Quality Improvements HBB
India Experience
Dr. Anju Puri
HBB Review Meeting
17th July 2012
Burden
 More than 2·3 million
children die annually
 1.1 million occur in
neonatal period
 Million Death Study
investigated
 10892 neonatal deaths
 12260 deaths in 1-59
months
 0-28 days – 3 causes
(78%)
 Prematurity & LBW 32%
 N. Infections - 26.7%
 B. asphyxia & trauma
18.8%
 1-59 months – 2 causes
(50%)
 Pneumonia 27.7%
 Diarrheal diseases 22.3%
Ref: Report on causes of Death 2001-2003, RGI
2009
2
Our overall goal is MDG 4
 ENC/R Goal: Support the MOHFW, State
health departments, USAID bilateral health
programs and the new National Newborn
Care and Resuscitation Initiative (NSSK) to
strengthen and expand access to ENC and
teach basic resuscitation technique.
3
Geographic presence to support and influence
implementation
Gonda
Uttar Pradesh
Deoghar
Jamtar
a
Giridih
Jharkhand
Immunization focus districts
Integrated districts
Simdega
Chaibas
a
Landscape of program inputs








Facility readiness assessment using 8 parameters was conducted in
Oct 2010 using a structured questionnaire and 75 indicators generated.
KAP performance for maternal and newborn care especially neonatal
resuscitation was mapped.
District mapping of the gaps generated and facility wise plan made for
realistic program. Based on this implementation included provider
mapping,
3- Day skill based training in essential newborn care and resuscitation
skills of all district level primary providers conducted (250)
Job-aides and skill lab of key providers (28) in the demo-facilities.
Supportive supervision involving quantitative and qualitative checklists
was used to provide on-going hand holding. Involving district authorities
at each step was critical to success of the program.
Strengthening of health information systems by improved reporting and
feedback mechanism,
Follow up of facility births of birth asphyxia newborns conducted in the
community.
Quality Improvement
Quality Improvement (QI) approach is being
used to analyse performance of the providers
during training; and thereafter using systematic
effort to improve the competence for the skill
proficiency on neonatal resuscitation for
improved outcomes.
QI areas
Skill
acquisition
Skill
competency
Criteria
Knows the steps and
their sequence to
perform the required
skill but needs
assistance
Knows the steps and
their sequence and can
perform the skill
Tools
Quality
Assurance
Checklist (QAC)
Purpose
Measured
QAC is used to document
the inputs and process
followed during the training
Results
QAC results
During training
Performance
checklist (PC)
Read and Do
tools (R&D)
Skill rating (Mega-Score)
using pre-post checklist
Health worker with a step
by step outline of the
procedure for use during
the practice phase of
lesson.
Pre-post test
results
Self – Practice
observations
During mentoring
Supportive
supervision (SS)
Skill
Proficiency
Knows the steps and
their sequence and
effectively performs the
required skill
Cross-learning
visits
Standard checklist used
during supervisory visits
regular intervals
Best Practices are focused
Knowledge
attitude Practice
(KAP)
Change in behaviour &
practice
HIMS trends
Survival rates
SS checklist
Facility
Readiness
During benchmarking exercises
Skill Acquisition - QI
Quality Assurance
Checklist
 Been used to assess and
adhere to a minimum
standard for quality of
process during the
training.
 10 observation questions
 Score less than 80,
training is repeated.
Pre-Post Performance
checklist
 Pre-post test scores are
used to rate the training
and provide feed-back to
the providers.
 Measure changes in both
the knowledge and skill
acquisition by the health
providers as a result of
the training.
S
no
Field for scoring.
1
Facilitator to participants ratio
2
Whether planning session conducted
before the start of the training?
