Int'l Forum

HAS wishes you a warm welcome to Paris

On the occasion of the International Forum on Quality

and Safety in Healthcare

2Int'l Forum

Welcome to the International Forum on Quality and Safety in Healthcare

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HAS (Haute Autorité de Santé)Ensuring High-Quality Healthcare for All

Int'l Forum

Plenary 1:

Introduced by: Laurent Degos, HASFiona Godlee, BMJ

Speaker:Donald M Berwick, President and Chief Executive Officer, Institute for Health Care Improvement

Troubles on a Hook:Global Health and Continual

Improvement

Donald M. Berwick, MD, MPP, FRCPPresident and CEO

Institute for Healthcare Improvement

Keynote AddressInternational Forum on Quality and Safety in Health Care

Paris, France: April 23, 2008

Millennium Development Goals

1. Eradicate extreme poverty and hunger.

2. Achieve universal primary education.

3. Promote gender equality.

4. Reduce child mortality.

5. Improve maternal health.

6. Combat HIV/AIDS, malaria, and other diseases.

7. Ensure environmental sustainability.

8. Develop a global partnership for development.

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MDG Progress

• Extreme poverty: 1/3 in 1990 to 1/5 in 2004.• Extreme poverty in Sub-Saharan Africa: 47% to 41%. • Children in primary education: 80% to 88%.• More women in parliaments.• Under-five mortality in developing countries: 10.6% in

1990 to 8.3% in 2005.• Measles deaths in children down by 60% between 1999

and 2005 (873,000 to 345,000).• Measles deaths in Africa down by 75% between 2000 and

2005 (506,000 to 126,000).• Tuberculosis per 100,000 down from 321 in 2000 to 255 in

2005.6

Progress toward MDG #4

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MDG Gap

At current rates of progress, sub-Saharan Africa will not hit its 2015 MDG target for

mortality reduction until 2115…

ONE CENTURY LATE!

41 million more children will die between now and 2015.

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Support Staff & Faculty

United States

Andrew Billi

Stacey Downey

Meredith Kimball

Nicholas Leydon

Barbara Tobin

Joe McCannon

Helen Smits

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W. Edwards Deming

“Trying harder is the worst plan.”

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Paul Batalden

“Every system is perfectly designed to achieve exactly the results it

gets.”

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“System”

“A collection of elements interacting to achieve a common aim.”

(Interdependency is inescapable.)

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Four “Theories” of Improvement

1. Just Set the Goals.

2. Create Better Markets.

3. Add Resources to the Current System.

4. Redesign the System for Better Performance.

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Mamphela Ramphele

“It is the poorest people on earth who can least afford

poor quality.”

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Bwaila Hospital – Lilongwe, Malawi

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IHI-Supported Sites in Malawi

Salima

Lilongwe

Kasungu

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Causes of Maternal Deaths

Countdown to 2015 Core Group. Countdown to 2015 for maternal, newborn, and child survival: The 2008 report on

tracking coverage of interventions. Lancet 2008;371:1247-58.17

Reducing Maternal & Neonatal Mortality

MALAWI

Florence Bwanali

Fannie Kachale

Uma Kotagal

Roger LeCompte

Marco Linden

Bejoy Nambiar

Olive Sambani

Eric Tsetekani

Karen Zeribi

Agnes Makonda-Ridley

Charles Makwenda

Violet Manjanja

Gibson Masache

Barbara Nagy

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Likuni Hospital, Malawi

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Likuni Hospital, Malawi

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Nkhoma Hospital Infant Mortality

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to ensure the primaryhealth care-based component of thePMTCT programme (as defined by current local policy) is executed at ≥ 95% reliability by1st Sept. 2008

≥95% all pregnant mothers presenting at PHC for 1st ANCvisit are tested for HIV

100% all pregnant mothers with CD4 counts <250 or WHOStage 4 are referred to & arrive at ARV site for initiation on ARVs within 2 weeks of clinic getting test results/staging

>95% all HIV+ ANC clients take PMCTC drugs as indicated prior to or during labour (currently stat. doseNevirapine (NVP) or HAART)

100% all babies born to HIV+ mothers receive PMTCT drugs as indicated (currently stat.dose Nevirapine within 72 hrs of birth)

