WHO Twinning Partnerships for Improvement A practical document to implement twinning partnerships Partnership preparation package WHO/HIS/SDS/2018.13 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/ igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Katthyana Aparicio, Melissa Kleine-Bingham and Shams Syed (Department of Service Delivery and Safety, WHO) coordinated and led the development and writing of this document. Maki Kajiwara, Nana Mensah Abrampah, Julie Storr (Department of Service Delivery and Safety, WHO) provided significant input to the development and drafting of this document. Special thanks to Sandra Hwang and Albert Wu (Johns Hopkins Bloomberg School of Public Health) for their technical contribution on quality improvement methods. External Peer Review Group Ngormbu Jusu Ballah (Liberia Ministry of Health), Jean Marc Chapplain (Centre Hospitalier Universitaire de Rennes), Graeme Chisholm (Tropical Health Education Trust - THET), Eric de Roodenbeke (International Hospital Federation - IHF), Charlie Evans (American College of Healthcare Executives), Koichi Izumikawa (Nagasaki University Hospital - NHU), Farid Lamara (Expertise France), Emmanuelle Maurin (Expertise France), Sandra Hwang (Johns Hopkins Armstrong Institute for Patient Safety and Quality), Andrew Jones, Samuel Seeigbeh (Tellewayon Memorial Hospital, Liberia) Albert Wu (Johns Hopkins Bloomberg School of Public Health) and ESTHER Alliance for Global Health Partnerships. CONTENTS 8 6 INTRODUCTION ABBREVIATIONS 12 PART 1: TPI OBJECTIVES 26 PART 2: OVERVIEW OF THE 6-STEP CYCLE 28 60 PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE REFERENCES 44 ANNEXES 42 KEEPING THE LEARNING GOING ABBREVIATIONS AHRQ Agency for Healthcare Research and Quality AMR antimicrobial resistance APIC Association for Professionals in Infection Control APPS African Partnerships for Patient Safety EEA ESTHER Alliance for Global Health Partnerships GLL Global Learning Laboratory HSAs Health Surveillance Assistants IHF International Hospital Federation IPC infection prevention and control LMICs low- and middle-income countries M&E monitoring and evaluation NHS National Health System NUH Nagasaki University Hospital OECD Organisation for Economic Co-operation and Development PDSA Plan-Do-Study-Act QI quality improvement SARA Service Availability and Readiness Assessment SDGs Sustainable Development Goals SMS short message services SWOC Strengths, weaknesses, opportunities and challenges THET Tropical Health Education Trust TMH Tellewayon Memorial Hospital TPI Twinning Partnerships for Improvement UHC universal health coverage USAID United States Agency for International Development WASH water, sanitation and hygiene WISN workload indicators of staffing needs WHO World Health Organization INTRODUCTION BACKGROUND T winning partnerships between health institutions are an innovative approach that can be used to improve various aspects of health service delivery. The WHO Twinning Partnerships for Improvement (TPI) model supports long-term efforts on quality health service delivery within the context of achieving universal health coverage (UHC). The work can contribute to building resilient health systems. Fundamental in the approach is to prioritize alignment with national health plans and strategies, while working to achieve the Sustainable Development Goals (SDGs). TPI builds on the learning from the WHO African Partnerships for Patient Safety (APPS) programme. These rich lessons and the subsequent application of twinning partnerships in the recovery effort in Ebola- affected countries have facilitated the design of WHO TPI. The key aim of WHO TPI is to support health care facilities in the improvement and enhancement of the quality of their service delivery, while aligning with the overall national strategic direction on improving quality service delivery. Institutional health partnerships can play a critical role in health systems strengthening. This has been increasingly recognized across the world. Many global health groups1 have highlighted the need to “promote the utility of institutional health partnerships in strengthening health systems and in delivering effective health services.” Recognizing the synergy that comes from a partnership approach, national policy documents over the past decade have also begun to highlight the potential for institutional partnerships as an entry point to strengthen services and health systems. In addition to the APPS programme, TPI also builds on the work undertaken in applying the Twinning model to support recovery from the 2014 West Africa Ebola outbreak. TPI Recovery focused upon building resilient health systems and reactivating safe essential health services in those countries most affected by the outbreak. The aim of TPI Recovery was to rebuild the health services in order to support implementation of national recovery plans. Implementation of twinning partnerships involves addressing a variety of service delivery and clinical care areas, including, but not limited to, infection prevention and control (IPC); patient safety; and specific clinical services. Health workforce capacity- building is embedded within the model. TPI can feed into work at the national level to improve the quality 1 For more information on global health groups and to view the consensus statement, please visit WHO’s web site at: http:// www.who.int/patientsafety/implementation/apps/global-catalyst-group. pdf?ua=1 WHO TPI Snapshot • Twinning Partnerships for Improvement focuses on the value of institution-to- institution partnerships in catalyzing health service improvement. • The hospital-to-hospital model developed by ‘African Partnerships for Patient Safety’ (APPS) is the foundation on which TPI has been developed. The emphasis is on a ‘doing while learning” model. • As a global network of twinning partners develops there is an opportunity to learn from and share learning across the TPI network. • The approach promotes collaboration, co-development and sharing of both tacit and explicit knowledge thus enhancing spread of successful approaches to improvement. 10 Partnership Preparation Package of service delivery. These partnerships can act as a valuable tool for health improvement strategies and bring real benefit to the front line of service delivery and ultimately to the health of an entire population. The power of twinning partnerships working together can bring effective health improvements beyond what an individual organization or team could achieve alone. Furthermore, the work of such twinning partnerships can feed into national strategic efforts to improve quality service delivery elsewhere. PURPOSE OF THE TPI PREPARATION PACKAGE The aim of this document is to provide a practical step-by-step approach for any health institution interested in improving the quality of health service delivery through twinning partnerships. The model is based on a 6-step cycle which begins when two or more partners agree on the establishment of the partnership. TPI guides the partners through a systematic process which involves identifying some specific areas for improvement, developing an action plan to implement improvements, and then evaluating the progression and changes made towards improvement. Institutional health partnerships have the potential not only to work as individual partnerships, but also to collaborate with other partnerships to support a national network of similar partnerships. This can support national efforts through joint problem-solving and sharing experiences in order to develop a body of evidence and experience that can inform national and district authorities. This can further encourage application of the partnership model at all levels of the health system. TARGET AUDIENCE The target audience for this partnership preparation package are those committed to improving the quality of healthcare and service delivery including, but not limited, to those in: TPI brings an opportunity to support improvement in the delivery of care at the local, sub-national and national levels. It can act as a catalyst for change in efforts to enhance quality in the context of UHC. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves. 11introduction • health institutions • health facilities • academic/research institutions • professional associations • donor organizations • health authorities • policy making • governments. The TPI preparation package also aims to inform decision-makers and authorities working at the national level that are responsible for planning, developing, implementing and evaluating national health strategies, including WHO country offices and ministries of health. When to use the package The package will be useful to any new or existing twinning health institutions in order to work through a partnership-based approach to improve the quality of health services and embed the effort within long-term service improvement. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves. PART 1: TPI OBJECTIVES OVERVIEW OF OBJECTIVES T PI focuses on the value of institution-to-institution partnerships in catalysing health service improvement following a “doing while learning”2 model. TPI takes into account a variety of entities, including health facilities, academic institutions, private institutions, etc.3 It provides the potential for implementing different types of 2 ”Doing while learning” refers to the experiential learning theory where one learns from experience in order to develop skills or new ways of thinking. (Lewis and Williams 1994, p.6) 3 While a variety of entities can be involved in the partnerships, the TPI preparation package will use the generic term institutions to cover all types of entities. partnerships, at local, sub-national and national level, and also across continents. Institutions from high- income countries or from low- and middle-income countries (LMICs) can initiate partnerships to support other institutions within LMICs and thus provide unique opportunities to catalyse the move towards quality health services, all within the context of achieving universal health coverage. Within the TPI model, there are three objectives that each partnership should focus on achieving. 1. The first objective is the development of the partnership. This objective focuses on fostering a strong bi-directional partnership between health institutions. 2. The second objective is improvement through implementing effective interventions based on needs identified at the front lines of service delivery. 3. The third objective is to spread the learning and experience within the local and national health system and also beyond. The ultimate benefits of TPI are bi-directional learning and improvement, motivated and committed staff; strengthened delivery of health services; and better patient and health worker outcomes. The Recovery Toolkit Twinning Partnerships for Improvement - Objectives 14 Partnership Preparation Package The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches towards improvement. As a global network of twinning partners emerges, there is an opportunity to learn from and share learning across the larger TPI network, to promote collaboration, co-development and sharing, and support the spread and replication of improvement. What is co-development? A process that brings together the collective intelligence for a collaborative development and applies joint decision- making that enhances trust. 15PART 1: TPI objectives OBJECTIVE 1 – PARTNERSHIP The formation of a partnership is the first step in the TPI journey. Under the first objective, two or more institutions come together to agree upon a common goal and define the partnership priorities which they hope will result in sustainable improvements at the health facility. Building on the APPS definition of partnership, which encompasses a sociological perspective focusing on the interaction of people, TPI has identified several values essential in building successful partnerships. These are: 1. collaborative relationships 2. trust 3. equality 4. mutuality 5. shared accountability 6. transparency. Building on the TPI values and the APPS partnership definition, the TPI principles below can be applied when implementing a partnership4. These principles can provide a foundation for forming and maintaining an effective and sustainable partnership. Shared vision and joint planning • Coordination and mutual agreement in setting objectives, time frames and an approach to evaluation. • Co-developing and establishing partnership plan and activities. • Mutually agreeing on key performance measures to assess impact. 4 These are a set of principles that have emerged from previous part- nerships but should be adapted to the context of each partnership. It is important and useful to recognize similar partnership princi- ples that have been established by a range of organizations (e.g. THET; ESTHER Alliance for Global Health Partnerships). Definition of partnership “A partnership can be defined as a collaborative relationship between two or more parties based on trust, equality and mutual understanding, for the achievement of a jointly agreed goal. Partnerships involve risks as well as benefits, making shared accountability critical.” ~APPS, 2009-2011 16 Partnership Preparation Package Ownership • Ensuring that ownership is supported by each arm of the institution and not individuals. • Involving and engaging stakeholders by developing an effective stakeholder strategy that emphasizes roles, responsibilities and commitments. • Strategizing and planning for the involvement of all levels of the health system. Good relationships • Building relationships based on trust, non- judgement and commitment. • Harnessing the passion and power of individuals. • Respecting and understanding local rules, culture and customs. Good communication • Communicating effectively to facilitate decision- making and information-sharing. • Agree on and securing channels for decision- making. • Clearly identifying focal points5 and the roles of each team member. Ways of working • Nurturing individuals to be self-motivated and considering the value of having a good sense of humour. • Building transparency, flexibility and adaptability into the partnership (while keeping an eye on the changing external environment). • Celebrating what went well and modifying what has not gone well. 5 Focal point can be defined as the designated or referent person serving as a coordinator of information related to a project, a pro- gramme or a specific activity. 17PART 1: TPI objectives The power of partnerships There is a growing understanding that health partnerships work in synergy to yield powerful results – the combined efforts often having greater impact than work in isolation. Both arms of the partnership benefit6 from learning about innovative practices coming from unique and unexpected sources. Sometimes this leads to lower costs for the same or better outcomes. For example, the partnership between Church of Uganda Kisiizi Hospital and Countess of Chester Hospital NHS Foundation Trust maximized the local resources and was able to obtain alcohol from local agriculture to produce hand-sanitizer. This innovative approach exposed and sensitized both arms of the partnership to “out of the box” thinking in order to make improvements. 6 More information about benefits for each partner can be found here: https://www.ache.org/pdf/nonsecure/White-Paper-International-Hos- pital-Partnerships.pdf “We were able to move faster towards our goal than we would have on our own”. ~Dr Emanuel Addo- Yobo, Komfe Anokye Teaching Hospital, Ghana APPS Partnership Strength Survey, 2012. SDG 17 Revitalize the global partnership for sustainable development. Targets relating to TPI • SDG Target 17.6: “Enhance North-South, South-South and triangular regional and international cooperation on and access to science, technology and innovation and enhance knowledge sharing on mutually agreed terms, including through improved coordination among existing mechanisms, in particular at the United Nations level, and through a global technology facilitation mechanism.” • SDG Target 17.9: “Enhance international support for implementing effective and targeted capacity-building in developing countries to support national plans to implement all the sustainable development goals, including through North-South, South-South and triangular cooperation.” 18 Partnership Preparation Package Partnerships and the global goals The twinning partnership approach provides a link between local institutional change, national health systems and the global arena. The SDGs acknowledge the importance of partnerships (Objective 17) by recognizing that partnerships help to “mobilize and share knowledge, expertise, technology and financial resources.” The SDG goes further to highlight that “a successful sustainable development agenda requires partnerships between governments, the private sector and civil society. These inclusive partnerships built upon principles and values, a shared vision, and shared goals that place people at the centre, are needed at the global, regional, national and local level”. Linkages with multiple SDGs are evident, particularly 3.8 on UHC, but a range of others are clearly evident too. For example, a partnership approach can contribute to the reduction of maternal mortality ratio (SDG 3.1) by improving the quality of care for mothers.7 While TPI focuses on local, front-line improvements in the quality of health services, the compounding results from all partnerships around the world can lead towards global cohesion and overall impact. It is important to note that the benefits produced by twinning partnerships not only enhance institutional capacity to deliver improved health services, but also contribute to strengthening of the entire health system, if designed and implemented effectively. OBJECTIVE 2 – IMPROVEMENT Improvement is at the core of the partnership. In general, improvement focuses on the act or process of making something better. In hospital settings, improvement implies organizational and structural change, in addition to a necessary change in attitudes and behaviour, very often - all of which makes this process complex since it involves people and often requires a culture shift. Gaps existing in quality of care within health care facilities should be agreed 7 Royal College of Midwives and Ugandan Midwives Association. Case study in THET: https://www.thet.org/case-studies/aligning-partner- ship-plans-institutions-strategic-plan-2/ 19PART 1: TPI objectives Partnership development and continued strengthening – Japan and Liberia The Partnership between Nagasaki University Hospital (NUH), Japan, and Tellewayon Memorial Hospital (TMH) in Lofa County, Liberia, was formed in August 2016. At the time, TMH was recovering from the West African Ebola outbreak of 2014 and relying on international support to reactivate its essential health services and moving forward with recovery efforts in alignment with national recovery plans. During the recovery at TMH, it was quickly realized that the impacts of the Ebola response had depleted many resources and that extensive work was needed in order to improve quality. NUH saw that the needs at TMH were extensive and agreed to form a partnership with TMH. The Ministry of Health and the County authorities in Liberia supported this partnership at the onset of the formal TPI agreement. Careful consideration was given to the architecture of the partnership, recognizing the distinct culture and context of the respective partners. Principles and definition of partnerships were carefully considered in recognition that success of the partnership would depend on the foundations developed in the early stages. This proved pivotal in the roll-out of the partnership. Moving forward from this initial partnership, a situational assessment and gap analysis were completed at TMH in October 2016. Following the gap analysis, an official “action planning” meeting took place in December 2016 where both partners agreed to improve infection prevention and control, with specific attention being given to hand hygiene and waste management. It was noted that by improving these two areas, the foundation could be created for overall quality improvement throughout the whole hospital. The partnership undertook two partnership exchange visits in Liberia and Japan respectively. The principles of the partnership were reinforced throughout while the improvement work proceeded. The bi-directionality of the partnership learning was emphasized. For example, the TMH team leader gave a talk about their experience in the Ebola response. NUH stated they benefited greatly from because they learned about the realities of diagnosis and treating Ebola affected patients. 20 Partnership Preparation Package upon. Based on these identified gaps, one or several priority action areas are identified to steer the focus of the partnership. The ultimate aim is to improve the quality of care and overall health outcomes through the successful implementation of interventions using effective improvement methods. Both arms of the partnership need to establish common goals and priorities in order to develop a strong, effective and sustainable partnership. Additionally, when defining areas of improvement, it is necessary for the focus to involve and engage local stakeholders, teams and individuals within the health system who will be the ones to sustain the efforts put forth by the partnership. Objective 2 involves the following necessities. • Both arms of the partnership needing to jointly agree on improvement entry points. This collective approach promotes an atmosphere of ownership, learning and innovation through a safe space supporting an open mind-set, the use of skills and an opportunity to work and learn together. • Achieving common goals set between partners. This includes defining clear targets, agreeing on the best methods of spread, setting clear reporting mechanisms and monitoring standards, methods and ways of working. • Coordinating the implementation of improvement activities through regular contact supported by a communication plan that holds people accountable for their own work. • Testing several changes until a desired process that leads to a desired outcome is achieved, allowing for a certain degree of flexibility, permitting necessary changes and adaptations. The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches to improvement. Areas of improvement can include a variety of service delivery and clinical care areas influenced by the baseline assessment, Improvement “The combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning).” Batalden, P. B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? Quality & Safety in Health Care, 16(1), 2–3. https://qualitysafety.bmj. com/content/16/1/2 21PART 1: TPI objectives such as infection prevention and control (IPC), patient safety, and specific clinical services. Examples abound but the unifying concept is that improvement in service delivery needs to have a direct and lasting impact on the quality of the entire health system8. The linkages between service delivery and health workforce are clearly evident. The inter-relatedness with each of the health system components is highlighted through all partnership action. In the example below, the partnership in Ethiopia illustrated how improvements in both service delivery and clinical care at the facility level have had a direct impact on the wider health system. Ultimately, achieving quality at the facility level can bring balance and improvements to the entire health system. OBJECTIVE 3 – SPREAD Spread allows for sharing and scale-up of improvement experiences and learning within the local and national health system, and beyond. This enhances the reach and impact of the partnership by sharing what did and did not work well. When considering Spread, a strategy to help document successful experiences should be developed and early conversations should be held on the following topics: (1) What are the new and creative health service improvements that have been made? Spreading the emerging success stories of improvement can help drive large scale spread. (2) What are the ways in which this improvement will be sustained? A way to sustain improvement is to allow sufficient time for new practice to become fully integrated as the standard (e.g. incorporating new practices in policies, procedures, job description, etc.). (3) How was the improvement made? For example, demonstrating the benefits and advantages arising 8 A health system has traditionally been described by WHO as comprised of six building blocks which include: leadership and governance; health information systems; health financing; essential medical products and technologies; human resources for health; and service delivery. Improvement – Gondar, Ethiopia and Leicester, England The partnership formed between the University of Gondar Hospital, in Ethiopia and the University Hospital of Leicester NHS Trust, in England, aimed to implement the WHO Surgical Safety Checklist in the operating theatres of Gondar Hospital. Through regular audits, staff feedback and multidisciplinary learning sessions, the monitored results showed that the Checklist had successful implementation, compliance and adherence among staff. Additionally, there was consistent focus on joint learning and participation which helped to build research capacity. This resulted in a multi-country research project to look at Checklist implementation in a partnership context. After monitoring the implementation of the Checklist programme, it was found that its use rose from 17% to 53%, with a 100% application in emergency procedures. Multi-professional groups are now trained in its use. Importantly, the research also provided an opportunity to critique the work of the partnership and enable further improvements. Of note, this long-standing partnership benefitted from the support of both THET and WHO. 22 Partnership Preparation Package from a new practice encourages both spread and sustainability. (4) Who is the target audience of the Spread? In considering the target audience, it is important to acknowledge if the spread will focus on individual buy-in, whole facility buy-in, or entire health system adoption. These details help to organize and structure a plan to disseminate the information and experiences of success. The work of the partnership, particularly in relation to spread, needs to take careful account of the national strategic direction on quality, where this exists. Many countries are now developing or refining national quality policies and strategies. The formation of these policies and strategies can be informed by experiences that emerge from twinning partnerships. When these national strategies already exist, the work of the twinning partnerships should be carefully aligned with the national direction. This allows the effort of the partnership to have maximal impact by supporting implementation of a nationally owned drive for quality. The initial situational assessment can identify the national quality direction and both arms of the partnership need to be fully aware of this at all stages of the partnership. Spread can be considered in three ways - horizontal, vertical and spontaneous. From the onset of the partnership, the following should be considered. 