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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

Improving Reproductive, Maternal, Newborn, and Child ...Improving Reproductive, Maternal, Newborn, and Child Health in Kenya 1 I. INTRODUCTION A. Background The USAID Applying Science

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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.

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University Research Co., LLC

5404 Wisconsin Avenue, Suite 800

Chevy Chase, MD 20815

Tel: (301) 654-8338

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