Wave 4: Consolidated
Sub District Change Package
Through Pictures
PRIMARY SYSTEM
DRIVERS OF
IMPROVED HEALTH
Seeking and
obtaining care
early
Accelerate
reduction of
Under-5
mortality in
Ghana by 60%
before 2015
using QI
methods
HEALTH SYSTEM
DESIGN FEATURES
COMMUNITY
Risk Awareness/Management
Enhanced Value of Lives
Financial /NHI Subscription
Proximity to Health Services
Attractiveness of Health
Services
Providing
prompt,
appropriate,
adequate &
client-centred
care
HEALTH FACILITY
Staff Attitude & Behaviour
Staff Clinical Knowledge &
Skills
Protocol Adherence
Staff Availability
Reliable Referral System
CULTURE OF QUALITY
Develop
culture of and
capacity for
continuous
improvement
using reliable
health data
Use of Local Data to Drive
Performance Improvement
Regular Supervision,
Coaching & Mentoring
Appropriate Data Capture &
Transmission Tools
CHANGE
INTERVENTIONS
S Aides
Client
Self-Management
& Family
Education
Emergency
Preparedness
Community Education &
Mobilization
Outreach & Domiciliary
Services
Client-centred Design
Acuity-oriented Design
Staff Training, Practice &
Monitoring
Reminder Systems
Supply Chain
Management
Staff Re-scheduling, Reassignment & Taskshifting
Communications &
Transport System
Application of QI
methods at Local Level
Longitudinal Data Quality
Assessments
Longitudinal Facilitative
Supervision
Development & Use of
Client Registers,
Reporting Forms,
Databases etc.
Outcome
Complexity of
problem?
Primary Drivers
Individual & Family
Barriers
Secondary Drivers
Delay in decision to seek skilled care
(recognition, permission, financial etc.)
Delay in acceptance of referral
Low risk awareness & management of
obstetric/neonatal complications
Sociocultural
Barriers
Preference for home/TBA deliveries and
self-medication (hospital as last resort)
Negative perceptions about health facilities
as places to “go and die”
Insufficient funds for transport & telephone
credits (both family & staff)
Maternal and
Neonatal Mortality
Due to Faulty
Referral Processes
Transportation &
Communication
Barriers
Unavailability of local transportation
Inadequate ambulance services
Unreliable telecom services
Long distances, poor or no roads/bridges
Late/no identification of high-risk clients
Failure to stabilize client before referral
Inadequate
Clinical Skills &
Management
Lack of readiness of receiving facility
Poor hand-off management processes
Poor documentation of indications for
referral & interventions to date
Delay in providing care
Governance &
Accountability
Unreliable use of referral
protocols
Inadequate supervision, monitoring
Antenatal Care
MNH Danger Sign Recognition at the Community:
Training and health education of pregnant women
and community-based health providers on danger
sign recognition:
• The midwife attended monthly meetings of
TBAs and trained them on:
– a. recognition of maternal & newborn danger
signs
– b. the need for prompt referral on recognition of
any of these danger signs
• During ANC sessions the midwife also
educated pregnant women on danger
signs and encouraged early care seeking
• Midwife and other QI team members
educated LCS and spiritualists on MNH
danger signs
Care-Seeking Behavior for ANC
Health education for identifiable community
groups:
• Health staff hold monthly talks with
spiritualist, MTMSGs, women’s group
meetings and pregnant women on:
–
–
–
danger signs in pregnancy
importance of early care seeking
address fears of early ANC registration
• Health staff identified pregnant women at
home visits and registered them, followed
by registration for NHIS by NHIA
ANC Registration in 1st Trimester:
• Community stakeholder meetings with
opinion leaders and other influential
groups about the importance of early
and regular ANC
• Community stakeholder meetings
followed by registration of pregnant
women by community volunteers on
monthly basis
At Least Four ANC Visits Before Delivery:
• Increase the number of days ANC is offered
at static site AND re-design clinic processes to
reduce visit duration per client to <1 hr
• Offer ANC as outreach service as well as
at static site AND re-design clinic
processes to reduce visit duration per
client to <1 hr
Skilled Delivery
Care Seeking Behavior for Skilled Delivery
Mobilizing Transport:
• Engagement of motor-bike owners within specific
communities to assist with transporting women
in labour and sick newborns to the clinic
Engaging Men:
• Men engaged to accompany their wives to
ANC in order to be present for discussion on
BPP:
– The Imam, during prayers at the mosque,
encouraged men to attend ANC with their
wives.
