix and affinity diagrams),
prioritization (Pareto principles), root cause analysis (cause-effect diagram and 5-why), measurement
of process indicators, tracking, and presentation of improvement (time series charts). The WITs would
brainstorm on the gaps, prioritize improvement initiatives and then institute changes to their
processes and track performance with the support of a coach. They developed action plans to
organize their work (see Appendix I). The duration of the meeting times was dependent on the team
itself. Factors that determine meeting times vary from situation to situation but it is important for the
coach to understand the basics of conducting a meeting. Because of the often very busy working
environment, a typical QI meeting shouldn’t last more than an hour.
C. Experiences from Coaching QI
Coaching is supporting individuals and teams involved in improvement to implement their technical
knowledge and know-how to improve compliance with the norms, so that problematic processes will
run more smoothly and efficiently. The teams are led by trained coaches, who may or may not be
members of the health management team. The roles of a coach include being a facilitator, a trainer
and desirably, a QI expert.
Figure 1: Model for improvement
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 5
Over the course of implementing QI activities to improve MNCH care in Kenya, many lessons were
learned about maximizing coaching. ASSIST offers counties and IPs the following lessons and
recommendations.
1. Training
Training is an essential part of QI. Most short trainings take a standard five days and this is what
ASSIST was to abide to in the initial QI trainings. However, this five-day training in many instances
doesn’t prepare the teams well enough for the post training activities. ASSIST recommends breaking
up of the traditional QI training into ‘bite-sizes’. This needs a lot of pre-training preparation by the
technical staff. Retention into the activity is also critical. Out of the 30 coaches trained in QI for Isiolo
county in 2013, only eight would provide follow through coaching support to facilities.
2. Supervision versus Coaching
Many of the coaches were trained and experienced supervisor in the normal routine work. The
supervision, is often a fact- and fault-finding rather than a mentorship engagement with facility teams.
Mentorship is the essence element of coaching in QI. One critical difference between supervision and
coaching is that while the former is based on managerial principals, the latter is dependent on
personality, approaches, systems appreciation, and reception from the teams being mentored. It is
also helpful to make avenues for the field team to provide feedback on how the process of QI
coaching is undertaken, as teams are liberty to express their dissatisfaction with the coach’s
approaches.
3. Subject matter expertise versus management roles
It would later be realized that not all the managers of specific health programs were experts in the
field of operations. Much as coaching can be an abstract and universal way of mentoring; it greatly
helps if the coach has grounding knowledge and sometimes skills in the technical aspects of the
program area. We had instances where with a lot of push from the county government, non-core
medic cadres would be assigned coaching roles and often faced difficulties in building a cohesive
improvement team. It should not be assumed (and many times it is about conforming to a structural
culture) that all senior or middle-level program managers can, by default, be QI coaches. There were
instances where junior officers offered very good mentorship to QI teams.
4. Coach-to-Coach peer support
In situations where there would be clear capacity gaps in mentoring aspects, coaches would be
paired to support each other. This led to a revision of coaching strategy. Initially, a coach would be
assigned one facility each, later changed to assigning two coaches to two facilities at the same time.
In this way, the two would cover for each and at times have joint coaching sessions with the support
of the ASSIST technical team.
5. Operational support
A lot of investment should go into logistics in the initial stages of the improvement activities. For
example, programs must invest in more frequent visits to facilities for at least three months. There is
no desired number of visits to offer coaching but from experience, there needs to be some level of
contact between the coach and the WITs at a minimum, every fortnight. The frequency can be
decreased to monthly meetings, then revert to fortnightly or even weekly meeting depending on the
improvement initiative at hand. The investment in time spent with teams is heavy in the initial stages,
but it eventually evens out as teams become more self-driven with understanding of the benefits of
QI.
One of the tools ASSIST developed to guide coaches in supporting teams was the QI team maturity
index (see Appendix II). Coaches could use the scoring criteria to gauge how well a team was
functioning and to identify capacities for the team to work toward.
6 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
6. Incentives for QI at the service delivery level
Quality improvement initiatives can be slow and frustrating in the early stages. Traditionally, facilities
are accustomed to reporting service outputs that are always reported upstream to national health
information systems. When ASSIST started supporting QI at facility level in 2013, there were
difficulties convincing the county and facility teams to focus their measurements on processes.
Examples abound:
• Report the number of deliveries versus the frequency of measuring blood pressure during the
process of childbirth.
• Easy to report number of antenatal care (ANC) attendance as opposed to monitoring how
many of the new ANC women receive the essential package of services.
• Facilities can easily count the ratios of caesarian section at a facility but find it difficult to
monitor time taken to prepare a woman for caesarian section.
• It is very easy to count the number of tins/liters of the disinfectant received and used every
month, but where consistency in the supplies is an issue, a team would want to monitor the
frequency at which such commodities area available for use.
ASSIST has often insisted that the burden of measurements of outputs is often placed a lot on the
frontline health workers’ shoulders even if there are other factors involved. Empowering the frontline
health care workers to focus on processes is a good incentive because they feel the burden of what
happens daily at their place of work. From ASSIST’s Kenya experience, it can be a difficult issue to
balance between the need for ‘reach all’ strategies as governments many times insist on equity and
access which are easy to measure, as opposed to efficiency and effect which often focus on
improving what is already in the system. There is also the push to get the ‘numbers’ as projects’
contractual obligations, which often compromises the quality of care.
7. Systems approach
ASSIST’s mandate to influence QI at all streams of governance was useful in the sense that changes
were made at service delivery while county and national structures were strengthened. This followed
the review of the KQMH (in completion stage as at June 2017). The document includes monitoring
critical processes of care. Over the period of ASSIST’s work in Kenya, there was continuous review of
monitoring tools used by different quality management entities at both national and county levels,
including the national health insurer, the National Health Insurance Fund (NHIF). The RMNCH quality
of care process measurements are now part the NHIF as an essential aspect of assessing facilities
for rebates/reimbursements.