1. As soon as partners begin planning for health facility improvement, spreading this improvement should also be discussed. 2. Consider broadcasting your improvement message through different channels, such as conferences, professional journals, media, word-of-mouth and first-hand accounts. 3. Make it as appealing as possible for others to want to copy your improvement. 4. Build a network to sustain and grow spread. 23PART 1: TPI objectives 5. Finally, consider, at the outset, how the experience arising from this project could be used to feed into learning systems, both at the national and global levels. Horizontal spread refers to spreading improvement across people and organizations within the same level of a health care system. An example of horizontal spread is replicating improvements from one unit in a health facility to another. Vertical spread refers to spreading the information and improvement efforts throughout the national, subnational and local levels of a health system. Vertical spread is particularly important because while national level can drive local change, local can also drive national level change. It is important to collect quantitative data and analysis of the improvements as it lays the groundwork for evidence-based practice and can be a critical component of vertical spread, and thereby influence changes in policy. Spread requires strong connections between quality improvement evidence in conjunction with both facility and national quality policies. This evidence and clear alignment with existing policy could help to facilitate the improvements made from TPI into facility and national quality policies. Spontaneous spread, is not planned for, but can spontaneously occur through informal channels such as social networks, or opinion leaders, which sometimes cross country’s borders. An example of spontaneous spread is the engagement that occurs between partnership facility leaders and key influencers within the health system. The power of human interaction and storytelling – often in informal meetings and gatherings – in achieving change then becomes clearly evident. Of further note is the necessity to consider the spread of ideas, competencies and skills from low-income countries to partners in high-income countries. This is inherently related to concepts of mutuality that are enhanced through partnerships. 24 Partnership Preparation Package The critical role of the community Involving patients and communities can stimulate spread and strengthen implementation and the sustainability of improvement programmes. Connecting with the local community can improve the quality of care and make services more people- centred. This is particularly important in low-resource settings where demand for health care is high. Co-developing health services around the needs of patients and the community, by empowering patients and communities by informing them and giving them the ability to make decisions in order to instigate change, can enhance the patient’s experience, health outcomes, confidence and trust in health care providers. Ideally, patient, family and community engagement should be part of all national health plans. In the absence of a formal mechanism to engage patients and the community, health care workers can carry out simple actions to engage them, such as providing practical training (e.g. on hand hygiene, waste management, use of medicines, etc.), invite patients’ representatives or community leaders to participate in orientation meetings and provide on- going support. Advocating for the partnership and the successes achieved will promote the work and lead to further interest within communities. This work can be celebrated and advertised to maintain motivation and create a positive atmosphere. When community spread occurs, the knowledge generated through an improvement process in the health care facility becomes part of normal practice and standards that have positive implications for the population’s health, e.g. hand hygiene improvement. The example below highlights horizontal and vertical spread. Spread - Yagaldo Ouedraogo Hospital, Burkina Faso and Montpellier Hospital, France Yagaldo Ouedraogo Teaching Hospital in Burkina Faso started partnering with the Teaching Hospital of Monpellier in France, and implemented a pilot project to improve hygiene in the neurosurgery ward in 2013. The objective was to meet the standards of hospital hygiene in this specific ward. Four areas were targeted: hand hygiene, waste management, management of nosocomial infections and capacity-building of health workers. The idea was to concentrate efforts on the selected activities in one of the wards of the hospital in order to understand what kind of improvements could then be replicated in other wards and units of the hospital. Improvement was spread horizontally, making the entire facility benefit. Furthermore, convinced of the advantages of partnerships work, Expertise France secured support from the European Commission to spread this improvement to other health care facilities across the country. Nine partnerships involving national and regional hospitals have been implemented since February 2017 with positive implications for the entire health system of Burkina Faso. Thus, horizontal and vertical spread is taking place simultaneously.
PART 2: OVERVIEW OF THE 6-STEP CYCLE T he partnership approach is a step-wise approach which facilitates the development of partnerships, the systematic identification of gaps and the development of an action plan and evaluation cycle. 1. Partnership development begins the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions. Both arms of the partnership agree to work together to improve the quality of health care. 2. The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership. 3. The gap analysis involves a review of the needs assessments and reveals key priority areas for action. From the gap analysis, the foundation for action planning is established in a systematic way, in order to help partners to implement a more focused improvement effort. 4. Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long-term targets for the twinning partnership. In this step, it is important to look at communication, spread and budget. 5. Action is the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. 6. Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. A variety of tools and resources are available (Annex 2) to support each step and will guide the partnership implementers throughout the process. PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE A t each step of the cycle, one or more tangible outputs or deliverables to work towards is expected. These outputs are designed to help the TPI partnership move the action forward. To assist partners, a list of supportive tools and resources is provided in annex 2. Implementing organizational and structural change is often complex, because in many cases it involves people and a cultural shift needs to take place. For this reason, when seeking appropriate tools for any given technical action area, it is important to consider how they can support planning for the partnership activities, their implementation, and in addition important cross-cutting themes, such as community engagement, knowledge management and communication/advocacy. It is also important to consider the broader national context, policies, frameworks and national strategic priorities and existing initiatives in planning twinning activities. Technical improvements must align with national policies and strategies. This will be particularly important in achieving objective 3 and spreading the experience from the twinning partnership improvement process both in the short and long term. STEP 1: PARTNERSHIP DEVELOPMENT This is the beginning of the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions. Both arms of the partnership agree to work together to improve the quality of health care, focusing on different aspects of service delivery, including clinical care. A requirement of successful partnership implementation is to have a stable funding structure. This has to be defined from the beginning, as the activities that the partners will undertake will depend on the availability of human and financial resources. Partnerships established through international cooperation9 can benefit from direct funding of one arm of the partnership. In other cases, partners can agree to share the costs or compete successfully for external funds. This requires the partners working together to identify potential sources of funding and develop joint proposals. Whatever model of funding is applied to implement the activities of the partnership, it is vital that partners agree on clear systems and procedures. Main activities 1. Secure formal management and leadership agreement on both sides of the twinning partnership to take joint action. This can be done through a written statement of understanding across the institutions, such as a letter of commitment. 9 The concept of international cooperation makes reference to the interaction of persons or groups of persons representing various nations, in the pursuit of a common goal or interest. Outputs or deliverables 1. Exchange of letters between institutional management as required (it can be a letter of commitment or a Memorandum of Understanding). 2. Agreement on a definition of the twinning partnership. 3. Team members on each arm of the partnership selected and contact details exchanged. 4. Communication plan drawn up. 5. Kick-off meeting notes indicating potential areas of work, next steps and a tentative date for conducting the needs assessment. 6. Official designation of a lead and deputy trained in the approach using the outline provided in this preparation package. Core resources for Step 1 – Partnership (see annex 2) 30 Partnership Preparation Package 7. Identify a twinning lead and deputy at each partner institution. Ideally the Quality Improvement Officer should be the designated lead. In the absence of a Quality Officer, a focal point responsible for quality and safety can be designated instead. 8. Ensure the engagement of multi-disciplinary staff committed to being part of the “improvement team”. For example, a dedicated person that collects data and monitors evaluation activities. Involving motivated staff will make the change process happen smoothly and positively influence staff who resist change. 9. Consider the suggested definition of partnership; refine and agree on it across the twinning partners as a foundation for moving forward. 10. Negotiate with managers to secure protected time for the improvement team to work on the identified technical action areas. 11. A kick-off meeting with the twinning teams is recommended for the teams to get to know each other. If an in-person meeting is not possible, the alternative is a virtual meeting. 12. Establish a schedule of regular communication (a minimum of once a month is recommended) using a variety of methods (telephone, SMS, text messaging, email, skype, etc.). 13. Establish a budget for the planned activities, including overheads. STEP 2: NEEDS ASSESSMENT The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership.10 10 For an example of a “How To” tool developed for the TPI partnership situational analysis between NUH and TMH, see annex 3. Core resources for Step 2 – Needs assessment (see annex 2) 31PART 3: Digging deep - Putting the 6-Step cycle into practice Main activities 1. Conduct a desk review on existing national, sub- national and institutional documents on quality of health services. Possible documents include: national health sector policy/plan, national quality policy or strategy. 2. Identify experienced and motivated leads to coordinate the assessment, as well as their assessment team members. The composition of the team will depend on the scope of the assessment, the time and resources available. Ideally the team should include a member from the district health management, the health care facility management and an expert of the technical area to be assessed. 3. All members of the assessment team should be briefed before starting the assessment and have an overview of the expected results of the exercise, including the data collection process. 4. Communicate to other facility staff about this exercise as it requires the collaboration of other teams when collecting data, ensure buy-in from the start and discuss confidentiality. 5. Undertake a specific needs assessment within the selected technical area using appropriate assessment tools. Examples of themes that could be assessed are: a. infection prevention and control b. patient safety and health worker safety c. essential surgical care d. waste management e. Water, sanitation and hygiene (WASH) f. maternal and newborn care g. health workforce. 6. Consider the use of a standardized tool to complete the needs assessment. See annex 3, as an example of the tool developed and then used for the TMH needs assessment. Outputs or deliverables Completed baseline and situational analysis report appropriate to technical area of focus. 32 Partnership Preparation Package Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. Core resources for Step 3 – Gap analysis (see annex 2) 33PART 3: Digging deep - Putting the 6-Step cycle into practice Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. 7. Outline specific steps that can be taken to fill the gaps. 8. Organize a meeting with senior leadership to secure endorsement and approval of the findings of the gap analysis and the priority areas identified. Quality Improvement (QI) at the core of TPI The TPI Preparation Package outlines all six steps and provides support and guidance for initiating the partnership and prioritizing which areas in service delivery or care need improvement. In addition to this TPI Preparation Package, a detailed practical field guide entitled “Taking Action: Steps 4 and 5 for Twinning Partnerships for Improvement” can be read alongside the overview of Steps 4 and 5 below. “Taking Action” dives into QI models and approaches and supports the planning, action, implementation, and guidance of QI within partnerships. “Taking Action” reviews the theories of practical application of action in a partnership and can be used by any QI team that has identified a quality challenge, specific needs and current gaps in services; and also that is ready to develop targeted action plans for intervention and improvement in health care setting. The “Taking Action” document also includes a list of common barriers and key factors for successful quality improvement gathered through the WHO Global Learning Laboratory for Quality UHC. The seven countries which provided feedback on common barriers and key factors for success included India, Malawi, Mexico, Nigeria, the United Kingdom, Venezuela and Zimbabwe. The feedback provided critical insights from the front line on the challenges and opportunities for quality improvement at the facility level. For additional information and for the common barriers and key factors, please refer to “Taking Action: Steps 4 & 5 in Twinning Partnerships for Improvement.” For additional information on the WHO Global Learning Laboratory, visit: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/ 34 Partnership Preparation Package STEP 4: ACTION PLANNING Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long- term targets for the twinning partnership. In this Step, it is important to also consider matters related to communication, spread and budget.12 Main activities 1. Hold a team meeting at the partnership facility • Identify and confirm the key team members at the partnership facility: • Facility leader or manager to endorse the partnership • QI team leader with dedicated time for the project • Technical/clinical/subject matter expert • Measurement and evaluation leader • Community/patient representative • QI team staff to provide technical and administrative support • Ensure consensus and common understanding of key definitions • Outline preparation activities • Review activities taken to date on Steps 1 to 3 of 6-Step Cycle • Ensure team is prepared with priority areas already identified • Assess ground level interest and capacity • Estimate expected costs in terms of personnel, time and money. 2. Agree on an intervention • Review evidence for possible interventions, focusing on improved outcomes • Seek relevant resources on all relevant 12 For an example of action planning templates, see Annexes 4-6 Core resources for Step 4 – Action Planning (see annex 2) 35PART 3: Digging deep - Putting the 6-Step cycle into practice literature on the subject area • Consult with experts on site and at partnership sites • Consult with other health workers • Select intervention with largest benefit, lowest barriers to use, and greatest potential for sustainability • Carefully consider how technical exchanges can support the intervention • Note sustainability of interventions post-partnership • Break down interventions into necessary behaviours, structural and procedural changes. 3. Outline implementation activities • Outline implementation plans • Summarize roles and responsibilities for implementing various aspects of the intervention • Identify local barriers to implementation and design accordingly13 • Engage stakeholders to identify potential concerns • Identify needs based on local context • Identify potential gains and losses associated with implementation • Evaluate current communication methods and adapt as needed. 4. Outline roles and ensure capacity • Estimate expected expenditure • Estimate costs/time for team members • Estimate costs/time for supplies/ equipment • Estimate amount of inputs and capacity available 13 For a list of common barriers, see Taking Action Steps 4&5. 36 Partnership Preparation Package • Determine roles and responsibilities of each team member and how they will contribute to the improvement aim • Ensure protected time and support for staff • Obtain the necessary approval from the facility leader to protect time for key staff • Designate an administrative support person or other assistance • Ensure clear roles are defined for team members in the partnership institution and communicated clearly across the partnership. 5. Outline monitoring and evaluation activities • Outline monitoring activities • Examine hospital epidemiology and existing measures taken by hospital • Identify key indicators of success in implementation • Identify key methods for collecting evaluation data • Outline evaluation activities • Identify key indicators of outcomes • Identity key methods for collecting evaluation data • Strive for simplicity in evaluation and monitoring • Consider benchmarking success from other hospitals in similar contexts. 6. Complete written action plans • Share preliminary plans – ensure teams in partnership health facilities are in agreement • Schedule a series of partnership visits with defined objectives, including twinning partner, other partners, country/WHO lead (if applicable) • Agree on a schedule of partner progress reports (see annexes 4-6). Outputs or deliverables 1. Complete written 2-year Partnership Plan 2. Complete written 6-month initial short-term action plan. 37PART 3: Digging deep - Putting the 6-Step cycle into practice STEP 5: ACTION Action marks the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. Reviewing progress every six months will allow corrective measures to be taken, if needed. The improvement team should carry out regular and planned monitoring reviews using the indicators previously defined. During this action stage, a method for tracking the budget is advised. Main activities 1. Put Partnership Plan into action with partners • Ensure continuous consensus in action between partners • Ensure continued alignment with national and sub-national efforts to strengthen quality of health services • Ensure that partners working within the same facility are continuously aware of improvement activities • Align existing improvement efforts already under way at the facility level • Mark the moment of initial action on both arms of the partnership • Choose a date. 2. Manage the implementation of activities • Set up a regular schedule for the QI team to share updates on progress of the project • Ensure methods are used to make data regularly visible to staff • Ensure involvement across the institution, including staff members not directly involved in the specific improvement intervention • Ensure regularly scheduled communication across the partnership on implementation activities. 38 Partnership Preparation Package 3. Coach the team to implement the QI activities • Provide facilitation and QI methods training for QI team leader • Provide mentoring, coaching and general on-site QI support using all assets available (local- and partnership-based) • Build in time for QI knowledge transfer from the team leader to team during team meetings, with the intention of creating cohorts of health workers who can act as catalysts and mentors. 4. Implement the quality initiatives and test changes • Implement intervention • Measure performance through small test of change – PDSA cycles or other agreed methods • Keep track of progress against the planned activities and budget • Make adjustments to intervention based on information received, e.g. outcomes and feedback in response to small test of change • Document issues that arise in a log, and how they were tackled • Set up rapid response mechanisms for trouble-shooting with partners. 5. Assess and refine the interventions • Implement review every six months • Develop interval reports • Adjust team efforts accordingly • Adjust any changes due to staff turnover, need for capacity-building, or need for re-training or training of additional staff • Report back to the partnership on issues that arise14 14 For an example of a partnership that confronted failure, see annex 1. 39PART 3: Digging deep - Putting the 6-Step cycle into practice • Celebrate small or large victories on both arms of the partnership. 6. Share learning and spread changes • Continuously refine change until ready for implementation on a broader scale • Implement a spread plan, taking careful consideration of sub-national and national contexts • Spread changes, taking a successful implementation process from pilot and replicating change throughout the organization • Identify opportunities to use partnership activities to bring about change in other institutions, encouraging national spread. 7. Document and disseminate the improvements observed • Distil the change stories • Distil learnings on implementation by developing knowledge products15 such as knowledge briefs and action briefs • Synthesize any learning to have emerged from one arm of the partnership that benefitted the other arm, emphasizing the bidirectional nature of learning • Disseminate a progress report using appropriate bodies at national, subnational and local levels to maintain to maintain dialogue and connection to overall national plans. 15 Visit the WHO Global Learning Laboratory for more information on Knowledge Briefs. Outputs or deliverables 1. Develop a series of reports outlining action and progress in partnership plan 2. Conduct mid-term review of implementation activities. 