3
Items present at the training
4
Number of participant’s for whom both pre
& post test was conducted
5
Whether the performance list was correctly
used
6
Feedback given using performance
checklist
7
List of skill demonstrations
8
Good quality video used in the training
(Thermal protection and feeding)
9
Mega code score conducted correctly
(Performed for all 5 bold items)
10
Number of participant’s with less than
minimum passing score (optional)
Total score
Scoring by observer/participants
Trainee
1
2
3
4
5
District A
District AI
District B
District BI
District A
District AI
District B
District BI
District A
District AI
District B
District BI
District A
District AI
District B
District BI
District A
District AI
District B
District BI
District A
District AI
District B
District BI
District A
District AI
District B
District BI
District A
District AI
District B
District BI
District A
District AI
District B
District BI
District A
District AI
District B
District BI
District A
District AI
District B
District BI
5
0
5
5
0
5
5
5
2
2
2
2
5
5
5
5
5
5
5
5
0
5
5
5
45
40
40
45
10
5
10
0
10
10
4
3
3
3
72
77
72
82
5
0
5
5
NA
NA
0
NA
2
2
2
2
5
5
5
5
0
5
0
5
0
5
0
5
35
35
45
45
10
5
10
0
10
10
0
4
3
3
5
0
5
5
NA
NA
NA
NA
2
2
2
2
5
5
5
5
5
5
5
5
5
0
5
5
45
40
45
45
10
5
10
0
10
-
5
0
5
5
NA
NA
NA
NA
2
2
5
2
5
5
5
5
5
5
5
0
5
5
5
0
50
40
50
40
10
5
0
0
10
10
5
0
5
5
NA
NA
NA
NA
2
2
5
2
5
5
5
5
5
5
5
5
5
5
5
5
50
40
50
40
10
5
10
0
10
10
-
67
72
62
77
87
62
72
70
82
77
70
85
82
77
90
72
6
0
5
NA
NA
2
5
5
5
5
5
5
5
40
45
5
10
10
10
-
82
85
Total
score
Average
score
Ideal
score
25
0
30
25
0
5
5
5
10
12
21
10
25
30
30
25
20
30
25
20
15
25
25
20
225
235
275
215
50
30
50
0
20
50
20
20
4.2
0.0
5.0
4.2
0.0
0.8
0.8
0.8
1.7
2.0
3.5
1.7
4.2
5.0
5.0
4.2
3.3
5.0
4.2
3.3
2.5
4.2
4.2
3.3
37.5
39.2
45.8
35.8
8.3
5.0
8.3
0.0
3.3
8.3
3.3
3.3
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
50
50
50
50
10
10
10
10
10
10
10
10
390
447
451
386
65
70
80
57
100
100
100
100
Pre-post test scores - trainings
Skill Competency – QI
Practice exercises at skill labs
Skill Competency – QI
Read and do tools
Supportive supervision
 A structured guide & training methodology for supportive
supervision was prepared
 An “yes and no “simple checklist” is being used for
regular supervision & feedback.
 Each skill is only scored, if all the steps is followed for
the skill.
 The checklist has two copies, one for the health provider
being supervised and the other for the one who
supervises the activity. By this mean we assured that the
provider who was supervised knows the misses and can
be motivated to improve his performance.
All
At-least one
None
All
No of observations
At-least one
None
All
Interventions
No of observations
May-12
None
Mar-12
At-least one
Jan-12
No of observations
Skill station
demo
Postnatal Care
Immediate newborn
care
Before Delivery
Month/ year
Provision of warmth
21
7
14
1
28
13
15
7
30
15
15
9
Infection prevention
20
15
5
3
30
21
7
9
30
23
7
11
Neonatal kit
20
12
20
16
28
Functioning of B&M
23
3
6
3
23
17
6
3
23
23
6
3
Effective partograph use
23
3
12
7
23
11
16
17
24
12
12
4
Looked for meconium
24
20
24
20
25
Immediate warmth
24
2
22
22
28
2
22
22
28
28
0
10
1-3 cord clamp
23
24
0
6
27
27
0
27
25
16
12
1
Skin to skin contact
21
12
12
0
25
13
12
1
27
16
12
1
Breast feeding initiation
24
24
0
2
26
26
0
0
18
18
0
4
Newborn examination
14
14
0
0
15
15
0
0
18
18
0
4
Vaccination
27
27
0
0
29
29
0
0
29
29
0
1
Counselling
28
16
12
0
29
21
12
0
27
22
5
5
% Demo mannequin
11
68.2
14
74.3
16
16
21
77.5
Skill Competency QI





Questionnaire and exercise methodology developed to focus on the
“preparedness” of the health facilities to deliver newborn care services as per
the national guidelines.
The results framework is quantifiable in operational terms rather than health
systems framework.
The analysis tool works on 75 broad indicators to generate color- codes to map
the status of 8 parameters – Infrastructure, Delivery and Newborn Care
services, Human resource, Essential drugs, equipment and supply, Register
and client case record, Protocols and guidelines, universal precautions &
infection prevention and Provider’s knowledge & competency on core skills.
A computerized SQL based analysis system has been developed to generate
score based color-codes.
Implementing a planning exercise based after this exercise is found very useful
and allowed us to bench mark the health facilities over a period of time.