D. Learning Sessions
Learning sessions were held throughout the life of the improvement work to enable facilities to
showcase their work, share experiences, learn from one another and in creation of best practices that
dictates the change package. In Isiolo 3 learning sessions were held; 2 in Kakamega and Kitui; and 1
in Taita Taveta. All remaining counties participated in these learning sessions.
1. Preparation
Preparation for learning sessions start at inception Every team is aware that after a few months they
will be expected to showcase their improvement work as they share and learn from other teams.
Thus, the teams are encouraged to keep minutes for each meeting detailing the challenges and
results as they implement using the team journal (Appendix III). At least a month before the learning
session, the teams come together and have the learning session as an agenda in their meetings.
Each team picks an indicator or two which has had successful improvement. The team then compiles
information from the background and history of the facility and/or department. A learning sessions is a
two-day activity but requires similar preparation as for a five-day short course training.
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 7
The teams then follow a guideline to come up with an abstract. Most of the information is found in
their minutes: aims and objectives, change ideas tested, benefits and challenges, amongst others.
A coaches’ meeting is held before the learning session with representation from the various
improvement teams in the collaborative.
2. Participation
Each learning session was held in a different county and most participants come from the host
county. It is important to involve the county’s health care leadership in the learning session. In all the
learning session that ASSIST was part, we had either County health executives or at least the county
health director as well as the CHMTs from participating counties also attend. To foster close inter-
governmental (county-national) collaboration, an officer from the national division or program of
interest is invited to attend the learning session. Participation is drawn from the facilities who have
improvement initiatives to share and facilities with no improvement initiatives to provoke initiation of
their own QI activities.
Every other county that implements QI in a program area has a QI officer as well as a coach or a
team member representing them.
The different non-state agencies and implementing partners in the counties that have QI activities
also participate. They take the opportunity to explain their roles and even identify areas to collaborate
work on based on the different counties’ experiences.
3. Presentations
The most common mode of presentation used is a poster (preferably size 0), which gives in-depth
details on the background of the facility/department and the team’s QI process. This can also be
improvised by using newsprints and marker pens.
The presentations are done by the WITs and not the coaches. The coach is only there to provide
support and offer clarifications as required. Teams are encouraged to have more than one presenter
to allow them to also move around and listen as well as learn from other improvement teams. Each
WIT is provided an exhibition station with enough space for small group discussions. Participants are
divided into different groups and each group moves around to different stations listening, asking
questions, and making recommendations.
After a cycle of presentations, participants sit in groups and discuss as well as have a plenary
discussion on what they have learned. These cycles are repeated until all participant groups have
viewed all the presentations.
In addition to the presentations, emerging important topics are discussed by different facilitators,
depending on feedback from the presentations. Short sessions on improvement science, the steps of
QI and the tools used are some of the topics commonly reference for emphasis during the learning
sessions. A few individual and group exercises are also done at this point. This is to ensure clarity for
participating teams as well as information for new participants. PowerPoint presentations is the most
common mode of presentation, but handouts can also be distributed to participants for further
reference.
4. Experience sharing from other counties
Each visiting county is expected to show their QI journey and share their experiences. The counties’
representatives give a general background, a status update, and show their QI journey. At this point
overall county performance and/or specific facility/department performance is also outlined. This is
followed by a plenary discussion where all participants are encouraged to comment. Other counties
are also able to share their change ideas during the host county presentations as they move around
the stations in groups and in the plenary discussions that follow.
Since most learning sessions are shared activities, some new participants give feedback and ask for
assistance in their facilities to start implementing. These learning sessions are good start points for
8 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
scale-up and spread of QI. Change ideas are also shared and some teams will try and test the learnt
change ideas in their improvement process.
Motivation of the teams is an important result of the learning sessions. Improvement teams are both
challenged and/or recognized for their good work. They are exposed to audience and many have
proceeded to provide presentation in bigger international forums after. This helps team members work
harder and goes along way into ensuring sustainability. All materials used for explaining the QI
process and tools are shared with the participants for later use.
E. Results
In Kitui, 12 facilities increased the percentage of women giving labor with a complete partograph from
31% in January 2015 to 90% in May 2017. Also in Kitui, the 12 sites increased the percentage of
deliveries for which oxytocin was delivered within one minute of delivery from 42% in April 2015 to
82% in January 2016. In Turkana, the percentage of deliveries with complete partographs increased
from 13% in April 2016 to 84% in May 2017. In Migori, partograph use increased from 6% in July
2015 at one site to 91% by May 2017 in six sites. Oxytocin delivered within one minute of delivery
increased from 83% in July 2016 to 94% in May 2017. See Figure 2.
Figure 2: Proportion of women giving birth in health facility with complete partograph in Kitui,
Turkana, and Migori counties (January 2015-May 2017)
F. Transition of QI support
ASSIST has planned in its final year work plan to close out all activities at the end of the third quarter
with the last quarter left for project close out and transition. The transition plans include;
• Putting together learning materials for knowledge sharing and learning
• Conduct meetings with stakeholders on project’s transition plans and how both government
and non-government organs can continue providing support for quality improvement
• Provide an analysis to the counties on the costs
• Structural support to ensure governance and policy direction
• Conducting team functionality assessments (see Appendix II for QI team maturity index).
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 9
III. A closer look: Isiolo County
Isiolo County is one of the 47 counties within Kenya and is among the 15 counties with the highest
maternal mortality ratios at 790/100,000 live births. ASSIST began support to Isiolo County to improve
RMNCH services in 2013, and it is one of the counties that had, through county health management
expressed desire to collaborate with ASSIST and other partners to quality of care. ASSIST worked
with the APHIA Plus Imarisha Project. APHIA Plus Imarisha selected some high-volume facilities from
the counties they support, and ASSIST supported and trained select staff from those facilities. APHIA
Plus Imarisha technical teams worked with the facilities to collect baseline data from the facilities and
the data was used to determine where to focus improvement. Indicators that were performing below
national expectations were identified. A QI collaborative of high-volume facilities was selected in Isiolo
County, initially focusing on HIV care and treatment and RMNCH between 2013-2014, but narrowed
the focus to RMNCH from 2015.