– For those men who did the ANC visit with
their wives, the health staff used the visit as a
means for reinforcing the referral aspect of
the BPP (Birth Preparedness Planning).
• Male advocacy group in communities to
promote skilled delivery
Care Seeking Behavior for Skilled Delivery
• Motivate TBAs with half bar soap and the
other half to the mother who delivered at
the facility
Redefinition of TBAs role:
• Chief threatened to fine those who
delivered at home
• Educated community members on obstetric
complications and announced that TBAs
will be allowed to support deliveries in the
clinic
• TBA directing clients to
CHPS and supporting CHNs
in the delivery. Clinic
motivates the TBA with half
bar of soap
Care Seeking Behavior for Skilled Delivery
TBAs /community engagement:
• Health staff held interactive meetings with TBAs
& spiritualist on benefits of early care especially
for neonates & labour and explained the
dangers of unskilled delivery.
• Using community durbars the midwife and other
QI team members explained benefits of facility
delivery.
• Using daily home visit and personal carers
approach, a pregnant woman was assigned to a
health worker to encourage them and take
personal responsibility for the woman to deliver
at the facility
• Health staff hold monthly family conversation
involving mother-in-laws, husband and other
family members to agree on facility delivery
Care Seeking Behavior for Skilled Delivery
• Video show in communities on the
risks of labor & delivery
• TBA engagement on risks of unskilled
delivery and provide incentives
Skilled Delivery & Immediate Postnatal Care
• Provide domiciliary delivery
if, upon notification by
mobile phone, labor too
advanced, woman has no
means of transport from
community or health staff
cannot arrange transport
from clinic or hospital
• Use ANC register to
identify women at
36+ weeks gestation
for home visits to
remind them &
family members
about skilled delivery
• Create a welcoming,
patient-friendly
environment in health
facility for labouring
women
Skilled Delivery & Immediate Postnatal Care
• Create systems to ensure consistent
and correct use of partographs
• Create systems for reliable neonatal
resuscitation
Postnatal Care
Postnatal Care on Day 1 & 2
• If facility skilled delivery: detain for
observation for 24hrs if possible. If not,
discharge after minimum of 6 hrs and
follow-up on Day 2 with facility or home
visit
• If domiciliary skilled delivery: followup on Day 2 with facility or home visit
• If unskilled delivery: ask family members or
volunteers to notify health staff immediately by
mobile phone/bicycle/motorbike. Woman
comes to facility on Day 1 if possible or health
staff follow-up with home visit on Day 1 or 2
Postnatal Care on Day 6 & 7
• During Day 1 & 2 visit, make appointment for
Day 6/7 visit at facility or home. Use
reminder systems at community,
clinic/hospital to improve reliability
• If a woman lives in different sub-district or
distant community within CHPS Zone,
refer to other sub-district or CHO for Day
6/7 visit. Contact CHO to follow up if no
show.
• If woman lives in distant
community without CHO AND
return facility visit not possible AND
health staff home visit not possible,
train IMCI volunteers to provide
Day 6/7 care
Referral Compliance
Referral Compliance
Focused ANC:
• A health worker is assigned to take personal
responsibility for a pregnant woman or a group
of women to specifically ensure they have a
skilled delivery.
• Midwife and other QI members educated
community on importance of referral
compliance, early care seeking and facility
delivery. The midwife also used monthly TBAs
meeting to explain importance of early care
seeking
• Using MOTECH (mobile messaging service)
facility the midwife+ CHN sent reminders to
pregnant women about facility delivery and
contingency plan in case of referral
• Health staff conducted home visits twice a day to
discuss the importance of referrals and benefits
of facility delivery
Socio-cultural Barriers
Referral Compliance
Community mobilization:
(1)Health talks in churches & mosque, to
groups of men playing games, men on farms,
men’s fun club on:
•
•
•
the importance of male involvement in
health care
barriers to referrals referral compliance
wrong perceptions about facility delivery and
general maternal and newborn health issues
(2)Used community information center, to
educate the community on importance of
referrals and benefits of early care seeking
Referral Compliance
Birth Preparedness Plan with Motivation:
• Health staff at ANC educated pregnant
mothers on the importance of BPP.