40 Partnership Preparation Package STEP 6: EVALUATION Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work (against their baseline) and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. Monitoring and evaluation are key components for a successful partnership and must be implemented from the outset of the partnership cycle. This step marks the closure of the cycle and allows the partners to review and assess how well the partnership has met its objectives, but also the partnership’s true impact. The evaluation is the final stage, but the monitoring has taken place thorough the cycle and the results will inform the overall assessment. In addition to local review meetings and partnership discussions, each twinning partnership provides periodic monitoring reports (6-month reports; 1-year repeated baseline assessment; and a 2-year review). Some suggest an external evaluation by specialists to ensure objectivity and others suggest using the teams within the project to gather optimal learning. A combination of the two approaches can generate better results and partner satisfaction. Whatever is decided, the partners should be involved in the exercise; specialists should be responsible for certain aspects of the evaluation, and the evaluation and monitoring process must be planned for at the beginning of the partnership. By including the three objectives as an underpinning structure of the evaluation, a successful evaluation reflects on the strength of the partnership, the priority areas of improvement, along with its spread. Main activities Initial evaluation planning activities should be conducted in earlier parts of the 6-step partnership cycle. This planning activity should include consideration of: Core resources for Step 6 – Evaluation and Review (see annex 2) 41PART 3: Digging deep - Putting the 6-Step cycle into practice • key indicators on the effectiveness of the improvement effort • assessment of partnership strength • spread beyond the partnership • training on evaluation approaches for those involved in the partnership • periodicity of reporting. Evaluation activities are conducted throughout the 6 steps. Step 6 is focused on activities to synthesize findings, as well as conducting any necessary assessments. 1. The partners together review the monitoring reports and decide how to synthesize evaluation (collection of statistical data, interviews, focus group, surveys, etc.) 2. Synthesize findings from key indicators that demonstrate effectiveness of the activities conducted, as well as the long-term impact of the partnership. 3. Prepare an evaluation report based on the actions outlined in the partnership plan (and informed by appropriate evaluation tools). 4. Reflect on the success of the evaluation training. 5. Conduct a repeat of the baseline assessment/ situational analysis to consider progress. 6. Conduct assessment on the strength of the collaboration. 7. Conduct assessment of the spread activities. 8. Synthesize all findings and agree on key lessons learned (consider limiting to top ten). 9. Prepare an evaluation report to demonstrate impact and to advocate for financial support. The reports will focus on the achievement of project outputs and outcomes. 10. Disseminate findings internally and externally. Outputs or deliverables 1. For a 2-year project, three monitoring reports should be generated and shared across the partnership and with hospital leaders outlining action and progress towards achieving the Partnership Plan (at 6 months, 1 year and 2 years). 2. Repeated baseline assessment/ situational analysis. 3. Evaluation report KEEPING THE LEARNING GOING T here have been notable successes among the hospitals and health systems that have participated in partnership-based approaches to improvement. These include sustained partnerships, co-developed products and programmes and spread. It has become clear, that in many cases, neither the technical experts from high-income settings, nor the local providers from low-income institutions have sufficient knowledge and know- how to affect improvements. Strong, trusting, inter- institutional partnerships are therefore needed to co-develop solutions that can lead to success and spread. Linkages with national efforts to enhance quality are key to successful cascading of learning for maximal impact on health outcomes. The 6-Step Partnership Improvement Cycle and the TPI Preparation Package provide a practical blueprint for action. It should be noted, however, that each partnership is different - adaptation will invariably be required. Learning will certainly emerge, and this document will also be improved over time. Quality improvement is still an evolving science, and humility is essential for partners on all sides of the TPI. Indeed, successful partnering is rewarding for all those involved. There is much to be learned about how to apply the principles and practices of quality improvement to strengthen the delivery of health services and build resilient health systems in developing countries, yet, lessons also flow back to the so-called developed world. The prototype partnership between Tellewoyan Memorial Hospital in Liberia and Nagasaki University Hospital in Japan proved invaluable in informing the design of the larger TPI initiative. The experiences from this and other efforts will help refine the different approaches to quality improvement. These experiences can also inform and be informed by wider efforts on quality, which have become increasingly prominent in the context of continued advancement of global efforts to achieve universal health coverage. Resources are limited, and continued global learning about quality improvement will depend on the sharing of knowledge, experiences and ideas. Entities such as the WHO Global Learning Laboratory (GLL) for Quality UHC can foster such sharing. The GLL is also a space where successes can be celebrated and knowledge, experience, and ideas shared. Sometimes there is failure, but resilience is needed to find a way to succeed – a huge body of learning resides in these initial failures. The words of Benjamin Franklin ring true - “Tell me and I forget, teach me and I may remember, involve me and I learn.” That is the power of human interaction that lies at the heart of a partnership. ANNEXES ANNEX 1 Case study - Adjusting action when it’s not working Developing a culture of learning in Malawi16 Partnerships work together to identify what works, what does not and what can be learned from this. The Zomba Mental Health Services (Malawi) partnered with the Department of Health Sciences at the University of York (UK) and worked together on a project designed to strengthen the system of community mental health care in Zomba District, Malawi. The project aimed to develop the role of local village-based health workers, known as health surveillance assistants (HSAs), through training and support, in delivering mental health interventions 16 This partnership was supported by THET. for the first time. Planning and delivery of the project involved key professionals in Zomba from mental health services and district health offices, as well as discussions with the HSAs. To collect data, the project manager of Zomba conducted visits to the village-based HSAs on a monthly basis. This allowed him to capture relevant data and discuss it with them. This process allowed them to engage HSAs in the project as a whole. “It enthused people, kept them motivated and interested, and kept the momentum of the project going. This wouldn’t have happened if we hadn’t built in face-to-face visits”, admitted the project manager. There were practical difficulties and the data required for monitoring and evaluation was not efficiently collected. The project manager of Zomba had planned to capture all data on his laptop on a monthly visits, but this proved too time-consuming. Having realized the data collection system was not working, the team agreed that paper copies of the data would be taken off-site between visits, and that the timescales should be allowed to slip. This affected the progress of the partnership improvements and the colleagues involved agreed to improvise and adjust the action planning. The project manager of Zomba believes that learning has been facilitated by the partners having respect for each other’s views and ideas, and making decisions collectively. “The UK partner was very supportive of our new ideas on the implementation of the work. This has helped the partnership to work better together for one common goal, evidenced in the successful results. In the process, the Malawi partners have gained knowledge and learnt skills, including in relation to good project and financial management, and analysis, interpretation and reporting of data.” Acknowledging problems allows partners to look for solutions and turn challenges into lessons learned. 46 Partnership Preparation Package ANNEX 2. TOOLS AND RESOURCES The tools and resources listed below aim to provide support in the development and execution of your action plan. The resources are diverse and span, not exclusively, advocacy, business/financial, guidance/policies/standards, templates, toolkits and selected academic publications. The resources are included after careful review of WHO materials. Inclusion of a resource is based on its perceived usefulness and also its availability. Inclusion of a resource does not imply endorsement by WHO of any specific organization associated with the resource. Many tools and resources that are applicable in hospitals can be accessed through the WHO website of Hospital of the XXI Century: http://www.who.int/hospitals/en/ Type of resource Location Starting a health partnership (THET) https://www.thet.org/wp-content/uploads/2017/09/How-to-start-a-Health-Partnership.pdf Example of letter of commitment http://www.who.int/patientsafety/implementation/apps/APPS_registration/en/ Example of memorandum of understanding https://www.thet.org/wp-content/uploads/2017/09/Memorandum-of-Understanding-Template. pdf La coopération internationale hospitalière – guide des bonnes pratiques. (French Hospital Federation) https://www.fhf.fr/Europe-International/La-cooperation-internationale/ Guide-cooperation-internationale-hospitaliere Guide de la coopération hospitalière pour l’aide au développement https://www.cultura.com/guide-de-la-cooperation-hospitaliere-pour-l-aide-au- developpement-9782859526849.html Successful partnerships, a guide of OECD https://www.oecd.org/cfe/leed/36279186.pdf Position Statement - Global Catalyst Group for Institutional Health Partnerships http://www.who.int/patientsafety/implementation/apps/global-catalyst-group.pdf Core resources for Step 1 – Partnership development 47Annexes Core resources for Step 2 – Needs assessment The needs assessment tools that you see below are not exhaustive. They were identified from the process undertaken by the partnership prototype between Tellewoyan Memorial Hospital and Nagasaki University Hospital. Type of resource Location Year of publication IPC and patient safety Situational analysis for patient safety. A tool to assess the current level of patient safety in a health care facility based on 12 action areas http://www.who.int/servicedeliverysafety/ twinning-partnerships/tools/en/ 2009, revised in 2015 WHO Hand hygiene Self-Assessment Framework. A critical first step in improving hand hygiene in a health facility is to complete this assessment http://www.who.int/gpsc/country_work/ hhsa_framework_October_2010.pdf 2010 Twinning Partnerships for Improvement. Situational assessment report: quality and patient safety- Tellewoyan Memorial Hospital and Lofa County Health System http://apps.who.int/iris/bitstream/10665/2 53523/1/9789241511872-eng.pdf?ua=1 2017 A tool for Infection prevention and control for supporting national implementation through effective baseline assessment and evaluation http://www.who.int/infection-prevention/ tools/core-components/ICPAT2.pdf 2017 Workforce Human Resource Management Rapid Assessment Tool for Public and Private-Sector Health Organizations http://www.lmgforhealth.org/sites/default/ files/HRM_Rapid_Assessment_Tool_0.pdf 2005 Guidelines: Incentives for health professionals. This underlines both financial and non-financial incentives as critical to ensuring effective recruitment, retention and performance of health workers across the world. http://www.who.int/workforcealliance/doc- uments/Incentives_Guidelines%20EN.pdf 2008 Water, sanitation and hygiene WASH FIT. A practical guide for improving quality of care through water sanitation and hygiene in health care facilities http://www.who.int/water_sanitation_ health/publications/water-and-sanita- tion-for-health-facility-improvement-tool/ en/ 2017 Health service delivery management Service availability and readiness assessment (SARA). A tool to assess and monitor service delivery in terms of availability and readiness of the health sector and to generate evidence to support the planning and managing of a health system http://apps.who.int/iris/bit- stream/10665/104075/1/WHO_HIS_HSI_ RME_2013_1_eng.pdf 2015 Situational analysis of quality improvement in health care, Tanzania. This analysis covers the current status of QI work, standards and their assessment, indicators for QI, methods and approaches in use, progress made, SWOC analysis. http://www.tzdpg.or.tz/fileadmin/ documents/dpg_internal/dpg_work- ing_groups_clusters/cluster_2/ health/Sub_Sector_Group/Quality_ Assurance/11.a_Situation_Analysis_of_ Quality_Improvement_in_Health_Care_ Tanzania_-_Final.pdf 2012 Essential sur- gical care Tool for Situational Analysis to Assess Emergency and Essential Surgical Care http://www.who.int/surgery/publications/ s15986e.pdf?ua=1 2012 48 Partnership Preparation Package Core resources for Step 3 – Gap analysis Type of resource Location Year of publication Gap analysis Implementing a gap analysis framework to im- prove quality of care for your patients. USAID case study showing a gap analysis step-by-step. https://www.usaidassist.org/sites/assist/files/ hci.ghc_gap_framework_workbook.14jun10_1. pdf 2010 Gap analysis AHRQ Quality indicators toolkit – Instructions for doing a gap analysis https://archive.ahrq.gov/professionals/systems/ hospital/qitoolkit/d5-gapanalysis.pdf 2012 Practical resource Twinning Partnerships for Improvement. Japan- Liberia Partner Planning Workshop Report http://www.who.int/servicedeliverysafety/twin- ning-partnerships/partnership-planning-report. pdf 2016 Core resources for Step 4 – Action Planning The WHO Recovery Toolkit, accessible here, is a library of guidance resources in a single place which can be quickly and easily accessed, to guide action. A key purpose of the Recovery Toolkit is to support countries in the reactivation of health services which may have suffered as a result of a large-scale emergency. These services include ongoing programmes such as immunization and vaccinations, maternal and child health services, and noncommunicable diseases. In addition, and because the Toolkit contains core information needed to achieve functioning national health systems, it also supports countries with implementation of their national health plans during the recovery phase following a public health emergency. Type of resource Location Year of publication Knowledge translation Translating evidence into practice: a model for large scale knowledge translation http://www.bmj.com/content/337/bmj. a1714 2008 Planning and implementation WHO planning and implementation of district health services http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 WHO implementation strategy and tools. A guide to implementation of the WHO Multimodal Hand Hygiene Improvement Strategy http://apps.who.int/iris/bit- stream/10665/70030/1/WHO_IER_ PSP_2009.02_eng.pdf?ua=1 2009 Implementation tools and resources for supporting facility and national level implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes http://www.who.int/infection-prevention/ tools/core-components/en/ 2018 Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Evidence-based guideline to support countries as they develop and execute their national antimicrobial resistance (AMR) action plans. http://apps.who.int/iris/bitstream/10 665/251730/1/9789241549929-eng. pdf?ua=1 2017 Planning and implementation of district health services. 10 steps in planning, essential health package, health systems research, disaster preparedness http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 49Annexes Tools for assessing the operationality of district health. A set of tools aimed at district health management teams to generate the information that will serve as a basis for improving the operationality of health districts http://www.who.int/management/dis- trict/assessment/assessment_tool.pdf 2003 WHO Safe management of wastes from health care activities. Provides comprehensive guidance on safe, efficient and environmentally sound methods for the handling and disposal of health care waste in normal situations and also emergencies. http://www.searo.who.int/srilanka/doc- uments/safe_management_of_wastes_ from_healthcare_activities.pdf?ua=1 2014 Sanitation Safety Planning (Implementation tool). Manual for safe use and disposal of wastewater, greywater and excreta. http://apps.who.int/iris/bitstre am/10665/171753/1/9789241549240_ eng.pdf?ua=1 2015 WHO - Workload indicators of Staffing Needs (WISN) – User’s Manual http://www.who.int/hrh/resources/ WISN_Eng_UsersManual.pdf?ua=1 2010 Association for Professionals in Infection Control and Epidemiology (APIC) HAI cost calculator: http://www.apic.org/Resources/ Cost-calculators Core resources for Step 6 – Evaluation and Review Type of resource Location Year of publication Monitoring and evaluation M&E planning tool for both implementing and reviewing M&E plans https://www.thet.org/resources/ hps-monitoring-evaluation-plan/ 2014 Evaluation FAQs Step-by-step guide for health partnerships to effectively carry out an evaluation of their projects and partnerships in the form of frequently asked questions. https://www.thet.org/resources/ health-partnerships-evaluation-faq/ 2014 APPS -Evaluation Handbook A guide to evaluate five domains of a partnership: situational analysis, partnership strength, patient safety improvements, patient safety spread and annual evaluation report http://www.who.int/patientsafe- ty/implementation/apps/ Evaluation-Handbook_EN.pdf?ua=1 2012 Monitoring, evaluation and learning Webinar: sharing of experiences to provide some reflections around M&E https://www.youtube.com/ watch?v=v_oHEvgE_aA 2016 Monitoring and evaluation Health partnership symposium on monitoring, evaluation and learning. Document gathering tips to understand the value of M&E. Examples and exercises are provided. https://www.thet.org/wp-content/ uploads/2017/09/Monitoring-and- Evaluation.pdf 2017 Monitoring and evaluation EFFECt tool stands for EFFective in Embedding Change. This tools focuses on assessing implementation best practice, embedding change and the added benefits to individuals and institutions using a partnership approach https://esther.eu/index.php/effect-tool/ 2017 50 Partnership Preparation Package Core resources for improvement Type of resource Location Year PDSA Cycle (Plan-Do-Study-Act) Systematic process for gaining valuable learning and knowledge for the continual improvement https://deming.org/explore/p-d-s-a 2018 Model for improvement The Model for Improvement, is a simple, yet powerful tool for accelerating improvement http://www.ihi.org/resources/Pages/ HowtoImprove/default.aspx 2018 Confronting staffing issues and turnover of health facility staff Understanding the barriers to setting up a health care quality improvement process in resource- limited settings: a situational analysis at the Medical Department of Kamuzu Central Hospital in Lilongwe, Malawi https://bmchealthservres.biomedcentral.com/ articles/10.1186/1472-6963-14-1 2014 WHO Multimodal Improvement Strategy A one-page visual describing the five-part multimodal strategy to support IPC improvement in a health care facility http://www.who.int/infection-prevention/publi- cations/ipc-cc-mis.pdf?ua=1 2017 51Annexes ANNEX 3. TPI SITUATIONAL ASSESSMENT “HOW TO” TOOL EXAMPLE Step 2: TPI Situational Assessment “How To” Tool The following “how to” tool is presented as a practical guide explaining steps to plan and execute an in-depth situational assessment to inform a twining partnership initiative between two interested partner institutions. This assessment seeks to provide a foundational basis for the co-development of an effective and sustainable twinning partnership between partner institutions. This “how to” tool informs the process of conducting Step 2 of the 6-Step Partnership Improvement Cycle. The “how to” document is to be used together with the TPI Preparation Package and its associated resources. Post-Assessment: Build (4 weeks post-assessment) O B J E C T I V E : T R A N S L A T E F I N D I N G , S H A R E W I T H K E Y S T A K E H O L D E R S A N D I N I T I A T E A C T I O N P L A N N I N G P R O C E S S • Develop and finalize detailed assessment report in collaboration with the thematic lead persons, seeking any approvals where required • Develop short story from assessment highlighting quality improvement and safety opportunities and share with WHO Learning Laboratory for Quality Universal Health Coverage network • Participate in action-planning workshop for the twining partnership initiative presenting summary of the scoping mission findings and recommendations • Co-develop a partnership plan around the focused action areas identified by partner institutions • Use the assessment results to form the basis of the TPI partnership plan development • Provide feedback to WHO TPI team on assessment planning checklist • Discuss opportunities to leverage partner initiatives to support bottlenecks identified at district-/country-level • During Steps 4-6 of TPI cycle, consult quality improvement resources in TPI preparation package for action steps and evaluation/ review. • Conduct evaluation assessment as part of Step 6 of partnership Improvement cycle • Conduct Situational assessment on an annual basis ( as needed) • Align and build monitoring and evaluation system for the partnership with in-country quality of care measurement initiatives • Consult TPI quality improvement resources for hospital partnerships to inform monitoring and evaluation system of the partnership Assessment: Learn (10 days in-country) O B J E C T I V E : B U I L D R E L A T I O N S H I P S A N D L E A R N F R O M F R O N T - L I N E P E R S P E C T I V E S • Conduct team exercise with health facility staff and district health team to gain: • an understanding of the partner institutions • current understanding on quality and safety within local context. • Consult TPI Preparation Package for core technical tools and resources used for Step 2 • Identify key informant(s). Individual(s) should be a respected person amongst his/her peers. • Review interview guide with key informants or group and collectively refine tool to adapt to local context. • Key informant schedules interview times with health worker (HW) cohort. Recommendation for focused group discussions (FGD) with homogenous health worker cohort, if total cohort number exceeds five. Small homogenous groups allow for open discussion and confidentiality • During day of HH and PS assessment, do not hold any FGD. This is to allow limited HW participation in assessment. • Collect, analyse and crosslink data for all five thematic areas daily • Summarize and present preliminary findings to: • Hospital staff and district level staff • WHO Country Office/Ministry of Health • Relevant partners such as funding agency • Summarize preliminary recommendations according to actions needed for different stakeholders: • TPI initiative • Health facility • District health team • Ministry of Health • Hold daily assessment team meeting to debrief from day’s activities, address emerging key issues and prepare for next day Pre-Assessment: Deconstruct (minimum 4 weeks prior to assessment) O B J E C T I V E : R E V I E W I N - C O U N T R Y N A T I O N A L D O C U M E N T S , I D E N T I F Y Q I O P P O R T U N I T I E S A N D R E L E V A N T I N - C O U N T R Y P A R T N E R S • Identify experienced and motivated lead person to coordinate assessment • Inform WHO country office and regional office of impending situational assessment • Conduct desk review of existing national, sub-national and institutional documents on quality and safety. Possible documents include: • National health sector policy/plan • National quality health strategy • District/county-level operational or work plan • Health facility annual plan or workplan • artner coordination mechanisms • In-country quality of care measurement documents/projects • Identify areas you intend to evaluate during the assessment. Ideally, all five assessment thematic areas should be considered: • Quality Improvement • Patient Safety (PS) • Hand Hygiene (HH) • District-level health system • Patient & Community Perspective • Review long-form of interview guide addressing any unanswered questions that arise • Determine situational assessment schedule and share with WCO • WCO country office to schedule meetings in-country and facilitate facility/ district site visit • Identify composition of mission team and assign lead roles for five thematic areas • Ideally, team should include representation from MOH, multiple levels of the organization (if available) and the partner institutions • Ensure availability of relevant skill set, aligned with selected thematic areas • Identify relevant development partners/stakeholders to be consulted • Initiate series of coordination calls and email exchange with assessment team to discuss technical scope of mission and logistics • If funding allows, initiate scoping mission to sensitize Ministry officials and partners in-country ( if funding does not allow, initiate as part of in-country assessment) E X A M P L E S O F H E A L T H W O R K E R C O H O R T FACILITY- LEVEL DISTRICT/COUNTY-LEVEL • Clinical staff: doctor, physician assistant, nurses, midwives, pharmacist, lab technician, aides etc. • Non-clinical staff: maintenance staff, cleaners • Hospital Management • Patient & Community Representatives • Partners within Health Facility • Health Boards • Management Teams • Health Structure Directors • District/County Superintendent, District Commissioners, Traditional chiefs • Partners 53Annexes ANNEX 4. TPI PLANNING TEMPLATE SUMMARY INFORMATION Name of twinning institution 1: Name of lead: Name of twinning institution 2: Name of lead: Name and date of situational analysis/ baseline assessments used: Names of individuals completing the plan: Technical action areas for focus: Partners to consider specific areas to work on, based on situational analysis (experience highlights the need to focus on 2-3 areas maximum) Example: Project 1: Infection prevention and control Project 2: Knowledge and competency on quality improvement. For each action area, complete the template below. Use as many forms as required depending on the additional action areas addressed. Project number and action area • E.g. Project 1: Infection prevention and control Brief description of project • Provide a 1-2 sentence outline of the project Project goals • List the change the project will contribute to in 1- 2 sentences. • Where possible, link to national and/or local policies and plans including the national direction on quality. • Try to emphasize how the goals of the project respond to the needs identified in the baseline assessment. Project outcome(s) • Describe the improvement that you hope will result from the project. • Outcomes often relate to changes in practice or health outcomes. • The outcomes should contribute to the achievement of the goal. Project output(s) • The direct results of the project e.g. 20 people trained in infection control. The outputs should lead to achievement of the outcomes. Main activities • List all planned activities. For each activity, briefly outline what will be done; where and who will be involved on each side of the twinning partnership; how long it will take; methods to be used; and associated costs. • List technical exchange schedule ie. Fortnightly skype connection, monthly leads 1-to-1, 6-monthly visits, ... • Is a visit planned in conjunction with this project? (if yes, list likely human and financial costs.) • Twinning visit plans for year 1 should be thought through in detail. Plans for year 2 may be more general. Include a draft timeline. • What mechanisms are planned to allow receipt of just-in-time input to technical issues? • How will you connect with WHO efforts to support quality improvement? 