A. Implementation
In Isiolo, QI training was conducted in August 2013, where a team of 30 health care workers drawn
from county and sub-county management and representatives from high volume facilities were
trained. This was at a time when counties were going through structural changes following devolution
of health services to the county level. Ten facilities were selected and fifteen coaches attached to
various facilities.
These teams looked at QI process and outcome indicators on reduction in the variation of care
provided at ante-natal clinics, completion of four ANC visits, delivery by skilled birth attendants,
improved monitoring of labor and management of third stage of labor, post-delivery care of mother
and baby, care of the newborn and reduction of infection in maternity units and family planning
services at facility level. WITs included nurses, clinical officers, medical officers, nutritionists,
laboratory technologists, hospital administrators, support staff, and student interns.
Subsequently, two more of QI and KQMH trainings were done supported by the Isiolo County by
national government supported with technical facilitation by ASSIST. Currently, Isiolo County is self-
sufficient and has trainers that continue training the other members of staff and have been called to
support QI in two neighboring counties of Marsabit and Samburu.
Isiolo County QI activities took place at eight facilities: Isiolo County Referral Hospital, Avi Matercare
Mission Hospital, Oldonyiro Dispensary and Eremet Dispensary of Isiolo Sub-County, Kinna Health
Center, Sericho Health Center, Garbatulla Sub-County Hospital of Garbatulla Sub-County and Merti
Health Center of Merti Sub-County.
At an inception meeting with the county health management team, Isiolo county teams focused on
addressing the following indicators:
• Reduce neonatal sepsis from 27% to less than 10% within 12 months (for the Isiolo County
referral hospital.
• Improving monitoring of labor
• Improve hemoglobin (Hb) screening at first ANC visit
• Increase complete ANC attendance
• Improve administration of oxytocin within one minute of delivery.
These were considered top priorities based on baseline data.
Descriptions of how teams collected data to track these indicators is available in Appendix IV.
For each of these five improvement areas, teams in Isiolo tested various change ideas and monitored
their effect on the indicator of interest using a time series chart. At the beginning of the
implementation, teams were at different levels in their respective QI steps. ASSIST would support
10 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
monthly coaches’ meetings to discuss each team’s progress in their improvement journeys. The WITs
that worked on each area were asked to review the collated changes from across the county and rate
each change based on a 1-5 scale according to:
• Evidence from guidelines in support of the change;
• Evidence from pilot test, what results did the change yield;
• Relative importance of the change;
• Difficulty or complexity;
• Scale-ability, how replicable is the change.
The tool teams used to rate the changes is available in Appendix V. The collated set of changes
tested and recommended by WITs in Isiolo is found in Appendix VI. Below, we summarize the main
changes that teams in Isiolo found to be effective to improve each indicator and describe the results
across a few facilities. Appendix VI provides additional details on how the sites carried out each
change to guide other facilities that might wish to try these changes.
Reducing neonatal sepsis
To reduce neonatal sepsis, teams tested the following changes:
• Require regular hand washing by all people handling neonate;
• Structured hand-over procedures;
• Increase number of trained critical newborn care nurses;
• Avail clean baby wraps for babies after delivery;
• Motivate newborn care nurses through capacity building;
• Orient all staff in the newborn unit on infection prevention and control (IPC) protocols;
• Educate patients on handling of the newborn;
• Establish an isolation room for the very sick babies; and
• Educate women about personal hygiene especially before handling their infants.
Isiolo County Referral Hospital achieved a significant reduction in the percentage of neonates with
suspected or confirmed sepsis, from 22% in September 2015 to 0 in September 2016 (Figure 3).
Figure 3: Percentage of neonates with suspected or confirmed neonatal sepsis, Isiolo County
Referral Hospital (September 2015-September 2016)
0%
5%
10%
15%
20%
25%
Wk1
-Se
pt
Wk3
-Se
pt
Wk1
-Oct
Wk3
-Oct
Wk
1 -
No
v
Wk3
-No
v
Wk1
-Jan
Wk3
-Jan
Wk5
-Jan
Wk2
-Fe
b
Wk4
-Fe
b
Wk2-…
Wk4-…
Wk1
-Ap
r
Wk3
-Ap
r
Wk1
-May
Wk3
-May
Wk1
-Ju
ne
Wk3
-Ju
ne
Wk5
-Ju
ne
Wk2
-Ju
ly
Wk4
-Ju
ly
Wk2
-Au
g
Wk4
-Au
g
Wk1
-Se
pt
Wk3
-Se
pt
0
100 Den: Number of live births at Isiolo County RH
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 11
Improving monitoring of labor
To improve monitoring of labor, teams tested the following changes:
• On site mentoring staff on use of partographs
• Pairing of experienced and new staff
• Proper handing over during shift changes
• Emergency Obstetric and Newborn Care training
Sericho Health Centre increased the proportion of women delivering who had a complete partograph
from 33% in January 2016 to 100% in September 2016 (Figure 4). Garbatulla Sub County Hospital
increased it from 77% in January 2015 to 92% in September 2016 (Figure 5).
Figure 4: Proportion of women delivering who had a complete partograph, Sericho Health
Center (Jan 2016-Sept 2016)
Figure 5: Proportion of women delivering who had a complete partograph, Garbatulla Sub
County Hospital (Jan 2015-Sept 2016)
Improving hemoglobin (Hb) screening at first ANC visit
To increase Hb screening at first ANC, teams tested the following changes:
• Ensuring lab request is written for mother
• Procure laboratory testing services
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
J-16 F-16 M-16 A-16 M-16 J-16 J-16 A-16 S-16
Percentage
Proportion of women giving birth in the health facility with a complete partograph in Sericho Health Centre, January – September, 2016
0%
20%
40%
60%
80%
100%
J-1
5
F-1
5
M-1
5
A-1
5
M-1
5
J-1
5
J-1
5
A-1
5
S-1
5
O-1
5
N-1
5
D-1
5
J-1
6
F-1
6
M-1
6
A-1
6
M-1
6
J-1
6
J-1
6
A-1
6
S-1
6
Proportion of women giving birth in the health facility with a complete partograph in Garbatulla SubCounty Hospital, January, 2015 –
September, 2016
12 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
See the MaterCare case study to see how one team improved HB screening in first ANC in Appendix
VII.