≥95% all HIV+ mothers make feeding choice that presents the lowest risk of serious illness/death of their child and that they can consistently maintain

≥95% all babies born to HIV+ mothers or those whose statusis unknown receive a PCR testat 6 weeks

involvement of all PHC staff in VCT awareness; health education on programme and benefits delivered in waiting room

provide transportation; providing escorts; follow up with clinic

fast-tracking of ANC patients at ARV site

reliable means of communicating mothers’ HIV status to other health care facilities without it being explicitly stated

educate mothers about need to bring in their babies to the clinic within 72 hours of giving birth at home; ensure reliable means of communicating mothers’ HIV status to other health care facilities

use risk assessment tool as part of counsellors’ script and recording of feeding choice; support groups for HIV+ mothers (e.g. m-2-m)

encourage transfer of PMTCT mothers onto pre-ART registers; do routinely at one of immunisation sessions

dry blood spot tests introduced; health education to encourage mothers to have babies (and siblings) tested; linking PCRs to first immunisation visit

early issuing of NVP

≥95% all HIV+ mothers with CD4 >250 during pregnancy receive further test within 6months

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Model for Improvement(Ref: Associates in Process Improvement)

Act Plan

Study Do

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

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Life Expectancy and AIDS

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Increasing Access to HIV/AIDS Treatment & Care

SOUTH AFRICA

Pierre Barker

Brandon Bennett

Cathy Green

Wendy Mphatswe

Kimesh Naidoo

Patty Webster

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Before and after Initiation of Antiretroviral Therapy

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Before and after Initiation of Antiretroviral Therapy

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PROBLEM:HIV+ Patients

not gettingCD4 counts

Clinic Design

Prompts and Care Paths Patient and Family Input

No formal way to track

Poor record keeping/history taking

Staff lack knowledge and skills

Fishbone Diagram

No time to stay

Feel fine now / misconceptions

Long queue / waiting time

No supplies available

Lack of available staff

Denial/attitude

Protocol not understood

Data Systems

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Mother attends ANC- 1st

visit

HIV test pos

CD4 test

CD4 <200

CD4 >200

Start ART

Nevirapine to mother and infant

HIV test

Potential “botlenecks” or failures

Sample Process Map: PMTCT

3131

Mhlontlo Subdistrict

Progressive Engagement of Primary Care Clinics in Comprehensive HIV/AIDS Care

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Mhlontlo Subdistrict

Cumulative ART Initiations in Mhlontlo Sub-District

Tota

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Pati

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ts S

tart

ed o

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RV

s

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Mhlontlo – Resources Matter

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South Africa

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Umkhanyakude DistrictKwaZulu-Natal

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Inner City Johannesburg Project

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Inner City Johannesburg

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Western Cape –Helderberg and Eertse River

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Ghana

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Ghana

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Causes of Deaths under Five Years

Countdown to 2015 Core Group. Countdown to 2015 for maternal, newborn, and child survival: The 2008 report on

tracking coverage of interventions. Lancet 2008;371:1247-58.42

Saving Lives Under Five

Ghana

George Dabuo

Cleytus Dakura

Gilbert Buckle

Nii Coleman

Enoch Osafo

Lloyd Provost

Nana Twum-Danso

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Reducing Under-Five Mortality

Countdown to 2015 Core Group. Countdown to 2015 for maternal, newborn, and child survival: The 2008 report on

tracking coverage of interventions. Lancet 2008;371:1247-58.44

Wave 4: 42 – 60 months

Wave 3: 30 – 42 months

Wave 2: 12 – 30 months

Wave 1: 0 – 12 months

Sequential Scale up of Improvement in Ghana

Challenges for Improvement in Developing Nations

• Logistics – Travel, Communications, Infrastructure• Information Systems• Data Quality• Habits of Hierarchy• Misaligned Policies• Thin Staffing and No Slack• Workforce Training in Improvement Skills• Despair

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My Hopes

• Hit the goal of 0.7% of GDP for development assistance.

• Link new resources to new designs.• Involve the workforce in redesign.• Incorporate improvement skills into all workforce

development.• Foster formats, systems, and sponsors to share

freely new models and lessons learned.

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A Dream…

A “Learning World” for Global Health and Development

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