54 Partnership Preparation Package Beneficiaries • Include information about the people who will benefit (directly and indirectly) from the project e.g. lab technicians; hospital managers; nurses and different groups of patient and community members. • Describe how they will benefit and provide realistic estimates of how many people in each group will benefit. • Will benefits span both sides of the twinning partnership? Stakeholders • Identify the key stakeholders and their interest in the project (e.g. other department, district and national health offices) i.e. any individual or group that may exert influence over the project activities and outcomes (across both arms of the partnership). • Consider the local community and key stakeholders, including patients and families who could contribute and add value to the planned efforts. • Outline which stakeholders the twinning partnership will report to and how often. Monitoring and evaluation • Define key indicators to be used to monitor whether the outcomes of your project have been achieved. • Provide an overview of your monitoring and evaluation plans, providing an outline of methods, who will be involved, how the process will be managed, and how partners will learn together. Sustainability and spread • Describe how long the activities will continue and what the plans are for long-term funding. • What benefits will continue after the initial 2-year project ends and how? • List your plans for building on project achievements. • Describe how you will actively disseminate new information gathered and consider activities to support vertical, horizontal and spontaneous spread opportunities. Risks • Identify potential risks associated with the plan e.g. key personnel moving on, changing institutional priorities, conflict between twinning partners, and how you will manage each of these risks. • List external risks and how you will manage them (e.g. ICT breakdown, problems with visas, political uncertainty). Project management and support • Outline project responsibilities including division of responsibilities across the twinning partnership. • Provide details of the key personnel involved in each arm of the partnership. • Consider key management questions: What systems will be used to manage finances in both locations? Who will have the main responsibility for budgets? How will you ensure that communication is effective and that all partners know what is happening? Approved by Date of approval 55Annexes ANNEX 5. TPI VISIT PROPOSAL TEMPLATE The Visit proposal template should be completed once a visit has been agreed, to ensure that the visit has clear objectives and contributes to the overall partnership planning. Twinning partnership (list both institutions within the partnership): Institution 1: Institution 2: Name of person completing the visit proposal form: Purpose of visit - describe which partnership project(s) the visit relates to: What are the dates of the proposed visit? Start date: End date: Is the visit aligned with existing in-country activity with no duplication of training or policy development work? Yes No Not applicable Does the visit clearly meet the needs of the twinning partner institutions? Yes No Not applicable Briefly describe the expected outcomes of the planned visit (outcomes are clear, realistic and logical): Briefly describe the outputs of the planned visit (outputs are clear, realistic and logical): Briefly describe any risks you think might be associated with the visit: List estimated costs of the visit: Briefly describe how the proposed visit will contribute to monitoring and evaluation of the associated partnership plan: List the number of people involved in the proposed visit and their role in achieving the visit objectives: Has the visit been jointly planned and agreed across the partnership? Yes No Will the visit offer potential benefits to both twinning partners (if yes, de- scribe briefly)? Yes No Not applicable Briefly describe how the visit will help achieve sustainability and spread of effective essential health service delivery. 56 Partnership Preparation Package ANNEX 6. TPI ACTION REPORT TEMPLATE The Action report template allows key outputs of each period of the partnership to be documented, lessons learned and actions arising logged. This is part of developing a strong, effective, action-focused partnership and contributes to partnership governance. Twinning partnership (list both institutions within the partnership): Name of person completing the report and date completed: Time period covered by this progress report: Key actions undertaken: Key achievements resulting from action taken: Key challenges faced: Date of next expected progress report: 57Annexes ANNEX 7: DEFINITIONS Accountability: The obligation to report, or give account of one’s actions – for example, to a governing authority through scrutiny, contract, management, regulation and/or to an electorate (19). African Partnerships for Patient Safety (APPS) programme: The WHO APPS programme is a hospital- to-hospital focused approach that was results- oriented and co-developed by hospital partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the African Partnerships’ work providing a common relevant goal that everyone was committed to improving. As a result, substantial implementation experience and learning have been achieved in this field across the African Region. The APPS approach demonstrated how working in partnership results in more motivated staff, increased commitment to change, strengthened capacity-building, focused drive and a desire to find appropriate solutions that will impact immediately on the quality and safety of patient care. This in turn can be used to strengthen the delivery of health services to communities globally (20). Clinical effectiveness: The application of the best knowledge, derived from research, clinical experience and patient preferences to achieve optimal processes and outcomes of care for patients (21). Community partner: Member of a quality improvement team representing a unit of population, often generally geographically defined, that is the locus of basic political and social responsibility and in which everyday social interactions involving all or most of the spectrum of life activities of the people within it takes place (22). Continuous Improvement: The process of making something better or of getting better (23). Integrated People-Centred Health Services (IPCHS) framework: The IPCHS Framework calls for a fundamental shift in the way health services are funded, managed and delivered to respond to these 58 Partnership Preparation Package challenges. The IPCHS vision is that “All people have equal access to quality health services that are co-produced in a way that meets their life course needs, are coordinated across the continuum of care and are comprehensive, safe, effective, timely, efficient and acceptable; and all carers are motivated, skilled and operate in a supportive environment.” WHO recommends five interwoven strategies that need to be implemented in order to achieve IPCHS. Application of the approach can build robust and resilient health services and are critical for progress towards universal health coverage and fulfilling the Sustainable Development Goals (24). Partnership: A partnership is a collaborative relationship between two or more parties based on trust, equality and mutual understanding for the achievement of a specified goal. Partnerships involve risks as well as benefits, making shared accountability critical (20). Patient-centredness: Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions (25). Patient safety: The reduction of risk and unnecessary harm associated with health care to an acceptable minimum (26). Performance: How well a person, team, project, programme, organization, or policy is being implemented against expected results (27). Quality: Quality has been defined and understood in different ways around the world. Two of the main definitions are below. • The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (28). • The totality of characteristics of an entity that bear on its ability to satisfy stated and implied needs (29). 59Annexes Quality audit: a systematic and independent examination to determine whether quality activities and related results comply with planned arrangements and whether these arrangements are implemented effectively and are suitable to achieve objectives (1). Quality assurance: all the planned and systematic activities implemented within the quality system, and demonstrated as needed, to provide adequate confidence that an entity will fulfill requirements for quality (1). Quality control: A process to evaluate actual performance, compare actual performance with quality goals, and take action on the difference (1). Quality improvement: A process to create beneficial change and attain unprecedented performance (1). Quality planning: A process to establish quality goals to develop goods and services that meet customer needs (1). Stakeholder: An individual, group or organization that has an interest in the organization and delivery of health care (29). REFERENCES 1. African Partnerships for Patient Safety Spread Pack. Improvement series. Geneva: World Health Organization;2012. (http://www.who.int/patientsafety/ implementation/apps/resources/APPS_Improv_Spread_ Pack_2012_04_EN.pdf?ua=1, accessed 13 April 2018). 2. Chisholm G. Gree E. Simms B. In our mutual interest. (https://www.thet.org/wp-content/ uploads/2017/08/In-Our-Mutual-Interest.pdf, accessed 13 April 2018). 3. Dean L, Njelesani J, Smith H, Bates I. Promoting sustainable research partnerships: a mixed- method evaluation of a United Kingdom–Africa capacity strengthening award scheme. Health research Policy and Systems .2015. 13:81. (https:// doi.org/10.1186/s12961-015-0071-2, accessed 13 April 2018). 4. Edwards S, Ritman D, Burn E, Dekkers N, Baraitser P. Towards a simple typology of international health partnerships. Globalization and Health. 2015.11:49. (https://doi.org/10.1186/s12992-015- 0132-x, accessed 13 April 2018). 5. EQUAL Partnership Development toolkit. European Commission. Directorate-General for Employment, Social Affairs and Equal Opportunities ; 2005 (http://ec.europa.eu/employment_social/equal_ consolidated/data/document/pdtoolkit_en.pdf, accessed 13 April 2018). 6. Health Partnership Scheme: Evaluation synthesis report. Tropical Health Education Trust; 2017 (https://www.gov.uk/government/publications/evaluation- of-health-partnership-scheme, accessed 13 April 2018). 7. Health Partnership Scheme: Impact report 2011- 2017. Tropical Health Education Trust; 2017 8. (https://www.thet.org/wp-content/uploads/2017/09/ Health-Partnership-Scheme-2011-2017-Impact-Report. pdf, accessed 13 April 2018). 9. Jones A. Envisioning a global health partnership movement. Globalization and Health. 2016.12:1. (https://doi.org/10.1186/s12992-015-0138-4, accessed 13 April 2018). 10. Jones F, Knights D, Sinclair V, Baraitser P. Do health partnerships with organisations in lower income countries benefit the UK partner? A review of the literature. Globalization and Health. 2013. 9:38. (https://doi.org/10.1186/1744-8603-9-38, accessed 13 April 2018). 11. Kulasabanathan K, Issa H, Bhatti Y, Prime M, Del Castillo J, Darzi A, et al. Do International Health Partnerships contribute to reverse innovation? a mixed methods study of THET- supported partnerships in the UK. Global Health. 2017;18;13(1):25. doi: 10.1186/s12992-017-0248- 2. (https://www.ncbi.nlm.nih.gov/pubmed/28420405, accessed 13 April 2018). 12. Lewis L, Williams C, Jackson L, Caffarella R, editors. Experiential Learning: A New Approach. San Francisco: Jossey-Bass;1994:5-16. 62 Partnership Preparation Package 13. Quality improvement made simple. What everyone should know about health care quality improvement. Quick guide. London: The Health Foundation; 2013 (http://www.health.org.uk/ publication/quality-improvement-made-simple, accessed 13 April 2018). 14. Reverse innovation in global health systems: learning from low-income countries. In: BMC collections/reverse innovations [website]. United Kingdom: BioMed Central, 2018 (https://www. biomedcentral.com/collections/reverseinnovations, accessed 22 June 2018). 15. Ritman D. Health partnership research and the assessment of effectiveness. Globalization and Health. 2016.12:43. (https://doi.org/10.1186/s12992- 016-0181-9, accessed 13 April 2018). 16. The European ESTHER Alliance. Bringing together our expertise for capacity building and health care. (https://esther.eu/wp-content/uploads/2018/01/ BrochureAllianceEsther.pdf, accessed 13 April 2018). 17. WHO Community Engagement framework for quality, people-centred and resilient health services. Geneva: World Health Organization;2017 (http://apps.who.int/iris/bitstream/10665/259280/1/WHO- HIS-SDS-2017.15-eng.pdf?ua=1, accessed 13 April 2018). 18. WHO Handbook for national quality policy and strategy. Geneva: World Health Organization; 2018 (http://apps.who.int/iris/bitstream/hand le/10665/272357/9789241565561-eng.pdf?ua=1, accessed 22 June 2018 ). 19. Partnership preparation package: a practical document to implement twinning partnerships: WHO twinning partnerships for improvement: http://apps.who.int/iris/bitstream/handle/10665/273158/ WHO-HIS-SDS-2018.13-eng.pdf, accessed on 19 July 2018).
.\ World Health \ , J Organization�� ��· 'j 1 jl ..-::: 1 ' i 1 A practical document to implement twinning partnerships WHO Twinning Partnerships for lmprovement ••• • • WHO/HIS/SDS/2018.13 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/ igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in Switzerland ACKNOWLEDGEMENTS The World Health Organization (WHO) would like to acknowledge the support and contribution that many individuals and organizations have made to the development of this document. Katthyana Aparicio, Melissa Kleine-Bingham and Shams Syed (Department of Service Delivery and Safety, WHO) coordinated and led the development and writing of this document. Maki Kajiwara, Nana Mensah Abrampah, Julie Storr (Department of Service Delivery and Safety, WHO) provided significant input to the development and drafting of this document. Special thanks to Sandra Hwang and Albert Wu (Johns Hopkins Bloomberg School of Public Health) for their technical contribution on quality improvement methods. External Peer Review Group Ngormbu Jusu Ballah (Liberia Ministry of Health), Jean Marc Chapplain (Centre Hospitalier Universitaire de Rennes), Graeme Chisholm (Tropical Health Education Trust - THET), Eric de Roodenbeke (International Hospital Federation - IHF), Charlie Evans (American College of Healthcare Executives), Koichi Izumikawa (Nagasaki University Hospital - NHU), Farid Lamara (Expertise France), Emmanuelle Maurin (Expertise France), Sandra Hwang (Johns Hopkins Armstrong Institute for Patient Safety and Quality), Andrew Jones, Samuel Seeigbeh (Tellewayon Memorial Hospital, Liberia) Albert Wu (Johns Hopkins Bloomberg School of Public Health) and ESTHER Alliance for Global Health Partnerships. CONTENTS 8 6 INTRODUCTION ABBREVIATIONS 12 PART 1: TPI OBJECTIVES 26 PART 2: OVERVIEW OF THE 6-STEP CYCLE 28 60 PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE REFERENCES 44 ANNEXES 42 KEEPING THE LEARNING GOING ABBREVIATIONS AHRQ Agency for Healthcare Research and Quality AMR antimicrobial resistance APIC Association for Professionals in Infection Control APPS African Partnerships for Patient Safety EEA ESTHER Alliance for Global Health Partnerships GLL Global Learning Laboratory HSAs Health Surveillance Assistants IHF International Hospital Federation IPC infection prevention and control LMICs low- and middle-income countries M&E monitoring and evaluation NHS National Health System NUH Nagasaki University Hospital OECD Organisation for Economic Co-operation and Development PDSA Plan-Do-Study-Act QI quality improvement SARA Service Availability and Readiness Assessment SDGs Sustainable Development Goals SMS short message services SWOC Strengths, weaknesses, opportunities and challenges THET Tropical Health Education Trust TMH Tellewayon Memorial Hospital TPI Twinning Partnerships for Improvement UHC universal health coverage USAID United States Agency for International Development WASH water, sanitation and hygiene WISN workload indicators of staffing needs WHO World Health Organization INTRODUCTION BACKGROUND T winning partnerships between health institutions are an innovative approach that can be used to improve various aspects of health service delivery. The WHO Twinning Partnerships for Improvement (TPI) model supports long-term efforts on quality health service delivery within the context of achieving universal health coverage (UHC). The work can contribute to building resilient health systems. Fundamental in the approach is to prioritize alignment with national health plans and strategies, while working to achieve the Sustainable Development Goals (SDGs). TPI builds on the learning from the WHO African Partnerships for Patient Safety (APPS) programme. These rich lessons and the subsequent application of twinning partnerships in the recovery effort in Ebola- affected countries have facilitated the design of WHO TPI. The key aim of WHO TPI is to support health care facilities in the improvement and enhancement of the quality of their service delivery, while aligning with the overall national strategic direction on improving quality service delivery. Institutional health partnerships can play a critical role in health systems strengthening. This has been increasingly recognized across the world. Many global health groups1 have highlighted the need to “promote the utility of institutional health partnerships in strengthening health systems and in delivering effective health services.” Recognizing the synergy that comes from a partnership approach, national policy documents over the past decade have also begun to highlight the potential for institutional partnerships as an entry point to strengthen services and health systems. In addition to the APPS programme, TPI also builds on the work undertaken in applying the Twinning model to support recovery from the 2014 West Africa Ebola outbreak. TPI Recovery focused upon building resilient health systems and reactivating safe essential health services in those countries most affected by the outbreak. The aim of TPI Recovery was to rebuild the health services in order to support implementation of national recovery plans. Implementation of twinning partnerships involves addressing a variety of service delivery and clinical care areas, including, but not limited to, infection prevention and control (IPC); patient safety; and specific clinical services. Health workforce capacity- building is embedded within the model. TPI can feed into work at the national level to improve the quality 1 For more information on global health groups and to view the consensus statement, please visit WHO’s web site at: http:// www.who.int/patientsafety/implementation/apps/global-catalyst-group. pdf?ua=1 WHO TPI Snapshot • Twinning Partnerships for Improvement focuses on the value of institution-to- institution partnerships in catalyzing health service improvement. • The hospital-to-hospital model developed by ‘African Partnerships for Patient Safety’ (APPS) is the foundation on which TPI has been developed. The emphasis is on a ‘doing while learning” model. • As a global network of twinning partners develops there is an opportunity to learn from and share learning across the TPI network. • The approach promotes collaboration, co-development and sharing of both tacit and explicit knowledge thus enhancing spread of successful approaches to improvement. 10 Partnership Preparation Package of service delivery. These partnerships can act as a valuable tool for health improvement strategies and bring real benefit to the front line of service delivery and ultimately to the health of an entire population. The power of twinning partnerships working together can bring effective health improvements beyond what an individual organization or team could achieve alone. Furthermore, the work of such twinning partnerships can feed into national strategic efforts to improve quality service delivery elsewhere. PURPOSE OF THE TPI PREPARATION PACKAGE The aim of this document is to provide a practical step-by-step approach for any health institution interested in improving the quality of health service delivery through twinning partnerships. The model is based on a 6-step cycle which begins when two or more partners agree on the establishment of the partnership. TPI guides the partners through a systematic process which involves identifying some specific areas for improvement, developing an action plan to implement improvements, and then evaluating the progression and changes made towards improvement. Institutional health partnerships have the potential not only to work as individual partnerships, but also to collaborate with other partnerships to support a national network of similar partnerships. This can support national efforts through joint problem-solving and sharing experiences in order to develop a body of evidence and experience that can inform national and district authorities. This can further encourage application of the partnership model at all levels of the health system. TARGET AUDIENCE The target audience for this partnership preparation package are those committed to improving the quality of healthcare and service delivery including, but not limited, to those in: TPI brings an opportunity to support improvement in the delivery of care at the local, sub-national and national levels. It can act as a catalyst for change in efforts to enhance quality in the context of UHC. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves. 11introduction • health institutions • health facilities • academic/research institutions • professional associations • donor organizations • health authorities • policy making • governments. The TPI preparation package also aims to inform decision-makers and authorities working at the national level that are responsible for planning, developing, implementing and evaluating national health strategies, including WHO country offices and ministries of health. When to use the package The package will be useful to any new or existing twinning health institutions in order to work through a partnership-based approach to improve the quality of health services and embed the effort within long-term service improvement. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves. PART 1: TPI OBJECTIVES OVERVIEW OF OBJECTIVES T PI focuses on the value of institution-to-institution partnerships in catalysing health service improvement following a “doing while learning”2 model. TPI takes into account a variety of entities, including health facilities, academic institutions, private institutions, etc.3 It provides the potential for implementing different types of 2 ”Doing while learning” refers to the experiential learning theory where one learns from experience in order to develop skills or new ways of thinking. (Lewis and Williams 1994, p.6) 3 While a variety of entities can be involved in the partnerships, the TPI preparation package will use the generic term institutions to cover all types of entities. partnerships, at local, sub-national and national level, and also across continents. Institutions from high- income countries or from low- and middle-income countries (LMICs) can initiate partnerships to support other institutions within LMICs and thus provide unique opportunities to catalyse the move towards quality health services, all within the context of achieving universal health coverage. Within the TPI model, there are three objectives that each partnership should focus on achieving. 1. The first objective is the development of the partnership. This objective focuses on fostering a strong bi-directional partnership between health institutions. 2. The second objective is improvement through implementing effective interventions based on needs identified at the front lines of service delivery. 3. The third objective is to spread the learning and experience within the local and national health system and also beyond. The ultimate benefits of TPI are bi-directional learning and improvement, motivated and committed staff; strengthened delivery of health services; and better patient and health worker outcomes. The Recovery Toolkit Twinning Partnerships for Improvement - Objectives 14 Partnership Preparation Package The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches towards improvement. As a global network of twinning partners emerges, there is an opportunity to learn from and share learning across the larger TPI network, to promote collaboration, co-development and sharing, and support the spread and replication of improvement. What is co-development? A process that brings together the collective intelligence for a collaborative development and applies joint decision- making that enhances trust. 15PART 1: TPI objectives OBJECTIVE 1 – PARTNERSHIP The formation of a partnership is the first step in the TPI journey. Under the first objective, two or more institutions come together to agree upon a common goal and define the partnership priorities which they hope will result in sustainable improvements at the health facility. Building on the APPS definition of partnership, which encompasses a sociological perspective focusing on the interaction of people, TPI has identified several values essential in building successful partnerships. These are: 1. collaborative relationships 2. trust 3. equality 4. mutuality 5. shared accountability 6. transparency. Building on the TPI values and the APPS partnership definition, the TPI principles below can be applied when implementing a partnership4. These principles can provide a foundation for forming and maintaining an effective and sustainable partnership. Shared vision and joint planning • Coordination and mutual agreement in setting objectives, time frames and an approach to evaluation. • Co-developing and establishing partnership plan and activities. • Mutually agreeing on key performance measures to assess impact. 4 These are a set of principles that have emerged from previous part- nerships but should be adapted to the context of each partnership. It is important and useful to recognize similar partnership princi- ples that have been established by a range of organizations (e.g. THET; ESTHER Alliance for Global Health Partnerships). Definition of partnership “A partnership can be defined as a collaborative relationship between two or more parties based on trust, equality and mutual understanding, for the achievement of a jointly agreed goal. Partnerships involve risks as well as benefits, making shared accountability critical.” ~APPS, 2009-2011 16 Partnership Preparation Package Ownership • Ensuring that ownership is supported by each arm of the institution and not individuals. • Involving and engaging stakeholders by developing an effective stakeholder strategy that emphasizes roles, responsibilities and commitments. • Strategizing and planning for the involvement of all levels of the health system. Good relationships • Building relationships based on trust, non- judgement and commitment. • Harnessing the passion and power of individuals. • Respecting and understanding local rules, culture and customs. Good communication • Communicating effectively to facilitate decision- making and information-sharing. • Agree on and securing channels for decision- making. • Clearly identifying focal points5 and the roles of each team member. Ways of working • Nurturing individuals to be self-motivated and considering the value of having a good sense of humour. • Building transparency, flexibility and adaptability into the partnership (while keeping an eye on the changing external environment). • Celebrating what went well and modifying what has not gone well. 5 Focal point can be defined as the designated or referent person serving as a coordinator of information related to a project, a pro- gramme or a specific activity. 17PART 1: TPI objectives The power of partnerships There is a growing understanding that health partnerships work in synergy to yield powerful results – the combined efforts often having greater impact than work in isolation. Both arms of the partnership benefit6 from learning about innovative practices coming from unique and unexpected sources. Sometimes this leads to lower costs for the same or better outcomes. For example, the partnership between Church of Uganda Kisiizi Hospital and Countess of Chester Hospital NHS Foundation Trust maximized the local resources and was able to obtain alcohol from local agriculture to produce hand-sanitizer. This innovative approach exposed and sensitized both arms of the partnership to “out of the box” thinking in order to make improvements. 6 More information about benefits for each partner can be found here: https://www.ache.org/pdf/nonsecure/White-Paper-International-Hos- pital-Partnerships.pdf “We were able to move faster towards our goal than we would have on our own”. ~Dr Emanuel Addo- Yobo, Komfe Anokye Teaching Hospital, Ghana APPS Partnership Strength Survey, 2012. SDG 17 Revitalize the global partnership for sustainable development. Targets relating to TPI • SDG Target 17.6: “Enhance North-South, South-South and triangular regional and international cooperation on and access to science, technology and innovation and enhance knowledge sharing on mutually agreed terms, including through improved coordination among existing mechanisms, in particular at the United Nations level, and through a global technology facilitation mechanism.” • SDG Target 17.9: “Enhance international support for implementing effective and targeted capacity-building in developing countries to support national plans to implement all the sustainable development goals, including through North-South, South-South and triangular cooperation.” 18 Partnership Preparation Package Partnerships and the global goals The twinning partnership approach provides a link between local institutional change, national health systems and the global arena. The SDGs acknowledge the importance of partnerships (Objective 17) by recognizing that partnerships help to “mobilize and share knowledge, expertise, technology and financial resources.” The SDG goes further to highlight that “a successful sustainable development agenda requires partnerships between governments, the private sector and civil society. These inclusive partnerships built upon principles and values, a shared vision, and shared goals that place people at the centre, are needed at the global, regional, national and local level”. Linkages with multiple SDGs are evident, particularly 3.8 on UHC, but a range of others are clearly evident too. For example, a partnership approach can contribute to the reduction of maternal mortality ratio (SDG 3.1) by improving the quality of care for mothers.7 While TPI focuses on local, front-line improvements in the quality of health services, the compounding results from all partnerships around the world can lead towards global cohesion and overall impact. It is important to note that the benefits produced by twinning partnerships not only enhance institutional capacity to deliver improved health services, but also contribute to strengthening of the entire health system, if designed and implemented effectively. OBJECTIVE 2 – IMPROVEMENT Improvement is at the core of the partnership. In general, improvement focuses on the act or process of making something better. In hospital settings, improvement implies organizational and structural change, in addition to a necessary change in attitudes and behaviour, very often - all of which makes this process complex since it involves people and often requires a culture shift. Gaps existing in quality of care within health care facilities should be agreed 7 Royal College of Midwives and Ugandan Midwives Association. Case study in THET: https://www.thet.org/case-studies/aligning-partner- ship-plans-institutions-strategic-plan-2/ 19PART 1: TPI objectives Partnership development and continued strengthening – Japan and Liberia The Partnership between Nagasaki University Hospital (NUH), Japan, and Tellewayon Memorial Hospital (TMH) in Lofa County, Liberia, was formed in August 2016. At the time, TMH was recovering from the West African Ebola outbreak of 2014 and relying on international support to reactivate its essential health services and moving forward with recovery efforts in alignment with national recovery plans. During the recovery at TMH, it was quickly realized that the impacts of the Ebola response had depleted many resources and that extensive work was needed in order to improve quality. NUH saw that the needs at TMH were extensive and agreed to form a partnership with TMH. The Ministry of Health and the County authorities in Liberia supported this partnership at the onset of the formal TPI agreement. Careful consideration was given to the architecture of the partnership, recognizing the distinct culture and context of the respective partners. Principles and definition of partnerships were carefully considered in recognition that success of the partnership would depend on the foundations developed in the early stages. This proved pivotal in the roll-out of the partnership. Moving forward from this initial partnership, a situational assessment and gap analysis were completed at TMH in October 2016. Following the gap analysis, an official “action planning” meeting took place in December 2016 where both partners agreed to improve infection prevention and control, with specific attention being given to hand hygiene and waste management. It was noted that by improving these two areas, the foundation could be created for overall quality improvement throughout the whole hospital. The partnership undertook two partnership exchange visits in Liberia and Japan respectively. The principles of the partnership were reinforced throughout while the improvement work proceeded. The bi-directionality of the partnership learning was emphasized. For example, the TMH team leader gave a talk about their experience in the Ebola response. NUH stated they benefited greatly from because they learned about the realities of diagnosis and treating Ebola affected patients. 20 Partnership Preparation Package upon. Based on these identified gaps, one or several priority action areas are identified to steer the focus of the partnership. The ultimate aim is to improve the quality of care and overall health outcomes through the successful implementation of interventions using effective improvement methods. Both arms of the partnership need to establish common goals and priorities in order to develop a strong, effective and sustainable partnership. Additionally, when defining areas of improvement, it is necessary for the focus to involve and engage local stakeholders, teams and individuals within the health system who will be the ones to sustain the efforts put forth by the partnership. Objective 2 involves the following necessities. • Both arms of the partnership needing to jointly agree on improvement entry points. This collective approach promotes an atmosphere of ownership, learning and innovation through a safe space supporting an open mind-set, the use of skills and an opportunity to work and learn together. • Achieving common goals set between partners. This includes defining clear targets, agreeing on the best methods of spread, setting clear reporting mechanisms and monitoring standards, methods and ways of working. • Coordinating the implementation of improvement activities through regular contact supported by a communication plan that holds people accountable for their own work. • Testing several changes until a desired process that leads to a desired outcome is achieved, allowing for a certain degree of flexibility, permitting necessary changes and adaptations. The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches to improvement. Areas of improvement can include a variety of service delivery and clinical care areas influenced by the baseline assessment, Improvement “The combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning).” Batalden, P. B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? Quality & Safety in Health Care, 16(1), 2–3. https://qualitysafety.bmj. com/content/16/1/2 21PART 1: TPI objectives such as infection prevention and control (IPC), patient safety, and specific clinical services. Examples abound but the unifying concept is that improvement in service delivery needs to have a direct and lasting impact on the quality of the entire health system8. The linkages between service delivery and health workforce are clearly evident. The inter-relatedness with each of the health system components is highlighted through all partnership action. In the example below, the partnership in Ethiopia illustrated how improvements in both service delivery and clinical care at the facility level have had a direct impact on the wider health system. Ultimately, achieving quality at the facility level can bring balance and improvements to the entire health system. OBJECTIVE 3 – SPREAD Spread allows for sharing and scale-up of improvement experiences and learning within the local and national health system, and beyond. This enhances the reach and impact of the partnership by sharing what did and did not work well. When considering Spread, a strategy to help document successful experiences should be developed and early conversations should be held on the following topics: (1) What are the new and creative health service improvements that have been made? Spreading the emerging success stories of improvement can help drive large scale spread. (2) What are the ways in which this improvement will be sustained? A way to sustain improvement is to allow sufficient time for new practice to become fully integrated as the standard (e.g. incorporating new practices in policies, procedures, job description, etc.). (3) How was the improvement made? For example, demonstrating the benefits and advantages arising 8 A health system has traditionally been described by WHO as comprised of six building blocks which include: leadership and governance; health information systems; health financing; essential medical products and technologies; human resources for health; and service delivery. Improvement – Gondar, Ethiopia and Leicester, England The partnership formed between the University of Gondar Hospital, in Ethiopia and the University Hospital of Leicester NHS Trust, in England, aimed to implement the WHO Surgical Safety Checklist in the operating theatres of Gondar Hospital. Through regular audits, staff feedback and multidisciplinary learning sessions, the monitored results showed that the Checklist had successful implementation, compliance and adherence among staff. Additionally, there was consistent focus on joint learning and participation which helped to build research capacity. This resulted in a multi-country research project to look at Checklist implementation in a partnership context. After monitoring the implementation of the Checklist programme, it was found that its use rose from 17% to 53%, with a 100% application in emergency procedures. Multi-professional groups are now trained in its use. Importantly, the research also provided an opportunity to critique the work of the partnership and enable further improvements. Of note, this long-standing partnership benefitted from the support of both THET and WHO. 22 Partnership Preparation Package from a new practice encourages both spread and sustainability. (4) Who is the target audience of the Spread? In considering the target audience, it is important to acknowledge if the spread will focus on individual buy-in, whole facility buy-in, or entire health system adoption. These details help to organize and structure a plan to disseminate the information and experiences of success. The work of the partnership, particularly in relation to spread, needs to take careful account of the national strategic direction on quality, where this exists. Many countries are now developing or refining national quality policies and strategies. The formation of these policies and strategies can be informed by experiences that emerge from twinning partnerships. When these national strategies already exist, the work of the twinning partnerships should be carefully aligned with the national direction. This allows the effort of the partnership to have maximal impact by supporting implementation of a nationally owned drive for quality. The initial situational assessment can identify the national quality direction and both arms of the partnership need to be fully aware of this at all stages of the partnership. Spread can be considered in three ways - horizontal, vertical and spontaneous. From the onset of the partnership, the following should be considered. 1. As soon as partners begin planning for health facility improvement, spreading this improvement should also be discussed. 2. Consider broadcasting your improvement message through different channels, such as conferences, professional journals, media, word-of-mouth and first-hand accounts. 3. Make it as appealing as possible for others to want to copy your improvement. 4. Build a network to sustain and grow spread. 23PART 1: TPI objectives 5. Finally, consider, at the outset, how the experience arising from this project could be used to feed into learning systems, both at the national and global levels. Horizontal spread refers to spreading improvement across people and organizations within the same level of a health care system. An example of horizontal spread is replicating improvements from one unit in a health facility to another. Vertical spread refers to spreading the information and improvement efforts throughout the national, subnational and local levels of a health system. Vertical spread is particularly important because while national level can drive local change, local can also drive national level change. It is important to collect quantitative data and analysis of the improvements as it lays the groundwork for evidence-based practice and can be a critical component of vertical spread, and thereby influence changes in policy. Spread requires strong connections between quality improvement evidence in conjunction with both facility and national quality policies. This evidence and clear alignment with existing policy could help to facilitate the improvements made from TPI into facility and national quality policies. Spontaneous spread, is not planned for, but can spontaneously occur through informal channels such as social networks, or opinion leaders, which sometimes cross country’s borders. An example of spontaneous spread is the engagement that occurs between partnership facility leaders and key influencers within the health system. The power of human interaction and storytelling – often in informal meetings and gatherings – in achieving change then becomes clearly evident. Of further note is the necessity to consider the spread of ideas, competencies and skills from low-income countries to partners in high-income countries. This is inherently related to concepts of mutuality that are enhanced through partnerships. 24 Partnership Preparation Package The critical role of the community Involving patients and communities can stimulate spread and strengthen implementation and the sustainability of improvement programmes. Connecting with the local community can improve the quality of care and make services more people- centred. This is particularly important in low-resource settings where demand for health care is high. Co-developing health services around the needs of patients and the community, by empowering patients and communities by informing them and giving them the ability to make decisions in order to instigate change, can enhance the patient’s experience, health outcomes, confidence and trust in health care providers. Ideally, patient, family and community engagement should be part of all national health plans. In the absence of a formal mechanism to engage patients and the community, health care workers can carry out simple actions to engage them, such as providing practical training (e.g. on hand hygiene, waste management, use of medicines, etc.), invite patients’ representatives or community leaders to participate in orientation meetings and provide on- going support. Advocating for the partnership and the successes achieved will promote the work and lead to further interest within communities. This work can be celebrated and advertised to maintain motivation and create a positive atmosphere. When community spread occurs, the knowledge generated through an improvement process in the health care facility becomes part of normal practice and standards that have positive implications for the population’s health, e.g. hand hygiene improvement. The example below highlights horizontal and vertical spread. Spread - Yagaldo Ouedraogo Hospital, Burkina Faso and Montpellier Hospital, France Yagaldo Ouedraogo Teaching Hospital in Burkina Faso started partnering with the Teaching Hospital of Monpellier in France, and implemented a pilot project to improve hygiene in the neurosurgery ward in 2013. The objective was to meet the standards of hospital hygiene in this specific ward. Four areas were targeted: hand hygiene, waste management, management of nosocomial infections and capacity-building of health workers. The idea was to concentrate efforts on the selected activities in one of the wards of the hospital in order to understand what kind of improvements could then be replicated in other wards and units of the hospital. Improvement was spread horizontally, making the entire facility benefit. Furthermore, convinced of the advantages of partnerships work, Expertise France secured support from the European Commission to spread this improvement to other health care facilities across the country. Nine partnerships involving national and regional hospitals have been implemented since February 2017 with positive implications for the entire health system of Burkina Faso. Thus, horizontal and vertical spread is taking place simultaneously.