Increasing complete ANC attendance
To increase complete ANC attendance, teams tested the following changes:
• Informing patients on importance of early ANC care
• Integrate health education at FP clinics, child welfare clinics, general outpatients and special
clinics
• Introduction of mama-baby kits for women completing 4 ANC visits
• Transport reimbursement for mothers
• EmONC training
• Introduction of cash tokens for TBAs
• Training of TBAs to refer pregnant women to health facilities for early ante-natal care
It is important to note that achievements in increasing complete ANC attendance were a result of not
only facility-based changes but also inputs from partners, including APHIA Plus, UNICEF, and
AMREF. While teams worked on this, it was not tracked as a key indicator.
Improving administration of oxytocin within one minute of delivery
To Improve administration of oxytocin within one minute of delivery, teams tested the following
changes:
• Continuous on-the-job education on critical intra-partum care practices
• EmONC training
• Handover notes and delivery information to contain administration of oxytocin
• Avail heat-stable oxytocin
• Pre-filling syringes
• Having a cold box with oxytocin in the delivery room.
Through testing these changes, the 8 facilities implementing improvement activities in Isiolo County
increased the percentage of births where oxytocin was delivered within one minute of delivery from
42% in January 2015 to 100% in September 2016 (Figure 6).
Figure 6: Percentage of deliveries at the health facility for which oxytocin was delivered within
one minute of delivery, 8 facilities, Isiolo County (Jan 2015-Sept 2016)
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 13
IV. CONCLUSIONS AND RECOMMENDATIONS
A. CONCLUSION
Quality improvement is important to ensure that every person receives the best quality of care in any
health service facility in this county. Quality Improvement can be implemented in any industry and
should be simplified for application at industry and individual levels. Change is the heart of
improvement. Not all changes will bring about improvement, but testing of changing ideas proves
those that are worth standardizing and sustaining. QI teams need support to remove the burden of
looking for excellence but rather focus on small, continuous, measurable improvements in their daily
processes. Excellence will ensue.
B. RECOMMENDATIONS
It is recommended that the counties sustain those practices that have been proved to bring about
positive change, to sustain QITs and WITs at the county and facility levels and to apply the science of
improvement in all sectors of health. Some key recommendations include;
a. Investment in QI: While almost all QI approaches focus on evidence-based applications, there
is need for a continuous investment in focusing of frontline healthcare workers to the core
processes that influence patient care outcomes. This requires, many times, intense coaching
and processes measurement.
b. Focused approaches: Facility specific QI strategies as opposed to overall direction from the
county. The burden of improvement need to be left to the frontline workforce, but with assured
consistent technical support from management.
c. Bite-size QI learning: Having long QI training can be wasteful. QI trainings should be delivered
in mini doses with a clear follow-up mechanism. Having a 5-day QI training with no clear
investment or mechanism in team coaching, does not help even if a county or facility has a QI
department.
d. Establish a national award mechanism: As QI becomes slowly but surely engrained in the
health care system, there need be a structured award system. This can be designed to
recognize best efforts by individuals or QI team.
e. Online modules on quality improvement: An accessible short modular courses or reminders
can be available in the mainstream media platforms for the on-the-go medical practitioners.
They only need to customized to the local context.
f. Pre-service training: Include as a practicum a QI project in core health sciences courses– this
has been on-going but the process need to be fast-tracked
g. Cross county benchmarking: It is common to hear experiences from technical staff from
overseas technical tours. While there is a lot to learn from the global community, much is
sometimes left closer home. There need to be structured compilation of successful initiatives.
This can be done through a national guidance on regular inter-county learning sessions.
h. Conduct Virtual Learning Sessions: With the advent of online sharing platforms, team from
different parts of the world can share their QI journeys and experience through live internet
video feeds.
14 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
APPENDICES
Appendix I: QI Action Plan
INTEGRATED APPROACH TO QUALITY IMPROVEMENT ACTION PLAN Date______ Month ________ Year ______
Name of Facility ____________________________ Type of Facility: Dispensary ____ Health Center_______ Hospital ____________ Names of QI Team Members: Position at Facility Names of QI Team: Position at Facility 1. ________________________ 6.________________________ 2. ______________________ 7.________________________ 3. ________________________ 8.________________________ 4. ________________________ 9.________________________ 5. ________________________ 10.________________________
ACTION PLAN
Issue/Indica
tor
Identified Performance Gap
Change Package (Solutions/Actions/Next Steps)
Responsible Person(s)
Time
Fram
e
(By
Whe
n)
Resources needed
Status of Resolution (Not started, in progress, Completed)
Quality Improvement Coach: ____________________________________
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 15
Appendix II: QI team maturity index
This is used to measure the growth of the improvement teams, and to ensure their purpose is being
met.
QI Team Maturity Index1 Facility Name: …………………………………………………… Date: …………………………………………….. Purpose: To monitor progress in team maturity as they work through different stages of improvement and care steps.