Score-card and improvement scores
Graph showing change in knowledge
on diagnosis of birth asphyxia
Depresse
d
breathing
89.3
67.9
Central
cyanosis
(blue 67.9
tongue)
78.6
Floppines
s
0.0
53.6
3.6
0.0
Heart rate
below 10078.6
beats per
minutes
71.4
Not cried
at birth
100.0
89.3
Delayed
crying (1
or 5
minutes)
Deoghar Oct 10
Deoghar Jan 12
Graph
showing change in provider’s knowledge & practice in
using chronology of steps during resuscitation
process
Explain to
mother
condition of
baby
Were the
steps in
sequential
60.0
order
Explain to
mother
condition of
baby
Place the
newborn face
70.0
up
40.0
0.0
Start
ventilation
80.0
using using
bag and
mask
0.0
16.7
4.2
Suction
mouth then
90.0
nose
Place the
90.0
newborn face
50.0
0.0
4.2
70.2
80.0
Were the
steps in 88.0
sequential
order
44.0
Wrap or
cover baby
except for
face and
chest
Position
66.0baby’s head
so neck is
slightly
extended
Start
ventilation
using using 61.1
bag and
mask 98.0
0.0
Suction 83.3
mouth then
94.0
nose
up
0.0
Wrap or
cover baby
62.0 except for
5.6
face and
chest
Position
74.0 baby’s head
so neck is
slightly
extended
22.2
Deoghar Oct 10
Deoghar Jan 12
Jamtara Oct 10
Jamtara Jan 12
Sustaining and scaling efforts
Monthly HMIS data
HMIS Data ( Focus Facility Data)
Year 1
Year 2
Year 3*
Total number of deliveries
3354
3139
3107
No. of Live births
3176
3034
3019
No. of Still births
11
97
122
No. of Neonatal deaths
0
0
2
No. of full term deliveries
NA
1020
3064
No. of pre-term deliveries
NA
6
41
No. of neonates receiving vitamin K
NA
0
455
No. of newborns with weight <2.5kg
159
213
277
No. of newborns breastfed within 1hr
3176
1918
2734
0
10
124
NA
8
30
No. of newborns requiring Bag & mask resuscitation
No. of sick newborns referred to higher facility
District Hospital Jamtara
Year 1
%
Total number of deliveries
1541
No. of Live births
1275
82.7
246
16.2
(160 per
1000 LB)
No. of Still births
No. of Neonatal deaths
Year 3*
%
1510
1442
95.5
68
4.5
(41 per
1000 LB)
0
0
No. of full-term deliveries
NA
1477
No. of pre-term deliveries
NA
18
No. of neonates receiving vitamin K
0
0
No. of newborns with weight <2.5kg
42
3.3
139
9.6
1275
100
1263
87.6
No. of newborns breastfed within 1hr
No. of newborns requiring Bag & mask resuscitation
NA
86
No. of sick newborns referred to higher facility
NA
12
Consistency of reported Vs register
data
HMIS Data
N
Register Data
%
N
Difference
%
Total number of deliveries
3107
2433
No. of Live births
3019
97.2
2351
96.6
0.5
No. of Still births
122
38.8
91
37.3
1.6
No. of Neonatal deaths
2
0.7
0
0.0
0.7
No. of full term deliveries
3064
98.6
2319
95.3
3.3
No. of pre-term deliveries
41
1.3
10
0.4
0.9
No. of newborns with weight <2.5kg
No. of newborns requiring bag & mask
resuscitation
277
9.2
268
11.4
-2.2
124
4.1
86
3.7
0.4
Number of newborns with meconium
(AI)
Number of newborns who had
floppiness (AK)
JAM
DH
33
2
43
75
11
3
37
13
14
27
67
JAM
Pabia
36
0
8
10
0
0
4
8
0
8
10
DEO
Palajori
7
1
8
18
12
0
1
5
2
7
29
DEO
Madhupur
30
0
6
15
3
4
2
3
2
5
18
84
3
82
125
36
8
44
29
18
47
124
All sites total
Total number of newborns with asphyxia
or meconium or floppiness (AJ+AI+AK)
Total number of newborns on whom bag
and mask has been used
Number resuscitated by stimulation
,suction and bag and mask and oxygen
Number resuscitated by stimulation
,suction and bag and mask
Number resuscitated by stimulation and
suction
Number resuscitated by stimulation only
Number of newborns with asphyxia (AJ)
Still borns brought back to life (BV-CU)
Number of still borns resuscitated (X)
Facility Name
District Name
Resuscitation Details
Resuscitation indicators
Non - breathing
% newborns with birth asphyxia
Non - breathing or
meconium or
floppiness
3.5
5.3
Proportion of "Non - breathing" newborns resuscitated with
stimulation alone
9.8
6.5
Proportion of "Non - breathing " newborns resuscitated with
stimulation and suction
53.7
42.2
Proportion of " Non- Breathing" resuscitated with stimulation,
suction and bag and mask
35.4
48.2
Proportion of "Non-breathing" newborns resuscitated
successfully
98.8
96.9
Lessons Learned
 Newborn care programs have tended to be vertical,
and slow to take up, have not considered or
contributed to their quality.
 It is feasible and beneficial to integrate ENC with
Maternal Health programs and improve quality of care
and have access to their concomitant resources.
 The mother and baby dyad can be assessed and
managed together.
 The first week, especially the first three days, should
be covered as a priority in the most feasible and
effective manner at both facility and community levels
with links between the two.
26