PART 2: OVERVIEW OF THE 6-STEP CYCLE T he partnership approach is a step-wise approach which facilitates the development of partnerships, the systematic identification of gaps and the development of an action plan and evaluation cycle. 1. Partnership development begins the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions. Both arms of the partnership agree to work together to improve the quality of health care. 2. The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership. 3. The gap analysis involves a review of the needs assessments and reveals key priority areas for action. From the gap analysis, the foundation for action planning is established in a systematic way, in order to help partners to implement a more focused improvement effort. 4. Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long-term targets for the twinning partnership. In this step, it is important to look at communication, spread and budget. 5. Action is the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. 6. Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. A variety of tools and resources are available (Annex 2) to support each step and will guide the partnership implementers throughout the process. PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE A t each step of the cycle, one or more tangible outputs or deliverables to work towards is expected. These outputs are designed to help the TPI partnership move the action forward. To assist partners, a list of supportive tools and resources is provided in annex 2. Implementing organizational and structural change is often complex, because in many cases it involves people and a cultural shift needs to take place. For this reason, when seeking appropriate tools for any given technical action area, it is important to consider how they can support planning for the partnership activities, their implementation, and in addition important cross-cutting themes, such as community engagement, knowledge management and communication/advocacy. It is also important to consider the broader national context, policies, frameworks and national strategic priorities and existing initiatives in planning twinning activities. Technical improvements must align with national policies and strategies. This will be particularly important in achieving objective 3 and spreading the experience from the twinning partnership improvement process both in the short and long term. STEP 1: PARTNERSHIP DEVELOPMENT This is the beginning of the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions. Both arms of the partnership agree to work together to improve the quality of health care, focusing on different aspects of service delivery, including clinical care. A requirement of successful partnership implementation is to have a stable funding structure. This has to be defined from the beginning, as the activities that the partners will undertake will depend on the availability of human and financial resources. Partnerships established through international cooperation9 can benefit from direct funding of one arm of the partnership. In other cases, partners can agree to share the costs or compete successfully for external funds. This requires the partners working together to identify potential sources of funding and develop joint proposals. Whatever model of funding is applied to implement the activities of the partnership, it is vital that partners agree on clear systems and procedures. Main activities 1. Secure formal management and leadership agreement on both sides of the twinning partnership to take joint action. This can be done through a written statement of understanding across the institutions, such as a letter of commitment. 9 The concept of international cooperation makes reference to the interaction of persons or groups of persons representing various nations, in the pursuit of a common goal or interest. Outputs or deliverables 1. Exchange of letters between institutional management as required (it can be a letter of commitment or a Memorandum of Understanding). 2. Agreement on a definition of the twinning partnership. 3. Team members on each arm of the partnership selected and contact details exchanged. 4. Communication plan drawn up. 5. Kick-off meeting notes indicating potential areas of work, next steps and a tentative date for conducting the needs assessment. 6. Official designation of a lead and deputy trained in the approach using the outline provided in this preparation package. Core resources for Step 1 – Partnership (see annex 2) 30 Partnership Preparation Package 7. Identify a twinning lead and deputy at each partner institution. Ideally the Quality Improvement Officer should be the designated lead. In the absence of a Quality Officer, a focal point responsible for quality and safety can be designated instead. 8. Ensure the engagement of multi-disciplinary staff committed to being part of the “improvement team”. For example, a dedicated person that collects data and monitors evaluation activities. Involving motivated staff will make the change process happen smoothly and positively influence staff who resist change. 9. Consider the suggested definition of partnership; refine and agree on it across the twinning partners as a foundation for moving forward. 10. Negotiate with managers to secure protected time for the improvement team to work on the identified technical action areas. 11. A kick-off meeting with the twinning teams is recommended for the teams to get to know each other. If an in-person meeting is not possible, the alternative is a virtual meeting. 12. Establish a schedule of regular communication (a minimum of once a month is recommended) using a variety of methods (telephone, SMS, text messaging, email, skype, etc.). 13. Establish a budget for the planned activities, including overheads. STEP 2: NEEDS ASSESSMENT The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership.10 10 For an example of a “How To” tool developed for the TPI partnership situational analysis between NUH and TMH, see annex 3. Core resources for Step 2 – Needs assessment (see annex 2) 31PART 3: Digging deep - Putting the 6-Step cycle into practice Main activities 1. Conduct a desk review on existing national, sub- national and institutional documents on quality of health services. Possible documents include: national health sector policy/plan, national quality policy or strategy. 2. Identify experienced and motivated leads to coordinate the assessment, as well as their assessment team members. The composition of the team will depend on the scope of the assessment, the time and resources available. Ideally the team should include a member from the district health management, the health care facility management and an expert of the technical area to be assessed. 3. All members of the assessment team should be briefed before starting the assessment and have an overview of the expected results of the exercise, including the data collection process. 4. Communicate to other facility staff about this exercise as it requires the collaboration of other teams when collecting data, ensure buy-in from the start and discuss confidentiality. 5. Undertake a specific needs assessment within the selected technical area using appropriate assessment tools. Examples of themes that could be assessed are: a. infection prevention and control b. patient safety and health worker safety c. essential surgical care d. waste management e. Water, sanitation and hygiene (WASH) f. maternal and newborn care g. health workforce. 6. Consider the use of a standardized tool to complete the needs assessment. See annex 3, as an example of the tool developed and then used for the TMH needs assessment. Outputs or deliverables Completed baseline and situational analysis report appropriate to technical area of focus. 32 Partnership Preparation Package Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. Core resources for Step 3 – Gap analysis (see annex 2) 33PART 3: Digging deep - Putting the 6-Step cycle into practice Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. 7. Outline specific steps that can be taken to fill the gaps. 8. Organize a meeting with senior leadership to secure endorsement and approval of the findings of the gap analysis and the priority areas identified. Quality Improvement (QI) at the core of TPI The TPI Preparation Package outlines all six steps and provides support and guidance for initiating the partnership and prioritizing which areas in service delivery or care need improvement. In addition to this TPI Preparation Package, a detailed practical field guide entitled “Taking Action: Steps 4 and 5 for Twinning Partnerships for Improvement” can be read alongside the overview of Steps 4 and 5 below. “Taking Action” dives into QI models and approaches and supports the planning, action, implementation, and guidance of QI within partnerships. “Taking Action” reviews the theories of practical application of action in a partnership and can be used by any QI team that has identified a quality challenge, specific needs and current gaps in services; and also that is ready to develop targeted action plans for intervention and improvement in health care setting. The “Taking Action” document also includes a list of common barriers and key factors for successful quality improvement gathered through the WHO Global Learning Laboratory for Quality UHC. The seven countries which provided feedback on common barriers and key factors for success included India, Malawi, Mexico, Nigeria, the United Kingdom, Venezuela and Zimbabwe. The feedback provided critical insights from the front line on the challenges and opportunities for quality improvement at the facility level. For additional information and for the common barriers and key factors, please refer to “Taking Action: Steps 4 & 5 in Twinning Partnerships for Improvement.” For additional information on the WHO Global Learning Laboratory, visit: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/ 34 Partnership Preparation Package STEP 4: ACTION PLANNING Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long- term targets for the twinning partnership. In this Step, it is important to also consider matters related to communication, spread and budget.12 Main activities 1. Hold a team meeting at the partnership facility • Identify and confirm the key team members at the partnership facility: • Facility leader or manager to endorse the partnership • QI team leader with dedicated time for the project • Technical/clinical/subject matter expert • Measurement and evaluation leader • Community/patient representative • QI team staff to provide technical and administrative support • Ensure consensus and common understanding of key definitions • Outline preparation activities • Review activities taken to date on Steps 1 to 3 of 6-Step Cycle • Ensure team is prepared with priority areas already identified • Assess ground level interest and capacity • Estimate expected costs in terms of personnel, time and money. 2. Agree on an intervention • Review evidence for possible interventions, focusing on improved outcomes • Seek relevant resources on all relevant 12 For an example of action planning templates, see Annexes 4-6 Core resources for Step 4 – Action Planning (see annex 2) 35PART 3: Digging deep - Putting the 6-Step cycle into practice literature on the subject area • Consult with experts on site and at partnership sites • Consult with other health workers • Select intervention with largest benefit, lowest barriers to use, and greatest potential for sustainability • Carefully consider how technical exchanges can support the intervention • Note sustainability of interventions post-partnership • Break down interventions into necessary behaviours, structural and procedural changes. 3. Outline implementation activities • Outline implementation plans • Summarize roles and responsibilities for implementing various aspects of the intervention • Identify local barriers to implementation and design accordingly13 • Engage stakeholders to identify potential concerns • Identify needs based on local context • Identify potential gains and losses associated with implementation • Evaluate current communication methods and adapt as needed. 4. Outline roles and ensure capacity • Estimate expected expenditure • Estimate costs/time for team members • Estimate costs/time for supplies/ equipment • Estimate amount of inputs and capacity available 13 For a list of common barriers, see Taking Action Steps 4&5. 36 Partnership Preparation Package • Determine roles and responsibilities of each team member and how they will contribute to the improvement aim • Ensure protected time and support for staff • Obtain the necessary approval from the facility leader to protect time for key staff • Designate an administrative support person or other assistance • Ensure clear roles are defined for team members in the partnership institution and communicated clearly across the partnership. 5. Outline monitoring and evaluation activities • Outline monitoring activities • Examine hospital epidemiology and existing measures taken by hospital • Identify key indicators of success in implementation • Identify key methods for collecting evaluation data • Outline evaluation activities • Identify key indicators of outcomes • Identity key methods for collecting evaluation data • Strive for simplicity in evaluation and monitoring • Consider benchmarking success from other hospitals in similar contexts. 6. Complete written action plans • Share preliminary plans – ensure teams in partnership health facilities are in agreement • Schedule a series of partnership visits with defined objectives, including twinning partner, other partners, country/WHO lead (if applicable) • Agree on a schedule of partner progress reports (see annexes 4-6). Outputs or deliverables 1. Complete written 2-year Partnership Plan 2. Complete written 6-month initial short-term action plan. 37PART 3: Digging deep - Putting the 6-Step cycle into practice STEP 5: ACTION Action marks the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. Reviewing progress every six months will allow corrective measures to be taken, if needed. The improvement team should carry out regular and planned monitoring reviews using the indicators previously defined. During this action stage, a method for tracking the budget is advised. Main activities 1. Put Partnership Plan into action with partners • Ensure continuous consensus in action between partners • Ensure continued alignment with national and sub-national efforts to strengthen quality of health services • Ensure that partners working within the same facility are continuously aware of improvement activities • Align existing improvement efforts already under way at the facility level • Mark the moment of initial action on both arms of the partnership • Choose a date. 2. Manage the implementation of activities • Set up a regular schedule for the QI team to share updates on progress of the project • Ensure methods are used to make data regularly visible to staff • Ensure involvement across the institution, including staff members not directly involved in the specific improvement intervention • Ensure regularly scheduled communication across the partnership on implementation activities. 38 Partnership Preparation Package 3. Coach the team to implement the QI activities • Provide facilitation and QI methods training for QI team leader • Provide mentoring, coaching and general on-site QI support using all assets available (local- and partnership-based) • Build in time for QI knowledge transfer from the team leader to team during team meetings, with the intention of creating cohorts of health workers who can act as catalysts and mentors. 4. Implement the quality initiatives and test changes • Implement intervention • Measure performance through small test of change – PDSA cycles or other agreed methods • Keep track of progress against the planned activities and budget • Make adjustments to intervention based on information received, e.g. outcomes and feedback in response to small test of change • Document issues that arise in a log, and how they were tackled • Set up rapid response mechanisms for trouble-shooting with partners. 5. Assess and refine the interventions • Implement review every six months • Develop interval reports • Adjust team efforts accordingly • Adjust any changes due to staff turnover, need for capacity-building, or need for re-training or training of additional staff • Report back to the partnership on issues that arise14 14 For an example of a partnership that confronted failure, see annex 1. 39PART 3: Digging deep - Putting the 6-Step cycle into practice • Celebrate small or large victories on both arms of the partnership. 6. Share learning and spread changes • Continuously refine change until ready for implementation on a broader scale • Implement a spread plan, taking careful consideration of sub-national and national contexts • Spread changes, taking a successful implementation process from pilot and replicating change throughout the organization • Identify opportunities to use partnership activities to bring about change in other institutions, encouraging national spread. 7. Document and disseminate the improvements observed • Distil the change stories • Distil learnings on implementation by developing knowledge products15 such as knowledge briefs and action briefs • Synthesize any learning to have emerged from one arm of the partnership that benefitted the other arm, emphasizing the bidirectional nature of learning • Disseminate a progress report using appropriate bodies at national, subnational and local levels to maintain to maintain dialogue and connection to overall national plans. 15 Visit the WHO Global Learning Laboratory for more information on Knowledge Briefs. Outputs or deliverables 1. Develop a series of reports outlining action and progress in partnership plan 2. Conduct mid-term review of implementation activities. 40 Partnership Preparation Package STEP 6: EVALUATION Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work (against their baseline) and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. Monitoring and evaluation are key components for a successful partnership and must be implemented from the outset of the partnership cycle. This step marks the closure of the cycle and allows the partners to review and assess how well the partnership has met its objectives, but also the partnership’s true impact. The evaluation is the final stage, but the monitoring has taken place thorough the cycle and the results will inform the overall assessment. In addition to local review meetings and partnership discussions, each twinning partnership provides periodic monitoring reports (6-month reports; 1-year repeated baseline assessment; and a 2-year review). Some suggest an external evaluation by specialists to ensure objectivity and others suggest using the teams within the project to gather optimal learning. A combination of the two approaches can generate better results and partner satisfaction. Whatever is decided, the partners should be involved in the exercise; specialists should be responsible for certain aspects of the evaluation, and the evaluation and monitoring process must be planned for at the beginning of the partnership. By including the three objectives as an underpinning structure of the evaluation, a successful evaluation reflects on the strength of the partnership, the priority areas of improvement, along with its spread. Main activities Initial evaluation planning activities should be conducted in earlier parts of the 6-step partnership cycle. This planning activity should include consideration of: Core resources for Step 6 – Evaluation and Review (see annex 2) 41PART 3: Digging deep - Putting the 6-Step cycle into practice • key indicators on the effectiveness of the improvement effort • assessment of partnership strength • spread beyond the partnership • training on evaluation approaches for those involved in the partnership • periodicity of reporting. Evaluation activities are conducted throughout the 6 steps. Step 6 is focused on activities to synthesize findings, as well as conducting any necessary assessments. 1. The partners together review the monitoring reports and decide how to synthesize evaluation (collection of statistical data, interviews, focus group, surveys, etc.) 2. Synthesize findings from key indicators that demonstrate effectiveness of the activities conducted, as well as the long-term impact of the partnership. 3. Prepare an evaluation report based on the actions outlined in the partnership plan (and informed by appropriate evaluation tools). 4. Reflect on the success of the evaluation training. 5. Conduct a repeat of the baseline assessment/ situational analysis to consider progress. 6. Conduct assessment on the strength of the collaboration. 7. Conduct assessment of the spread activities. 8. Synthesize all findings and agree on key lessons learned (consider limiting to top ten). 9. Prepare an evaluation report to demonstrate impact and to advocate for financial support. The reports will focus on the achievement of project outputs and outcomes. 10. Disseminate findings internally and externally. Outputs or deliverables 1. For a 2-year project, three monitoring reports should be generated and shared across the partnership and with hospital leaders outlining action and progress towards achieving the Partnership Plan (at 6 months, 1 year and 2 years). 2. Repeated baseline assessment/ situational analysis. 3. Evaluation report KEEPING THE LEARNING GOING T here have been notable successes among the hospitals and health systems that have participated in partnership-based approaches to improvement. These include sustained partnerships, co-developed products and programmes and spread. It has become clear, that in many cases, neither the technical experts from high-income settings, nor the local providers from low-income institutions have sufficient knowledge and know- how to affect improvements. Strong, trusting, inter- institutional partnerships are therefore needed to co-develop solutions that can lead to success and spread. Linkages with national efforts to enhance quality are key to successful cascading of learning for maximal impact on health outcomes. The 6-Step Partnership Improvement Cycle and the TPI Preparation Package provide a practical blueprint for action. It should be noted, however, that each partnership is different - adaptation will invariably be required. Learning will certainly emerge, and this document will also be improved over time. Quality improvement is still an evolving science, and humility is essential for partners on all sides of the TPI. Indeed, successful partnering is rewarding for all those involved. There is much to be learned about how to apply the principles and practices of quality improvement to strengthen the delivery of health services and build resilient health systems in developing countries, yet, lessons also flow back to the so-called developed world. The prototype partnership between Tellewoyan Memorial Hospital in Liberia and Nagasaki University Hospital in Japan proved invaluable in informing the design of the larger TPI initiative. The experiences from this and other efforts will help refine the different approaches to quality improvement. These experiences can also inform and be informed by wider efforts on quality, which have become increasingly prominent in the context of continued advancement of global efforts to achieve universal health coverage. Resources are limited, and continued global learning about quality improvement will depend on the sharing of knowledge, experiences and ideas. Entities such as the WHO Global Learning Laboratory (GLL) for Quality UHC can foster such sharing. The GLL is also a space where successes can be celebrated and knowledge, experience, and ideas shared. Sometimes there is failure, but resilience is needed to find a way to succeed – a huge body of learning resides in these initial failures. The words of Benjamin Franklin ring true - “Tell me and I forget, teach me and I may remember, involve me and I learn.” That is the power of human interaction that lies at the heart of a partnership. ANNEXES ANNEX 1 Case study - Adjusting action when it’s not working Developing a culture of learning in Malawi16 Partnerships work together to identify what works, what does not and what can be learned from this. The Zomba Mental Health Services (Malawi) partnered with the Department of Health Sciences at the University of York (UK) and worked together on a project designed to strengthen the system of community mental health care in Zomba District, Malawi. The project aimed to develop the role of local village-based health workers, known as health surveillance assistants (HSAs), through training and support, in delivering mental health interventions 16 This partnership was supported by THET. for the first time. Planning and delivery of the project involved key professionals in Zomba from mental health services and district health offices, as well as discussions with the HSAs. To collect data, the project manager of Zomba conducted visits to the village-based HSAs on a monthly basis. This allowed him to capture relevant data and discuss it with them. This process allowed them to engage HSAs in the project as a whole. “It enthused people, kept them motivated and interested, and kept the momentum of the project going. This wouldn’t have happened if we hadn’t built in face-to-face visits”, admitted the project manager. There were practical difficulties and the data required for monitoring and evaluation was not efficiently collected. The project manager of Zomba had planned to capture all data on his laptop on a monthly visits, but this proved too time-consuming. Having realized the data collection system was not working, the team agreed that paper copies of the data would be taken off-site between visits, and that the timescales should be allowed to slip. This affected the progress of the partnership improvements and the colleagues involved agreed to improvise and adjust the action planning. The project manager of Zomba believes that learning has been facilitated by the partners having respect for each other’s views and ideas, and making decisions collectively. “The UK partner was very supportive of our new ideas on the implementation of the work. This has helped the partnership to work better together for one common goal, evidenced in the successful results. In the process, the Malawi partners have gained knowledge and learnt skills, including in relation to good project and financial management, and analysis, interpretation and reporting of data.” Acknowledging problems allows partners to look for solutions and turn challenges into lessons learned. 