Expectations: a) At the end coaching visit, coaches will discuss and provide a score for the team b) Coaches will review the team score as they are planning for the next visit c) The team will progress to a stage of maturity, working independently, at some point in the
project d) A score should be provided for each team at least once every quarter
Assessment/Description Definition
Score 1.0
Forming Team
Team has been formed and oriented on aims, target population
Team has held discussions on a minimum of one care component
Score 1.5
Planning for the improvement
has begun, but no changes
Team is actively meeting (with minutes of meetings, discussions)
Plans for testing changes have been made
No tests of changes have begun
Some baseline data may be collected
Score 2.0
Changes tested, but no improvement
Some changes are being tested in one or more care steps
Data on key measures is being collected, analyzed and reported
No improvement in measures
Score 2.5
Some changes are being tested in one or more care steps
Data on key measures is being collected, analyzed and reported
1 Adapted from the Institute for Healthcare Improvement’s (IHI) Breakthrough Collaborative Series
16 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
Changes tested, initial improvement
Some evidence of improvement from sites based on simple
indicators or anecdotal evidence
May or may not be evidence of improvement in process
measures (depending on sensitivity)
Starting to articulate changes and activities to coaches and at
Learning Sessions
Score 3.0
Modest Improvement
Change ideas tested, successful change ideas implemented for
(at least one care step)
Testing changes for at least two additional care steps begun
Data on key measures is being collected, analyzed and reported
Evidence of moderate improvement in process measures (two to
three months of data showing improvement over baseline based
on run chart)
Ability to articulate changes and activities effectively to coaches
and at Learning Sessions
Score 3.5
Improvement
Change ideas tested, successful changes implemented for at
least three care steps
Testing changes for all other care steps begun
Data on key measures is being collected, analyzed and reported
Team shows ability to prioritize and analyze further details of care
steps which are not showing improvement
Evidence of improvement in process measures (three to five
months of improvement in data over baseline based on run chart)
Evidence of care consistently provided in the facility (based on
checklist indicators)
Sharing of improvement steps at other county/collaborative sites
at QI meetings and learning sessions
Score 4.0
Significant improvement
For all care steps, changes have been tested and implemented
Data on key measures is being collected, analyzed and reported
Sustained improvement in process and outcome measures
observable
Team prioritizes and analyses further details of care steps which
are not showing sustained improvement
Team requested to support other facilities/counties in
implementing similar changes
Score 4.5 Sustained improvement in at least 3 outcome and process
measures for a minimum of 6 months
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 17
Sustainable improvement
Involved in self-initiated or team-driven spread to a larger
population, new facilities/counties, or different content areas
observed
Score 5.0
Outstanding sustainable results
Consistent improvement of care steps and changes implemented
for entire facility for at more than three years
All goals have been accomplished
Invited to participate in conceptualization and implementation of
spread phase as an outstanding example and leader in QI
concepts
18 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
Appendix III: Team journal
This is a journal used by teams that summarizes all the steps of quality improvement. This is also kept
in a QI file.
IMPROVEMENT OBJECTIVE
Part 1
Name of Site_________________________________________________
Team Leader________________________________________________
Team
Members_________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________
Journal Start Date_______________________________________
End date_____________________________________________
Improvement Objective:
1. _________________________________________________ _________________________________________________
_________________________________________________
Indicator for the
Objective
Description of the problem:
Briefly describe the problem being addressed and gaps between the current situation and your
improvement objectives. State the differences between the MOH standard of care and the current
practices. Also, describe some of the challenges with the current situation.
Part 2: Changes Worksheet-QI Team activities: Please list below the changes that the team has tried out to achieve the improvement objective. Write all
changes, whether effective or not. Also, note when it was started and when it ended (where applicable) to enable you annotate the results.
Test Changes:
In the space below, list all the changes that you are
implementing to address the improvement
objective. Use 1-2 sentences to briefly describe the
tested change.
Start
date:
DD/MM/Y
Y
End Date:
(If
applicable)
DD/MM/YY
Effective?
(Yes/No)
Was there
any
improvement
registered?
Comments:
Note here any potential reasons why the
change was or was not effective; also,
indicate any change in indicator value
observed related to this change.
1.
2.
3.
4.
5.
Part 3: Graph Template- Annotated/Plotted Results:
• Use the graph below to document you progress. Indicate the value of the numerator and denominator.
• Note on the graph the time the change was introduced
Title_________________________________________________________________________________________________________________
Indicator Value
Time in 0 1 2 3 4 5 6 7 8 9 10 11 12 ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ _______
Numerator Denominator %
Numerator Denominator %
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 21
Please give brief explanations for any notable trends in the graph:
Notes on the indicator: Write down any additional comments you may have on the performance of
indicators. Write anything derived from the changes worksheet and the graph template that might
explain the performance trends of the improvement objective.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_____________________________
______________________________________________________________________________
Notes on the other observed effects: please write here any effects (positive or negative) you are
currently observing as a result of the quality improvement effort such as comments from patients,
changes in your performance motivation, improved efficiency or the survival story of a sick patient.
You may use your notes to tell the complete story at the next learning session(s).
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_____________________________
______________________________________________________________________________
22 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
Appendix IV: Data collection guides
Table 1: Indicator: Neonatal sepsis
Type of Indicator Outcome Indicator
Indicator Percentage of neonates with suspected or confirmed neonatal sepsis
Numerator Number of neonates with suspected or confirmed neonatal sepsis
Denominator Number of live births
Sampling Plan No sampling
Data Collection
Frequency
Weekly
Aim/Objective Reduce neonatal sepsis from 27% to less than 10% within 12 months.
Table 2: Indicator: Use of Partographs
Type of Indicator Process Indicator
Indicator Proportion of women giving birth in the health facility with a complete
partograph
Numerator Number of women giving birth in the health facility with a complete partograph
Denominator Number of women in labor at facility
Sampling Plan High volume facilities should extract data from the first 35 maternity records
per month; counting backwards from the last day of the month.
Small health facilities with less than 100 deliveries over the preceding 3month
period should include all available records.