• Pregnant women engaged, individually, on
the various items on BPP at home and facility
explaining the need & use for each item
• Health staff inspect various items prepared by
family from the BPP list during home visit and
emphasizes the need to save for transport in
case of referral and talk with husbands to
support
• Welcome package (baby dresses) is also
presented to mothers who delivered at the
health facility as a way of motivating women
to have skilled delivery
Transportation
Transportation
Community-based emergency transport solution:
•
Influential QI team members led a meeting with
transport owners to discuss the need to provide
emergency transport for maternal and neonatal
cases.
•
Phone numbers of drivers distributed to pregnant
women during ANC, TBAs & CBV during
community meetings
•
To complement the efforts of health staff,
volunteers are coached and tasked to talk to
pregnant women in the community to put money
aside for emergency transport.
•
QI team then used community durbars to educate
the community about referrals and disseminated
information about the transport arrangement with
GPRTU for emergency referrals
Transportation
Community-based transport solution:
•
QI team met with GPRTU to reactivate MOU and
reached an agreement to provide emergency
transport services for maternal and newborn
cases
•
At community meetings and durbars, QI team
explained why patients should accept referrals.
The community chief then announced the
availability of community transport for mothers
and neonates in case of emergency.
•
QI team mobilize funds from churches to support
mothers who cannot pay for transport.
•
Team dialogued with the police to use their
vehicle in case of emergency and to allow a quick
pass for taxis carrying maternal emergency cases
at night
Transportation
Community-based transport solution:
•
MA & Midwife engaged GPRTU with
baseline performance on
emergency transport response time
& agreed to reduce delay of
emergency referrals reaching the
next level.
•
Updated drivers’ phone numbers to
be contacted for emergency
transport. Phone numbers were
pasted on a wall of the health
facility for easy access by all staff.
•
Quarterly meetings held with the
drivers to discuss progress and give
feedback for improvement.
Communication
Communication
Feedback & Pre-Referral
Communication Methods:
•
Midwife or any health worker
referring calls the receiving
facility to obtain information
about the condition of patient
•
Health staff do a follow up (face
to face ) with patients families
to ascertain condition and then
document feedback in referral
register
•
DDHS provided resources
(phone & credit) and then
mandated health staff to call
referral facility for feedback
Communication
Documentation: Stock and
Supplies
• DHMT photocopied
referral & feedback forms
for all facilities
• Health system printed
and distributed triplicate
referral forms + feedback
forms to all facilities
Communication
Referral documentation:
•
Using sub district review meeting
and LS, the medical
superintendent educated health
workers on how to fill the referral
form whenever they are
referring a patient to the hospital
•
Using mortality audit sessions,
the medical superintendent
educated health professionals on
proper referral documentation
Communication
Feedback
Verbal feedback:
• Names of referred clients
are picked by health staff
according to community
before departing for
outreach.
•
Staff conducts follow up
visits to the homes of
those referred to check
compliance and final
diagnosis during the
outreach.
Communication
Feedback
Verbal feedback:
• The midwife or any health
worker referring called the
receiving facility to obtain
information about the
condition of patient.
•
Health staff followed up to
patient’s family to ascertain
the patient’s condition and
documented feedback in
referral register.
Communication
Feedback
Verbal & written feedback:
•
The hospital's HIO collected
feedback forms every week and
put them in the respective pigeon
holes of referring facilities at the
DHMT.
•
Facilities referring without the
necessary documentation on the
referral form are notified on
phone and feedback given to
them during LS/performance
review meeting to improve
Communication
Feedback
Electronic & written feedback:
•
Using social media such as
WhatsApp, the HIO sent
feedback to referring facilities
weekly
•
Focal person at the hospital
later sent written feedback to
the DHMT for onward
collection by health facilities
•
District director gives directive
for sub district facilities to
procure Vodafone landline so
that the hospital can send
verbal feedback