46 Partnership Preparation Package ANNEX 2. TOOLS AND RESOURCES The tools and resources listed below aim to provide support in the development and execution of your action plan. The resources are diverse and span, not exclusively, advocacy, business/financial, guidance/policies/standards, templates, toolkits and selected academic publications. The resources are included after careful review of WHO materials. Inclusion of a resource is based on its perceived usefulness and also its availability. Inclusion of a resource does not imply endorsement by WHO of any specific organization associated with the resource. Many tools and resources that are applicable in hospitals can be accessed through the WHO website of Hospital of the XXI Century: http://www.who.int/hospitals/en/ Type of resource Location Starting a health partnership (THET) https://www.thet.org/wp-content/uploads/2017/09/How-to-start-a-Health-Partnership.pdf Example of letter of commitment http://www.who.int/patientsafety/implementation/apps/APPS_registration/en/ Example of memorandum of understanding https://www.thet.org/wp-content/uploads/2017/09/Memorandum-of-Understanding-Template. pdf La coopération internationale hospitalière – guide des bonnes pratiques. (French Hospital Federation) https://www.fhf.fr/Europe-International/La-cooperation-internationale/ Guide-cooperation-internationale-hospitaliere Guide de la coopération hospitalière pour l’aide au développement https://www.cultura.com/guide-de-la-cooperation-hospitaliere-pour-l-aide-au- developpement-9782859526849.html Successful partnerships, a guide of OECD https://www.oecd.org/cfe/leed/36279186.pdf Position Statement - Global Catalyst Group for Institutional Health Partnerships http://www.who.int/patientsafety/implementation/apps/global-catalyst-group.pdf Core resources for Step 1 – Partnership development 47Annexes Core resources for Step 2 – Needs assessment The needs assessment tools that you see below are not exhaustive. They were identified from the process undertaken by the partnership prototype between Tellewoyan Memorial Hospital and Nagasaki University Hospital. Type of resource Location Year of publication IPC and patient safety Situational analysis for patient safety. A tool to assess the current level of patient safety in a health care facility based on 12 action areas http://www.who.int/servicedeliverysafety/ twinning-partnerships/tools/en/ 2009, revised in 2015 WHO Hand hygiene Self-Assessment Framework. A critical first step in improving hand hygiene in a health facility is to complete this assessment http://www.who.int/gpsc/country_work/ hhsa_framework_October_2010.pdf 2010 Twinning Partnerships for Improvement. Situational assessment report: quality and patient safety- Tellewoyan Memorial Hospital and Lofa County Health System http://apps.who.int/iris/bitstream/10665/2 53523/1/9789241511872-eng.pdf?ua=1 2017 A tool for Infection prevention and control for supporting national implementation through effective baseline assessment and evaluation http://www.who.int/infection-prevention/ tools/core-components/ICPAT2.pdf 2017 Workforce Human Resource Management Rapid Assessment Tool for Public and Private-Sector Health Organizations http://www.lmgforhealth.org/sites/default/ files/HRM_Rapid_Assessment_Tool_0.pdf 2005 Guidelines: Incentives for health professionals. This underlines both financial and non-financial incentives as critical to ensuring effective recruitment, retention and performance of health workers across the world. http://www.who.int/workforcealliance/doc- uments/Incentives_Guidelines%20EN.pdf 2008 Water, sanitation and hygiene WASH FIT. A practical guide for improving quality of care through water sanitation and hygiene in health care facilities http://www.who.int/water_sanitation_ health/publications/water-and-sanita- tion-for-health-facility-improvement-tool/ en/ 2017 Health service delivery management Service availability and readiness assessment (SARA). A tool to assess and monitor service delivery in terms of availability and readiness of the health sector and to generate evidence to support the planning and managing of a health system http://apps.who.int/iris/bit- stream/10665/104075/1/WHO_HIS_HSI_ RME_2013_1_eng.pdf 2015 Situational analysis of quality improvement in health care, Tanzania. This analysis covers the current status of QI work, standards and their assessment, indicators for QI, methods and approaches in use, progress made, SWOC analysis. http://www.tzdpg.or.tz/fileadmin/ documents/dpg_internal/dpg_work- ing_groups_clusters/cluster_2/ health/Sub_Sector_Group/Quality_ Assurance/11.a_Situation_Analysis_of_ Quality_Improvement_in_Health_Care_ Tanzania_-_Final.pdf 2012 Essential sur- gical care Tool for Situational Analysis to Assess Emergency and Essential Surgical Care http://www.who.int/surgery/publications/ s15986e.pdf?ua=1 2012 48 Partnership Preparation Package Core resources for Step 3 – Gap analysis Type of resource Location Year of publication Gap analysis Implementing a gap analysis framework to im- prove quality of care for your patients. USAID case study showing a gap analysis step-by-step. https://www.usaidassist.org/sites/assist/files/ hci.ghc_gap_framework_workbook.14jun10_1. pdf 2010 Gap analysis AHRQ Quality indicators toolkit – Instructions for doing a gap analysis https://archive.ahrq.gov/professionals/systems/ hospital/qitoolkit/d5-gapanalysis.pdf 2012 Practical resource Twinning Partnerships for Improvement. Japan- Liberia Partner Planning Workshop Report http://www.who.int/servicedeliverysafety/twin- ning-partnerships/partnership-planning-report. pdf 2016 Core resources for Step 4 – Action Planning The WHO Recovery Toolkit, accessible here, is a library of guidance resources in a single place which can be quickly and easily accessed, to guide action. A key purpose of the Recovery Toolkit is to support countries in the reactivation of health services which may have suffered as a result of a large-scale emergency. These services include ongoing programmes such as immunization and vaccinations, maternal and child health services, and noncommunicable diseases. In addition, and because the Toolkit contains core information needed to achieve functioning national health systems, it also supports countries with implementation of their national health plans during the recovery phase following a public health emergency. Type of resource Location Year of publication Knowledge translation Translating evidence into practice: a model for large scale knowledge translation http://www.bmj.com/content/337/bmj. a1714 2008 Planning and implementation WHO planning and implementation of district health services http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 WHO implementation strategy and tools. A guide to implementation of the WHO Multimodal Hand Hygiene Improvement Strategy http://apps.who.int/iris/bit- stream/10665/70030/1/WHO_IER_ PSP_2009.02_eng.pdf?ua=1 2009 Implementation tools and resources for supporting facility and national level implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes http://www.who.int/infection-prevention/ tools/core-components/en/ 2018 Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Evidence-based guideline to support countries as they develop and execute their national antimicrobial resistance (AMR) action plans. http://apps.who.int/iris/bitstream/10 665/251730/1/9789241549929-eng. pdf?ua=1 2017 Planning and implementation of district health services. 10 steps in planning, essential health package, health systems research, disaster preparedness http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 49Annexes Tools for assessing the operationality of district health. A set of tools aimed at district health management teams to generate the information that will serve as a basis for improving the operationality of health districts http://www.who.int/management/dis- trict/assessment/assessment_tool.pdf 2003 WHO Safe management of wastes from health care activities. Provides comprehensive guidance on safe, efficient and environmentally sound methods for the handling and disposal of health care waste in normal situations and also emergencies. http://www.searo.who.int/srilanka/doc- uments/safe_management_of_wastes_ from_healthcare_activities.pdf?ua=1 2014 Sanitation Safety Planning (Implementation tool). Manual for safe use and disposal of wastewater, greywater and excreta. http://apps.who.int/iris/bitstre am/10665/171753/1/9789241549240_ eng.pdf?ua=1 2015 WHO - Workload indicators of Staffing Needs (WISN) – User’s Manual http://www.who.int/hrh/resources/ WISN_Eng_UsersManual.pdf?ua=1 2010 Association for Professionals in Infection Control and Epidemiology (APIC) HAI cost calculator: http://www.apic.org/Resources/ Cost-calculators Core resources for Step 6 – Evaluation and Review Type of resource Location Year of publication Monitoring and evaluation M&E planning tool for both implementing and reviewing M&E plans https://www.thet.org/resources/ hps-monitoring-evaluation-plan/ 2014 Evaluation FAQs Step-by-step guide for health partnerships to effectively carry out an evaluation of their projects and partnerships in the form of frequently asked questions. https://www.thet.org/resources/ health-partnerships-evaluation-faq/ 2014 APPS -Evaluation Handbook A guide to evaluate five domains of a partnership: situational analysis, partnership strength, patient safety improvements, patient safety spread and annual evaluation report http://www.who.int/patientsafe- ty/implementation/apps/ Evaluation-Handbook_EN.pdf?ua=1 2012 Monitoring, evaluation and learning Webinar: sharing of experiences to provide some reflections around M&E https://www.youtube.com/ watch?v=v_oHEvgE_aA 2016 Monitoring and evaluation Health partnership symposium on monitoring, evaluation and learning. Document gathering tips to understand the value of M&E. Examples and exercises are provided. https://www.thet.org/wp-content/ uploads/2017/09/Monitoring-and- Evaluation.pdf 2017 Monitoring and evaluation EFFECt tool stands for EFFective in Embedding Change. This tools focuses on assessing implementation best practice, embedding change and the added benefits to individuals and institutions using a partnership approach https://esther.eu/index.php/effect-tool/ 2017 50 Partnership Preparation Package Core resources for improvement Type of resource Location Year PDSA Cycle (Plan-Do-Study-Act) Systematic process for gaining valuable learning and knowledge for the continual improvement https://deming.org/explore/p-d-s-a 2018 Model for improvement The Model for Improvement, is a simple, yet powerful tool for accelerating improvement http://www.ihi.org/resources/Pages/ HowtoImprove/default.aspx 2018 Confronting staffing issues and turnover of health facility staff Understanding the barriers to setting up a health care quality improvement process in resource- limited settings: a situational analysis at the Medical Department of Kamuzu Central Hospital in Lilongwe, Malawi https://bmchealthservres.biomedcentral.com/ articles/10.1186/1472-6963-14-1 2014 WHO Multimodal Improvement Strategy A one-page visual describing the five-part multimodal strategy to support IPC improvement in a health care facility http://www.who.int/infection-prevention/publi- cations/ipc-cc-mis.pdf?ua=1 2017 51Annexes ANNEX 3. TPI SITUATIONAL ASSESSMENT “HOW TO” TOOL EXAMPLE Step 2: TPI Situational Assessment “How To” Tool The following “how to” tool is presented as a practical guide explaining steps to plan and execute an in-depth situational assessment to inform a twining partnership initiative between two interested partner institutions. This assessment seeks to provide a foundational basis for the co-development of an effective and sustainable twinning partnership between partner institutions. This “how to” tool informs the process of conducting Step 2 of the 6-Step Partnership Improvement Cycle. The “how to” document is to be used together with the TPI Preparation Package and its associated resources. Post-Assessment: Build (4 weeks post-assessment) O B J E C T I V E : T R A N S L A T E F I N D I N G , S H A R E W I T H K E Y S T A K E H O L D E R S A N D I N I T I A T E A C T I O N P L A N N I N G P R O C E S S • Develop and finalize detailed assessment report in collaboration with the thematic lead persons, seeking any approvals where required • Develop short story from assessment highlighting quality improvement and safety opportunities and share with WHO Learning Laboratory for Quality Universal Health Coverage network • Participate in action-planning workshop for the twining partnership initiative presenting summary of the scoping mission findings and recommendations • Co-develop a partnership plan around the focused action areas identified by partner institutions • Use the assessment results to form the basis of the TPI partnership plan development • Provide feedback to WHO TPI team on assessment planning checklist • Discuss opportunities to leverage partner initiatives to support bottlenecks identified at district-/country-level • During Steps 4-6 of TPI cycle, consult quality improvement resources in TPI preparation package for action steps and evaluation/ review. • Conduct evaluation assessment as part of Step 6 of partnership Improvement cycle • Conduct Situational assessment on an annual basis ( as needed) • Align and build monitoring and evaluation system for the partnership with in-country quality of care measurement initiatives • Consult TPI quality improvement resources for hospital partnerships to inform monitoring and evaluation system of the partnership Assessment: Learn (10 days in-country) O B J E C T I V E : B U I L D R E L A T I O N S H I P S A N D L E A R N F R O M F R O N T - L I N E P E R S P E C T I V E S • Conduct team exercise with health facility staff and district health team to gain: • an understanding of the partner institutions • current understanding on quality and safety within local context. • Consult TPI Preparation Package for core technical tools and resources used for Step 2 • Identify key informant(s). Individual(s) should be a respected person amongst his/her peers. • Review interview guide with key informants or group and collectively refine tool to adapt to local context. • Key informant schedules interview times with health worker (HW) cohort. Recommendation for focused group discussions (FGD) with homogenous health worker cohort, if total cohort number exceeds five. Small homogenous groups allow for open discussion and confidentiality • During day of HH and PS assessment, do not hold any FGD. This is to allow limited HW participation in assessment. • Collect, analyse and crosslink data for all five thematic areas daily • Summarize and present preliminary findings to: • Hospital staff and district level staff • WHO Country Office/Ministry of Health • Relevant partners such as funding agency • Summarize preliminary recommendations according to actions needed for different stakeholders: • TPI initiative • Health facility • District health team • Ministry of Health • Hold daily assessment team meeting to debrief from day’s activities, address emerging key issues and prepare for next day Pre-Assessment: Deconstruct (minimum 4 weeks prior to assessment) O B J E C T I V E : R E V I E W I N - C O U N T R Y N A T I O N A L D O C U M E N T S , I D E N T I F Y Q I O P P O R T U N I T I E S A N D R E L E V A N T I N - C O U N T R Y P A R T N E R S • Identify experienced and motivated lead person to coordinate assessment • Inform WHO country office and regional office of impending situational assessment • Conduct desk review of existing national, sub-national and institutional documents on quality and safety. Possible documents include: • National health sector policy/plan • National quality health strategy • District/county-level operational or work plan • Health facility annual plan or workplan • artner coordination mechanisms • In-country quality of care measurement documents/projects • Identify areas you intend to evaluate during the assessment. Ideally, all five assessment thematic areas should be considered: • Quality Improvement • Patient Safety (PS) • Hand Hygiene (HH) • District-level health system • Patient & Community Perspective • Review long-form of interview guide addressing any unanswered questions that arise • Determine situational assessment schedule and share with WCO • WCO country office to schedule meetings in-country and facilitate facility/ district site visit • Identify composition of mission team and assign lead roles for five thematic areas • Ideally, team should include representation from MOH, multiple levels of the organization (if available) and the partner institutions • Ensure availability of relevant skill set, aligned with selected thematic areas • Identify relevant development partners/stakeholders to be consulted • Initiate series of coordination calls and email exchange with assessment team to discuss technical scope of mission and logistics • If funding allows, initiate scoping mission to sensitize Ministry officials and partners in-country ( if funding does not allow, initiate as part of in-country assessment) E X A M P L E S O F H E A L T H W O R K E R C O H O R T FACILITY- LEVEL DISTRICT/COUNTY-LEVEL • Clinical staff: doctor, physician assistant, nurses, midwives, pharmacist, lab technician, aides etc. • Non-clinical staff: maintenance staff, cleaners • Hospital Management • Patient & Community Representatives • Partners within Health Facility • Health Boards • Management Teams • Health Structure Directors • District/County Superintendent, District Commissioners, Traditional chiefs • Partners 53Annexes ANNEX 4. TPI PLANNING TEMPLATE SUMMARY INFORMATION Name of twinning institution 1: Name of lead: Name of twinning institution 2: Name of lead: Name and date of situational analysis/ baseline assessments used: Names of individuals completing the plan: Technical action areas for focus: Partners to consider specific areas to work on, based on situational analysis (experience highlights the need to focus on 2-3 areas maximum) Example: Project 1: Infection prevention and control Project 2: Knowledge and competency on quality improvement. For each action area, complete the template below. Use as many forms as required depending on the additional action areas addressed. Project number and action area • E.g. Project 1: Infection prevention and control Brief description of project • Provide a 1-2 sentence outline of the project Project goals • List the change the project will contribute to in 1- 2 sentences. • Where possible, link to national and/or local policies and plans including the national direction on quality. • Try to emphasize how the goals of the project respond to the needs identified in the baseline assessment. Project outcome(s) • Describe the improvement that you hope will result from the project. • Outcomes often relate to changes in practice or health outcomes. • The outcomes should contribute to the achievement of the goal. Project output(s) • The direct results of the project e.g. 20 people trained in infection control. The outputs should lead to achievement of the outcomes. Main activities • List all planned activities. For each activity, briefly outline what will be done; where and who will be involved on each side of the twinning partnership; how long it will take; methods to be used; and associated costs. • List technical exchange schedule ie. Fortnightly skype connection, monthly leads 1-to-1, 6-monthly visits, ... • Is a visit planned in conjunction with this project? (if yes, list likely human and financial costs.) • Twinning visit plans for year 1 should be thought through in detail. Plans for year 2 may be more general. Include a draft timeline. • What mechanisms are planned to allow receipt of just-in-time input to technical issues? • How will you connect with WHO efforts to support quality improvement? 54 Partnership Preparation Package Beneficiaries • Include information about the people who will benefit (directly and indirectly) from the project e.g. lab technicians; hospital managers; nurses and different groups of patient and community members. • Describe how they will benefit and provide realistic estimates of how many people in each group will benefit. • Will benefits span both sides of the twinning partnership? Stakeholders • Identify the key stakeholders and their interest in the project (e.g. other department, district and national health offices) i.e. any individual or group that may exert influence over the project activities and outcomes (across both arms of the partnership). • Consider the local community and key stakeholders, including patients and families who could contribute and add value to the planned efforts. • Outline which stakeholders the twinning partnership will report to and how often. Monitoring and evaluation • Define key indicators to be used to monitor whether the outcomes of your project have been achieved. • Provide an overview of your monitoring and evaluation plans, providing an outline of methods, who will be involved, how the process will be managed, and how partners will learn together. Sustainability and spread • Describe how long the activities will continue and what the plans are for long-term funding. • What benefits will continue after the initial 2-year project ends and how? • List your plans for building on project achievements. • Describe how you will actively disseminate new information gathered and consider activities to support vertical, horizontal and spontaneous spread opportunities. Risks • Identify potential risks associated with the plan e.g. key personnel moving on, changing institutional priorities, conflict between twinning partners, and how you will manage each of these risks. • List external risks and how you will manage them (e.g. ICT breakdown, problems with visas, political uncertainty). Project management and support • Outline project responsibilities including division of responsibilities across the twinning partnership. • Provide details of the key personnel involved in each arm of the partnership. • Consider key management questions: What systems will be used to manage finances in both locations? Who will have the main responsibility for budgets? How will you ensure that communication is effective and that all partners know what is happening? Approved by Date of approval 55Annexes ANNEX 5. TPI VISIT PROPOSAL TEMPLATE The Visit proposal template should be completed once a visit has been agreed, to ensure that the visit has clear objectives and contributes to the overall partnership planning. Twinning partnership (list both institutions within the partnership): Institution 1: Institution 2: Name of person completing the visit proposal form: Purpose of visit - describe which partnership project(s) the visit relates to: What are the dates of the proposed visit? Start date: End date: Is the visit aligned with existing in-country activity with no duplication of training or policy development work? Yes No Not applicable Does the visit clearly meet the needs of the twinning partner institutions? Yes No Not applicable Briefly describe the expected outcomes of the planned visit (outcomes are clear, realistic and logical): Briefly describe the outputs of the planned visit (outputs are clear, realistic and logical): Briefly describe any risks you think might be associated with the visit: List estimated costs of the visit: Briefly describe how the proposed visit will contribute to monitoring and evaluation of the associated partnership plan: List the number of people involved in the proposed visit and their role in achieving the visit objectives: Has the visit been jointly planned and agreed across the partnership? Yes No Will the visit offer potential benefits to both twinning partners (if yes, de- scribe briefly)? Yes No Not applicable Briefly describe how the visit will help achieve sustainability and spread of effective essential health service delivery. 56 Partnership Preparation Package ANNEX 6. TPI ACTION REPORT TEMPLATE The Action report template allows key outputs of each period of the partnership to be documented, lessons learned and actions arising logged. This is part of developing a strong, effective, action-focused partnership and contributes to partnership governance. Twinning partnership (list both institutions within the partnership): Name of person completing the report and date completed: Time period covered by this progress report: Key actions undertaken: Key achievements resulting from action taken: Key challenges faced: Date of next expected progress report: 57Annexes ANNEX 7: DEFINITIONS Accountability: The obligation to report, or give account of one’s actions – for example, to a governing authority through scrutiny, contract, management, regulation and/or to an electorate (19). African Partnerships for Patient Safety (APPS) programme: The WHO APPS programme is a hospital- to-hospital focused approach that was results- oriented and co-developed by hospital partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the African Partnerships’ work providing a common relevant goal that everyone was committed to improving. As a result, substantial implementation experience and learning have been achieved in this field across the African Region. The APPS approach demonstrated how working in partnership results in more motivated staff, increased commitment to change, strengthened capacity-building, focused drive and a desire to find appropriate solutions that will impact immediately on the quality and safety of patient care. This in turn can be used to strengthen the delivery of health services to communities globally (20). Clinical effectiveness: The application of the best knowledge, derived from research, clinical experience and patient preferences to achieve optimal processes and outcomes of care for patients (21). Community partner: Member of a quality improvement team representing a unit of population, often generally geographically defined, that is the locus of basic political and social responsibility and in which everyday social interactions involving all or most of the spectrum of life activities of the people within it takes place (22). Continuous Improvement: The process of making something better or of getting better (23). Integrated People-Centred Health Services (IPCHS) framework: The IPCHS Framework calls for a fundamental shift in the way health services are funded, managed and delivered to respond to these 58 Partnership Preparation Package challenges. The IPCHS vision is that “All people have equal access to quality health services that are co-produced in a way that meets their life course needs, are coordinated across the continuum of care and are comprehensive, safe, effective, timely, efficient and acceptable; and all carers are motivated, skilled and operate in a supportive environment.” WHO recommends five interwoven strategies that need to be implemented in order to achieve IPCHS. Application of the approach can build robust and resilient health services and are critical for progress towards universal health coverage and fulfilling the Sustainable Development Goals (24). Partnership: A partnership is a collaborative relationship between two or more parties based on trust, equality and mutual understanding for the achievement of a specified goal. Partnerships involve risks as well as benefits, making shared accountability critical (20). Patient-centredness: Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions (25). Patient safety: The reduction of risk and unnecessary harm associated with health care to an acceptable minimum (26). Performance: How well a person, team, project, programme, organization, or policy is being implemented against expected results (27). Quality: Quality has been defined and understood in different ways around the world. Two of the main definitions are below. • The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (28). • The totality of characteristics of an entity that bear on its ability to satisfy stated and implied needs (29). 