Data Collection
Frequency
Monthly
Aim/Objective Specified target and duration to achieve
Table 3: Indicator: Hb Screening at 1st ANC Visit
Type of Indicator Outcome Indicator
Indicator Proportion of pregnant women screened for anemia during the first ANC visit
Numerator Number of women screened for anemia at first ANC visit
Denominator Number of first ANC visits
Sampling Plan No sampling
Data Collection
Frequency
Monthly
Aim/Objective Specified target and duration to achieve
Table 4: Indicator: Attendance of 4th ANC visit
Type of Indicator Outcome Indicator
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 23
Indicator Proportion of pregnant women screened for anemia during the first ANC
visit
Numerator Number of women screened for anemia at first ANC visit
Denominator Number of first ANC visits
Sampling Plan No sampling
Data Collection
Frequency
Monthly
Aim/Objective Specified target and duration to achieve
Table 5: Indicator: Administration of Oxytocin within 1 minute of Delivery
Type of Indicator Outcome Indicator
Indicator Percentage of deliveries with AMSTL documented (esp. oxytocin within a
minute of delivery)
Numerator Number of deliveries with AMSTL documented (esp. oxytocin within a
minute of delivery)
Denominator Total Number of deliveries in facility
Sampling Plan High volume facilities should extract data from the first 35 maternity
records per month; counting backwards from the last day of the month.
Small health facilities with less than 100 deliveries over the preceding
3month period should include all available records.
Data Collection
Frequency
Monthly
Aim/Objective Specified target and duration to achieve
Table 6: Indicator: Skilled Deliveries
Type of Indicator Outcome Indicator
Indicator Percentage of skilled deliveries in the facility catchment area per month
Numerator Percentage of skilled deliveries in the facility catchment area per month
Pregnant women in the catchment area completing at least 4 ANC visits
Denominator Expected number of deliveries in facility per month
Sampling Plan No sampling
Data Collection
Frequency
Monthly
Aim/Objective Specified target and duration to achieve
24 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
Appendix V: Changes rating table
Change Idea Evidence
from
guidelines
(1=Strongly
disagree
support,
5=strongly
agree)
Evidence
from pilot
test
(1=Strongly
disagree
support,
5=strongly
agree)
Relative
importance
(1=not
important
support,
5=very
important)
Difficulty or
complexity
(1=difficult,
5=easy)
Scale-
ability
(1=not
easily
replicable
or needs
work,
5=ready
to spread)
Total
rating
(out of 25
if all
categories
used)
Change Idea
1
Change Idea
2
Change Idea
3
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 25
Appendix VI: Detailed change package from Isiolo County
Changes to reduce neonatal sepsis
Gap or challenge being
addressed
Change(s) tested # sites tested this
change and ranking of
the change
How facilities tested this
change
Handling of newborns by
visitors was suspected to
contribute to infections to
the newborns
Regular hand washing of
all people handling
neonate
2 sites testing this change
rated it 5/5
Through the collaborative
with APHIA Plus Imarisha,
the maternity wings’ wash
basins were repaired and a
portable hand washing facility
was put at the wings’
entrance with written
instructions for the visitors to
wash their hands before and
after going into the wards.
Handover during shift
changes was inconsistent
and left babies
susceptible to sepsis
Structured hand-over
procedures
Both sites testing this
change ranked it 5/5
The teams changed
handover from reading case
files to receiving the patients’
reports at the bedside shift
handoffs.
There was only one
trained essential newborn
care nurse
Increase number of
trained Critical Newborn
Care nurses
One referral site
recommended this at 5/5
ASSIST supported two
nurses who were taken from
Isiolo to Kitui for a two-week
orientation on managing a
newborn unit
An orientation program by
the unit manager for all the
maternity staff on
management of newborn
units
Improve infection
prevention and control
Work area improvement
2 sites testing this change
rated it 5/5
Set up of weekly schedule of
general cleaning to be done
by all the maternity staff. This
initially included de-cluttering
the nursery wing and general
re-organization of the unit
through application of 5-S
principles. Isolation room for
very sick babies to reduce
exposure
Set up of isolation room
for sick babies
On site testing this change
rated it 5//5
Isolation rooms existed but
needed reorganization and
cleaning to be put into use
again
Out-sourcing of hospital
cleaning services
2 sites testing this change
rated 3/5
Managing of casual laborers
(cleaners) at the main referral
point became difficult and the
county government later
outsourced cleaning services
to an external company. This
wasn’t a unit’s sole idea, but
rather a result of intervention
by the hospital management
26 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
Improving monitoring of labor
Gap or challenge being
addressed
Change tested # sites tested this
change and ranking of
the change
How facilities tested this
change
Less than 30% of women
in maternity had labor
being monitored using a
partograph
On site mentoring staff on
use of partographs
5 facilities
Recommended at 5/5
The QI coach and ASSIST
program staff would visit
the teams during different
shifts to offer guidance on
how to use the partograph
Pairing of experienced
and new staff
5 facilities, recommended
at 5/5
The facility in-charge
would pair an experienced
midwife with a new staff to
provide continuous
guidance and mentorship
Proper handing over
during shift changes
5 facilities, recommended
at 3/5
The teams changed
handover from reading
case files to physically
walking around the ward
during shift handoffs.
EmONC training
20 facilities (in addition to
the 8 facilities engaged in
the QI activities, APHIA
Plus Imarisha supported
additional facilities to track
some output indicators),
recommended at 3/5
The county government
mobilized resources from
UNFPA, LSTM, DANIDA,
and USAID’s APHIA Plus
Imarisha to train all
facilities with delivery
services on EmONC (not
ASSIST funds).
By end of 2014, all
facilities had been trained
and ASSIST was part of
the training team to offer
sessions on QI.
Increasing Hb screening at first ANC visit
Gap or challenge being
addressed
Change tested # sites tested this
change and ranking of
the change
How facilities tested
this change
Ensuring lab request is
written for mother
5 facilities testing this
change rated it at 2/5
because of the
inconsistencies general
laboratory procedures
Weekly tracking by the
unit’s in-charge and the
lab team of number of
Hb testing against 1st
ANC attendance.
to look at improving the
hospitals infection prevention
Educating women about
personal hygiene
especially before handling
their infants
This was done through
routine health education after
delivery. Messaging of good
personal hygiene are part of
routine pre- and post-delivery
patient education
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 27
Less than 30%
screening of Hb at first
ANC
due to cost-related
issues.
