Improving the quality of maternal & newborn
health in Makueni county using small test of
change (STOCs): the case of Kanzokea
community unit
Oruko Happiness1, Gitimu Anne1, Karijo Evalin1
1 AMREF
Kenya
1
Outline
• Background
• Rationale
• Methods
• Results
• Conclusions & Recommendations
2
Background
• Quality Improvement was initiated in the
manufacturing industry
• STOCs is a process used in quality improvement
• It tests change on small scale, see how it works
and refine as necessary before implementing on
broader scale
• Applied by Institute of health care improvement,
University of Maryland –HIV programs
3
Rationale
• Testing or adopting change
• Implementing an improvement
• To minimize resistance upon implementation
• Spreading the improvements to the rest of the
organization
4
Map of Makueni County
5
Background
• Kanzokea CU and link facility selected as first
site for implementing Small Test of Change
• (February 2013- January 2014)
Problems Identified
Inadequate MNCH skills among health workers –
Low quality of care
Inaccurate, incomplete & untimely reports by CHWs
Low skilled birth attendance
37.5%
Low ANC attendance (timely four visits)
49.5%
6
PDSA Model
The Model for Improvement was developed by Associates in
Process Improvement
7
Methods
Trained:
• Two nurses from Kanzokea Health Centre on
BEmONC, and standards of quality care
• Two CHEWs on management of community
health units and data quality
• 50 CHWs on basic packages of health and data
management (MOH 513 & MOH 514)
8
Methods
• Used Partnership Defined Quality (PDQ) model to
improve the quality and accessibility of services
• PDQ- Involved the community in defining, implementing,
and monitoring the Quality Improvement (QI) process
• Facilitated formation and institutionalization of a QI Team
(Quality improvement team) of 11 - comprising of
SCHMT, facility and community members
9
Methods
• Agreed to Monitor two Quality of Service Indicators
a) Use of partograph in the management of labour
(correct plotting & Interpretation)
b) Community level data accuracy, timeliness and
completeness
• Developed work plans to track progress over a period of
twelve months
10
Methods
• Together with the SCHMT conducted support supervision
and mentorship:
(i) To health workers on correct
interpretation of partograph
plotting
and
(i) To CHWs on community level data quality control
(Spot checks, accompanied interviews,
retraining CHWs during data collection)
and
11
Results
Indicator 1: Quality of Care by health workers
• All health workers use
partograph
to
monitor
pregnant women during
delivery
35
30
Cases
• Shows progress of labour,
and
when HWs should
conduct
deliveries
and
referrals if need be
40
STOCs- Kanzokea Health
Centre
25
20
15
Skilled
delivery
10
Use of
Partograph
5
0
• HWs
fill
appropriately
partographs
F M A M J
J A S O N D J
Month (Feb 2013- Jan 2014)
12
Results
• Timely referral to higher level facilities
“When the health workers from Kanzokea Health centre refer
pregnant women, they refer them with the client records as well as
partographs. This assists the nurses from Makueni County Hospital
to track the progress of labour and also take appropriate actions
based on information on the partographs’’ (Angela* Not her real
name)
• Kanzokea health centre utilizes the CU data other than
population estimates for planning (Annual Work plan)
13
Results
Indicator 2: Community level data from CHWs
•
STOCs-Kanzokea Health Centre
236
250
•
Cases
200
150
113
100
107
65
0 0
4 0
•
0
Maternal
Deaths
Neonatal Skilled
ANC
Deaths Deliveries attendance
Indicators
CHWs collect accurate,
timely & complete reports
Before STOCs
After 12 months
50
CHWs
track
pregnant
women,
malnourished
children
•
Skilled attended delivery
improved from 37.5 % to
44.2 %
Four ANC visits improved
from 49.5 % to 54.8 %.
14
Conclusions
• The outcome of STOCs was positive and was
scaled up to 10 sites
• It’s a rigorous process, but once the QI team
learns it becomes part of their work
• County Leadership is needed for continuous
support
15
Recommendations
• Need for stakeholders to use STOCs to improve
service delivery/quality
• Need to dialogue on impediments towards
provision of quality services at the health facilities
(Use of PDQ model)
• Institutionalize
the
process
of
quality
improvement since it enables to achieve results
faster.
16
QIT members in meeting
17
Acknowledgements
• Donor-Comic Relief
• Amref Health Africa- UK
• Kanzokea Community Unit
• Kanzokea Health Centre
• Ministry of Health- Makueni County
• Makueni Sub County Health Management Team
• Project team members - Mama na Mtoto wa Afrika
18