Procure laboratory
testing services
1 facility, recommended
at 5/5
This required the
intervention of the
facility’s management.
Managed by a faith-
based organization, the
WIT team invited the
administrator (the local
priest) to one of the
meetings. When he
heard about the
importance of this
service and inquired
about the cost, an Hb
testing machine was
bought within 7 days.
Increasing complete ANC attendance (4 visits)
Gap or challenge
being addressed
Change tested # sites tested this
change and ranking
of the change
How facilities tested
this change
Less than 50%
completion of 4 ANC
visits
Informing patients on
importance of early ANC
care
All 7 facilities in the initial
collaborative had this as a
standard indicator, as
required by the county
Supported by APHIA Plus
Imarisha to:
Have job aids during microteaching sessions by the health care providers
Integrate health education
at FP clinics, child welfare
clinics, general outpatients
and special clinics
This was provided by the
both USG and non-USG
partners to all participating
facilities.
Recommended at 3/5
Put reminders in all the
service delivery points on
the importance of early
start and completion of
ANC. This was done by
the service delivery
mechanism.
Introduction of mama-baby
kits for women completing
4 ANC visits
This was provided by the
both USG and non-USG
partners to all participating
facilities.
Recommended at 4/5
This was provided by
different non-
governmental
organizations – DANIDA,
UNICEF, private donors,
APHIA Plus Imarisha.
ASSIST supported the
first TWG meetings that
brought together all the
partners, this enabled the
county to harmonize the
distribution of these kits
evenly across the
facilities.
Transportation barriers
to getting to facility
Transport reimbursement
for mothers
This was provided by the
both USG and non-USG
partners to all participating
facilities.
UNICEF supported this
initiative to provide
reimbursement to mothers
who came to the facility
28 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
Recommended at 2/5
Inadequate training of
health care providers
EmONC training
This was provided by the
both USG and non-USG
partners to all participating
facilities.
Recommended at 2/5
The county government
mobilized resources from
UNFPA, LSTM, DANIDA,
and USAID’s APHIA Plus
Imarisha to train all
facilities with delivery
services on EmONC (not
ASSIST funds).
By end of 2014, all
facilities had been trained
and ASSIST was part of
the training team to offer
sessions on QI.
Women prefer traditional
birth attendants (TBAs)
to health facilities
Introduction of cash tokens
for TBAs
This was provided by the
both USG and non-USG
partners to all participating
facilities.
Recommended at 1/5
because of issues around
sustainability
All facilities were provided
with cash to give TBAs
who referred women to
facility for maternity
services. This was mainly
a UNICEF funded
incentive program.
Training of TBAs to refer
pregnant women to health
facilities for early ante-
natal care
This was provided by the
both USG and non-USG
partners to all participating
facilities.
Recommended at 5/5
This is a community
based training of TBAs
and CHWs (not conducted
by ASSIST)
Improving administration of oxytocin within one minute of delivery
Gap or challenge
being addressed
Change tested # sites tested this
change and ranking
of the change
How facilities tested
this change
More than 50% of the
reviewed files indicated
incorrect administration
of oxytocic after delivery
Continuous education on
critical intra-partum care
practices
All the 7 facilities in the
initial collaborative
Recommended at 4/5
Avail job-aids in the
delivery room
Continuous CMEs on
quantification, storage of
Oxytocin
Application of 5S
principles of work area
improvement like early
preparation for delivery
to avoid delays.
EmONC training
Supported by other
partners, HCW from all
the facilities were trained
on EmONC
Recommended at 3/5
The county government
mobilized resources from
UNFPA, LSTM, DANIDA,
and USAID’s APHIA Plus
Imarisha to train all
facilities with delivery
services on EmONC (not
ASSIST funds).
By end of 2014, all
facilities had been
trained and ASSIST was
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 29
part of the training team
to offer sessions on QI.
Handover notes and
delivery information to
contain administration of
oxytocin
All the 7 facilities
Recommended at 5/5
The hospital head nurse would check patient notes as part of shift hand-offs
Weekly tracking of completeness using a check-list adapted from another partner
Avail heat-stable
oxytocin
This was a systems level
recommendation
Recommended at 5/5
The county pharmacist
was involved in the WIT
meetings and
procurement of heat-
stable oxytocin was
recommended. However,
the availability of this
commodity was not
always consistent
Pre-filling syringes
Recommended by 5
facilities at 5/5
This was agreed that at
every shift hand-off, the
staff would confirm
availability of prefilled
syringe for each delivery
pack. This was the
responsibility of the shift
in-charge.
Having a cold box with
oxytocin in the delivery
room
Recommended by 5
facilities at 5/5
Facilities had enough
unused cold boxes in the
stores that were often
used during national
polio immunization
campaigns. Facility in-
charges allocated cold
boxes specifically for
delivery rooms. It was
the responsibility of the
shift in-charge to ensure
that ice-packs were
always available in the
cold box. This practice
formed part of the written
hand-over notes
OCTOBER 2016
This case study was authored by Sr. Emily Jebiwott (MaterCare Hospital, Isiolo), Peter Mutanda, Janice Kangai, and Bill Okaka of University Research Co., LLC (URC) and produced by the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, funded by the American people through USAID’s Bureau for Global Health, Office of Health Systems. The project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC’s global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T.H Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write [email protected].
Appendix VII: CASE STUDY
Improving Screening for Anaemia in Pregnancy: MaterCare Mission
Hospital’s experience, Isiolo County, Kenya
Background
Situated 285 kilometers (177 miles) north of Nairobi, the capital city of Kenya, Isiolo County is an arid
region with less than 150 mm of rain received annually. This makes agricultural practices for both
food and cash crop not possible. With a population of 143,294 (51% of the population is male while
49% female, as per Kenya National Bureau of Statistics report of 2009) Isiolo County is inhabited by
the Borana, Turkana, Somali and Meru communities.
Problem Analysis
In addition to the unfavorable geographic conditions (lack of water, hot and dusty environment),
expectant women are faced with (i) food insecurity, resulting in poor eating habits; (ii) cultural barriers
that only specific foods can be taken during pregnancy; and (iii) long distances (8 to 10km) to reach
the nearest health facility on foot. In the event blood is needed for a transfusion, a patient would need
to get a vehicle and fuel to reach the nearest blood bank situated 50km away. However, it is not
always a given that matching blood will be found. These factors expose many pregnant women to
being anaemic. The same danger is extended to her delivery bed; possibly causing shock, heart
failure and eventually death. Anaemia is one of the top 10 causes of death in Isiolo County (Isiolo
County Health Strategic Plan,2014-2018).
Summary
In Isiolo county, Kenya, anaemia is one of the top 10 leading causes of death and it poses a threat to
pregnant women. Since 2013, the USAID Applying Science to Strengthen and Improve Systems
Project (ASSIST) has supported national and county governments to set up quality improvement
structures across USAID funded projects, including APHIA Plus Imarisha in Isiolo. ASSIST supported
formation of improvement teams at health facilities, including MaterCare Mission Hospital. The team
at MaterCare identified pregnant women attending antenatal care (ANC) and delivering with low
hemoglobin (Hb) as a gap and decided to work on it as one of their indicators with a focus on
screening women during their first ANC visit. The WIT aimed at reducing maternal mortalities through
new initiatives of services, training, research, and advocacy in Isiolo County. The work improvement
team at MaterCare focused on educating patients on risks associated with low HB; ensuring that lab
requests were made for screening; and patients were educated on diet change. From June-
December 2015, the percentage of women being screened for anaemia at ANC was 70%, while
during the next six months it increased to 95%. MaterCare continues to conduct screening for Hb
among pregnant mothers; however, it has sold the idea through learning sessions to other facilities
serving Isiolo County to adopt the same.
Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 31
Design of the Improvement Strategy
Isiolo County was identified as a reproductive, maternal, newborn, and child health (RMNCH) focus
county and USAID ASSIST was given the mandate to work with
implementing partner APHIA Plus Imarisha. ASSIST supports
national and county governments to set up quality improvement
structures across USAID–funded projects, which includes APHIA
Plus Imarisha. ASSIST started work in Isiolo County at the end of
2013. ASSIST led training on quality improvement and facility
identification. Different teams were formed, they conducted gap
identification which they followed with root cause analysis, using
fishbone diagram and 5 Whys, and development and implementation
of change ideas. MaterCare Mission Hospital was one of the selected
facilities. Training for the improvement team at MaterCare took place
in 2014 and implementation started thereafter. The team identified
pregnant women attending clinics and delivering with low hemoglobin
(Hb) as a gap and decided to work on it as one of their indicators.
The Work Improvement Team (WIT) comprising of the Laboratory Technologist, Nurses (at Triage
and Maternal Child Health [MCH] Department) and Pharmacist planned to ensure pregnant women
are screened for anaemia during the first antenatal care (ANC) visit. The WIT aimed at reducing
maternal mortalities through new initiatives of services, training, research, and advocacy in Isiolo
County. The same process was equally aimed at benefiting both the facility and patients by improving
efficiency of care given by the staff to the patients (by reducing maternal/neonatal mortality rates), and
by meeting patients’ expectations thus increasing patients’ satisfaction respectively.
Development of Change Ideas
In response to environmental issues affecting pregnant women, the MaterCare WIT ensured that: (i)
patients were educated on the risks associated with low Hb during pregnancy, labour, and delivery;
(ii) lab requests for Hb screening were done and communicated to both the patient and health worker;
and (iii) patients were educated on diet change. These are the countermeasures agreed upon after
going through the steps of QI.
Countermeasures were developed and prioritized. Writing a lab request for Hb screening and
communicating to both the patient and laboratory technologist was the most feasible change idea.
This was mainly done by the nurse at MCH. This change idea was then followed by educating
patients on the risks associated with low Hb during pregnancy, labour, and delivery. The change
ideas were tested simultaneously.
Results
Figure 1 below shows the proportion of women screened for anaemia during the first ANC visit. The
median percentage of women being screened for anaemia at ANC for the first six months from June
2015 to December 2015 was 70% with an improvement in the next six months to July 2016 with a
median of 95%.
Members of the WIT at
MaterCare Mission
Hospital
Clinicians
Laboratory Technologist
Triage Nurses
MCH Nurses
Pharmacist
Support staff (i.e. cleaners)
32 Improving Reproductive, Maternal, Newborn, and Child Health in Kenya
Figure 3: Percentage of pregnant women screened for anaemia during their first ANC visit,
MaterCare Mission Hospital, Isiolo County (June 2015-July 2016)
Conclusion
Engaging health workers to ensure pregnant women are screened at their first ANC visit has helped
in educating women on the risks associated with low Hb during pregnancy, labour, and delivery.
Availability of laboratory services in this facility went a long way in ensuring Hb screening was done. It
was also noted that after empowering pregnant women on the importance of the test, it ensured
accountability on both the health care worker and the patient. This was also shared in the community,
leading to increased awareness. Ensuring all clients get hemoglobin screening during first ANC visit
was one of the gaps identified in other facilities within the county, but availability of reliable laboratory
services affected its feasibility during prioritization of gaps.
Way Forward
MaterCare Mission Hospital continues to conduct screening for Hb in pregnant women. However, it
has also sold the idea through learning sessions to other facilities serving the hard-to-reach
population in Isiolo County to adopt the same. The Catholic mission and Camp Garba dispensaries in
Isiolo, both under Catholic Diocese like MaterCare, also started working on the same indicator in
2014. There was an identified need to procure portable Hb testing machines at these facilities. After
setting up improvement teams and involving the Catholic Diocese administration in their QI initiatives,
the facilities were provided with Hb testing machines. The hemoglobin screening at continues in the
three facilities. MaterCare also continues to improve its indicator on use of partographs for every
woman in labour in the facilities.