59Annexes Quality audit: a systematic and independent examination to determine whether quality activities and related results comply with planned arrangements and whether these arrangements are implemented effectively and are suitable to achieve objectives (1). Quality assurance: all the planned and systematic activities implemented within the quality system, and demonstrated as needed, to provide adequate confidence that an entity will fulfill requirements for quality (1). Quality control: A process to evaluate actual performance, compare actual performance with quality goals, and take action on the difference (1). Quality improvement: A process to create beneficial change and attain unprecedented performance (1). Quality planning: A process to establish quality goals to develop goods and services that meet customer needs (1). Stakeholder: An individual, group or organization that has an interest in the organization and delivery of health care (29). REFERENCES 1. African Partnerships for Patient Safety Spread Pack. Improvement series. Geneva: World Health Organization;2012. (http://www.who.int/patientsafety/ implementation/apps/resources/APPS_Improv_Spread_ Pack_2012_04_EN.pdf?ua=1, accessed 13 April 2018). 2. Chisholm G. Gree E. Simms B. In our mutual interest. (https://www.thet.org/wp-content/ uploads/2017/08/In-Our-Mutual-Interest.pdf, accessed 13 April 2018). 3. Dean L, Njelesani J, Smith H, Bates I. Promoting sustainable research partnerships: a mixed- method evaluation of a United Kingdom–Africa capacity strengthening award scheme. Health research Policy and Systems .2015. 13:81. (https:// doi.org/10.1186/s12961-015-0071-2, accessed 13 April 2018). 4. Edwards S, Ritman D, Burn E, Dekkers N, Baraitser P. Towards a simple typology of international health partnerships. Globalization and Health. 2015.11:49. (https://doi.org/10.1186/s12992-015- 0132-x, accessed 13 April 2018). 5. EQUAL Partnership Development toolkit. European Commission. Directorate-General for Employment, Social Affairs and Equal Opportunities ; 2005 (http://ec.europa.eu/employment_social/equal_ consolidated/data/document/pdtoolkit_en.pdf, accessed 13 April 2018). 6. Health Partnership Scheme: Evaluation synthesis report. Tropical Health Education Trust; 2017 (https://www.gov.uk/government/publications/evaluation- of-health-partnership-scheme, accessed 13 April 2018). 7. Health Partnership Scheme: Impact report 2011- 2017. Tropical Health Education Trust; 2017 8. (https://www.thet.org/wp-content/uploads/2017/09/ Health-Partnership-Scheme-2011-2017-Impact-Report. pdf, accessed 13 April 2018). 9. Jones A. Envisioning a global health partnership movement. Globalization and Health. 2016.12:1. (https://doi.org/10.1186/s12992-015-0138-4, accessed 13 April 2018). 10. Jones F, Knights D, Sinclair V, Baraitser P. Do health partnerships with organisations in lower income countries benefit the UK partner? A review of the literature. Globalization and Health. 2013. 9:38. (https://doi.org/10.1186/1744-8603-9-38, accessed 13 April 2018). 11. Kulasabanathan K, Issa H, Bhatti Y, Prime M, Del Castillo J, Darzi A, et al. Do International Health Partnerships contribute to reverse innovation? a mixed methods study of THET- supported partnerships in the UK. Global Health. 2017;18;13(1):25. doi: 10.1186/s12992-017-0248- 2. (https://www.ncbi.nlm.nih.gov/pubmed/28420405, accessed 13 April 2018). 12. Lewis L, Williams C, Jackson L, Caffarella R, editors. Experiential Learning: A New Approach. San Francisco: Jossey-Bass;1994:5-16. 62 Partnership Preparation Package 13. Quality improvement made simple. What everyone should know about health care quality improvement. Quick guide. London: The Health Foundation; 2013 (http://www.health.org.uk/ publication/quality-improvement-made-simple, accessed 13 April 2018). 14. Reverse innovation in global health systems: learning from low-income countries. In: BMC collections/reverse innovations [website]. United Kingdom: BioMed Central, 2018 (https://www. biomedcentral.com/collections/reverseinnovations, accessed 22 June 2018). 15. Ritman D. Health partnership research and the assessment of effectiveness. Globalization and Health. 2016.12:43. (https://doi.org/10.1186/s12992- 016-0181-9, accessed 13 April 2018). 16. The European ESTHER Alliance. Bringing together our expertise for capacity building and health care. (https://esther.eu/wp-content/uploads/2018/01/ BrochureAllianceEsther.pdf, accessed 13 April 2018). 17. WHO Community Engagement framework for quality, people-centred and resilient health services. Geneva: World Health Organization;2017 (http://apps.who.int/iris/bitstream/10665/259280/1/WHO- HIS-SDS-2017.15-eng.pdf?ua=1, accessed 13 April 2018). 18. WHO Handbook for national quality policy and strategy. Geneva: World Health Organization; 2018 (http://apps.who.int/iris/bitstream/hand le/10665/272357/9789241565561-eng.pdf?ua=1, accessed 22 June 2018 ). 19. Taking action: steps 4 and 5 in twinning partnerships for improvement for health care facility managers, quality improvement teams and institutional health partnerships: http://apps.who. int/iris/bitstream/handle/10665/273159/WHO-HIS-SDS- 2018.14-eng.pdf, accessed on 19 July 2018).
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Printed in Switzerland CONTENTS 8 6 INTRODUCTION ABBREVIATIONS 12 PART 1: TPI OBJECTIVES 26 PART 2: OVERVIEW OF THE 6-STEP CYCLE 28 46 62 PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE ANNEXES BIBLIOGRAPHY 44 REFERENCES 42 KEEPING THE LEARNING GOING ACKNOWLEDGEMENTS The World Health Organization (WHO) would like to acknowledge the support and contribution that many individuals and organizations have made to the development of this document. Katthyana Aparicio, Melissa Kleine-Bingham and Shams Syed (Department of Service Delivery and Safety, WHO) coordinated and led the development and writing of this document. Maki Kajiwara, Nana Mensah Abrampah, Julie Storr (Department of Service Delivery and Safety, WHO) provided significant input to the development and drafting of this document. Special thanks to Sandra Hwang and Albert Wu (Johns Hopkins Bloomberg School of Public Health) for their technical contribution on quality improvement methods. External Peer Review Group Ngormbu Jusu Ballah (Liberia Ministry of Health), Jean Marc Chapplain (Centre Hospitalier Universitaire de Rennes), Graeme Chisholm (Tropical Health Education Trust - THET), Eric de Roodenbeke (International Hospital Federation - IHF), Charlie Evans (American College of Healthcare Executives), Koichi Izumikawa (Nagasaki University Hospital - NHU), Farid Lamara (Expertise France), Emmanuelle Maurin (Expertise France), Sandra Hwang (Johns Hopkins Armstrong Institute for Patient Safety and Quality), Andrew Jones, Samuel Seeigbeh (Tellewayon Memorial Hospital, Liberia) Albert Wu (Johns Hopkins Bloomberg School of Public Health) and ESTHER Alliance for Global Health Partnerships. ABBREVIATIONS AHRQ Agency for Healthcare Research and Quality AMR antimicrobial resistance APIC Association for Professionals in Infection Control APPS African Partnerships for Patient Safety EEA ESTHER Alliance for Global Health Partnerships GLL Global Learning Laboratory HSAs Health Surveillance Assistants IHF International Hospital Federation IPC infection prevention and control LMICs low- and middle-income countries M&E monitoring and evaluation NHS National Health System NUH Nagasaki University Hospital OECD Organisation for Economic Co-operation and Development PDSA Plan-Do-Study-Act QI quality improvement SARA Service Availability and Readiness Assessment SDGs Sustainable Development Goals SMS short message services SWOC Strengths, weaknesses, opportunities and challenges THET Tropical Health Education Trust TMH Tellewayon Memorial Hospital TPI Twinning Partnerships for Improvement UHC universal health coverage USAID United States Agency for International Development WASH water, sanitation and hygiene WISN workload indicators of staffing needs WHO World Health Organization INTRODUCTION BACKGROUND T winning partnerships between health institutions are an innovative approach that can be used to improve various aspects of health service delivery. The WHO Twinning Partnerships for Improvement (TPI) model supports long-term efforts on quality health service delivery within the context of achieving universal health coverage (UHC). The work can contribute to building resilient health systems. Fundamental in the approach is to prioritize alignment with national health plans and strategies, while working to achieve the Sustainable Development Goals (SDGs). TPI builds on the learning from the WHO African Partnerships for Patient Safety (APPS) programme (1). These rich lessons and the subsequent application of twinning partnerships in the recovery effort in Ebola- affected countries have facilitated the design of WHO TPI. The key aim of WHO TPI is to support health care facilities in the improvement and enhancement of the quality of their service delivery, while aligning with the overall national strategic direction on improving quality service delivery. Institutional health partnerships can play a critical role in health systems strengthening. This has been increasingly recognized across the world. Many global health groups1 have highlighted the need to “promote the utility of institutional health partnerships in strengthening health systems and in delivering effective health services.” Recognizing the synergy that comes from a partnership approach, national policy documents over the past decade have also begun to highlight the potential for institutional partnerships as an entry point to strengthen services and health systems. In addition to the APPS programme, TPI also builds on the work undertaken in applying the Twinning model to support recovery from the 2014 West Africa Ebola outbreak. TPI Recovery focused upon building resilient health systems and reactivating safe essential health services in those countries most affected by the outbreak. The aim of TPI Recovery was to rebuild the health services in order to support implementation of national recovery plans (2). Implementation of twinning partnerships involves addressing a variety of service delivery and clinical care areas, including, but not limited to, infection prevention and control (IPC); patient safety; and specific clinical services. Health workforce capacity- building is embedded within the model. TPI can feed into work at the national level to improve the quality 1 For more information on global health groups and to view the consensus statement, please visit WHO’s web site at: http:// www.who.int/patientsafety/implementation/apps/global-catalyst-group. pdf?ua=1 WHO TPI Snapshot • Twinning Partnerships for Improvement focuses on the value of institution-to- institution partnerships in catalyzing health service improvement. • The hospital-to-hospital model developed by ‘African Partnerships for Patient Safety’ (APPS) is the foundation on which TPI has been developed. The emphasis is on a ‘doing while learning” model (3). • As a global network of twinning partners develops there is an opportunity to learn from and share learning across the TPI network. • The approach promotes collaboration, co-development and sharing of both tacit and explicit knowledge thus enhancing spread of successful approaches to improvement. 10 Partnership Preparation Package of service delivery. These partnerships can act as a valuable tool for health improvement strategies and bring real benefit to the front line of service delivery and ultimately to the health of an entire population. The power of twinning partnerships working together can bring effective health improvements beyond what an individual organization or team could achieve alone (4). Furthermore, the work of such twinning partnerships can feed into national strategic efforts to improve quality service delivery elsewhere. PURPOSE OF THE TPI PREPARATION PACKAGE The aim of this document is to provide a practical step-by-step approach for any health institution interested in improving the quality of health service delivery through twinning partnerships. The model is based on a 6-step cycle which begins when two or more partners agree on the establishment of the partnership. TPI guides the partners through a systematic process which involves identifying some specific areas for improvement, developing an action plan to implement improvements, and then evaluating the progression and changes made towards improvement. Institutional health partnerships have the potential not only to work as individual partnerships, but also to collaborate with other partnerships to support a national network of similar partnerships. This can support national efforts through joint problem-solving and sharing experiences in order to develop a body of evidence and experience that can inform national and district authorities. This can further encourage application of the partnership model at all levels of the health system. TARGET AUDIENCE The target audience for this partnership preparation package are those committed to improving the quality of healthcare and service delivery including, but not limited, to those in: TPI brings an opportunity to support improvement in the delivery of care at the local, sub-national and national levels. It can act as a catalyst for change in efforts to enhance quality in the context of UHC. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves (1). 11introduction • health institutions • health facilities • academic/research institutions • professional associations • donor organizations • health authorities • policy making • governments. The TPI preparation package also aims to inform decision-makers and authorities working at the national level that are responsible for planning, developing, implementing and evaluating national health strategies, including WHO country offices and ministries of health. When to use the package The package will be useful to any new or existing twinning health institutions in order to work through a partnership-based approach to improve the quality of health services and embed the effort within long-term service improvement. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves (1). PART 1: TPI OBJECTIVES OVERVIEW OF OBJECTIVES T PI focuses on the value of institution-to-institution partnerships in catalysing health service improvement following a “doing while learning”2 model. TPI takes into account a variety of entities, including health facilities, academic institutions, private institutions, etc.3 It provides the potential for implementing different types of 2 ”Doing while learning” refers to the experiential learning theory where one learns from experience in order to develop skills or new ways of thinking. (Lewis and Williams 1994, p.6) 3 While a variety of entities can be involved in the partnerships, the TPI preparation package will use the generic term institutions to cover all types of entities. partnerships, at local, sub-national and national level, and also across continents. Institutions from high- income countries or from low- and middle-income countries (LMICs) can initiate partnerships to support other institutions within LMICs and thus provide unique opportunities to catalyse the move towards quality health services, all within the context of achieving universal health coverage. Within the TPI model, there are three objectives that each partnership should focus on achieving. 1. The first objective is the development of the partnership. This objective focuses on fostering a strong bi-directional partnership between health institutions. 2. The second objective is improvement through implementing effective interventions based on needs identified at the front lines of service delivery. 3. The third objective is to spread the learning and experience within the local and national health system and also beyond. The ultimate benefits of TPI are bi-directional learning and improvement, motivated and committed staff; strengthened delivery of health services; and better patient and health worker outcomes. The Recovery Toolkit Twinning Partnerships for Improvement - Objectives 14 Partnership Preparation Package The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches towards improvement. As a global network of twinning partners emerges, there is an opportunity to learn from and share learning across the larger TPI network, to promote collaboration, co-development and sharing, and support the spread and replication of improvement. What is co-development? A process that brings together the collective intelligence for a collaborative development and applies joint decision- making that enhances trust. 15PART 1: TPI objectives OBJECTIVE 1 – PARTNERSHIP The formation of a partnership is the first step in the TPI journey. Under the first objective, two or more institutions come together to agree upon a common goal and define the partnership priorities which they hope will result in sustainable improvements at the health facility. Building on the APPS definition of partnership, which encompasses a sociological perspective focusing on the interaction of people, TPI has identified several values essential in building successful partnerships (1). These are: 1. collaborative relationships 2. trust 3. equality 4. mutuality 5. shared accountability 6. transparency. Building on the TPI values and the APPS partnership definition, the TPI principles below can be applied when implementing a partnership4. These principles can provide a foundation for forming and maintaining an effective and sustainable partnership. Shared vision and joint planning • Coordination and mutual agreement in setting objectives, time frames and an approach to evaluation. • Co-developing and establishing partnership plan and activities. • Mutually agreeing on key performance measures to assess impact. 4 These are a set of principles that have emerged from previous part- nerships but should be adapted to the context of each partnership. It is important and useful to recognize similar partnership princi- ples that have been established by a range of organizations (e.g. THET; ESTHER Alliance for Global Health Partnerships). Definition of partnership “A partnership can be defined as a collaborative relationship between two or more parties based on trust, equality and mutual understanding, for the achievement of a jointly agreed goal. Partnerships involve risks as well as benefits, making shared accountability critical.” ~APPS, 2009-2011 16 Partnership Preparation Package Ownership • Ensuring that ownership is supported by each arm of the institution and not individuals. • Involving and engaging stakeholders by developing an effective stakeholder strategy that emphasizes roles, responsibilities and commitments. • Strategizing and planning for the involvement of all levels of the health system. Good relationships • Building relationships based on trust, non- judgement and commitment. • Harnessing the passion and power of individuals. • Respecting and understanding local rules, culture and customs. Good communication • Communicating effectively to facilitate decision- making and information-sharing. • Agree on and securing channels for decision- making. • Clearly identifying focal points5 and the roles of each team member. Ways of working • Nurturing individuals to be self-motivated and considering the value of having a good sense of humour. • Building transparency, flexibility and adaptability into the partnership (while keeping an eye on the changing external environment). • Celebrating what went well and modifying what has not gone well. 5 Focal point can be defined as the designated or referent person serving as a coordinator of information related to a project, a pro- gramme or a specific activity. 17PART 1: TPI objectives The power of partnerships There is a growing understanding that health partnerships work in synergy to yield powerful results – the combined efforts often having greater impact than work in isolation. Both arms of the partnership benefit6 from learning about innovative practices coming from unique and unexpected sources. Sometimes this leads to lower costs for the same or better outcomes. For example, the partnership between Church of Uganda Kisiizi Hospital and Countess of Chester Hospital NHS Foundation Trust maximized the local resources and was able to obtain alcohol from local agriculture to produce hand-sanitizer. This innovative approach exposed and sensitized both arms of the partnership to “out of the box” thinking in order to make improvements. 6 More information about benefits for each partner can be found here: https://www.ache.org/pdf/nonsecure/White-Paper-International-Hos- pital-Partnerships.pdf “We were able to move faster towards our goal than we would have on our own” (5). ~Dr Emanuel Addo- Yobo, Komfe Anokye Teaching Hospital, Ghana APPS Partnership Strength Survey, 2012. SDG 17 Revitalize the global partnership for sustainable development (6). Targets relating to TPI • SDG Target 17.6: “Enhance North-South, South-South and triangular regional and international cooperation on and access to science, technology and innovation and enhance knowledge sharing on mutually agreed terms, including through improved coordination among existing mechanisms, in particular at the United Nations level, and through a global technology facilitation mechanism.” • SDG Target 17.9: “Enhance international support for implementing effective and targeted capacity-building in developing countries to support national plans to implement all the sustainable development goals, including through North-South, South-South and triangular cooperation.” 18 Partnership Preparation Package Partnerships and the global goals The twinning partnership approach provides a link between local institutional change, national health systems and the global arena. The SDGs acknowledge the importance of partnerships (Objective 17) by recognizing that partnerships help to “mobilize and share knowledge, expertise, technology and financial resources.” The SDG goes further to highlight that “a successful sustainable development agenda requires partnerships between governments, the private sector and civil society. These inclusive partnerships built upon principles and values, a shared vision, and shared goals that place people at the centre, are needed at the global, regional, national and local level” (6). Linkages with multiple SDGs are evident, particularly 3.8 on UHC, but a range of others are clearly evident too. For example, a partnership approach can contribute to the reduction of maternal mortality ratio (SDG 3.1) by improving the quality of care for mothers.7 While TPI focuses on local, front-line improvements in the quality of health services, the compounding results from all partnerships around the world can lead towards global cohesion and overall impact. It is important to note that the benefits produced by twinning partnerships not only enhance institutional capacity to deliver improved health services, but also contribute to strengthening of the entire health system, if designed and implemented effectively. OBJECTIVE 2 – IMPROVEMENT Improvement is at the core of the partnership. In general, improvement focuses on the act or process of making something better. In hospital settings, improvement implies organizational and structural change, in addition to a necessary change in attitudes and behaviour, very often - all of which makes this process complex since it involves people and often requires a culture shift. Gaps existing in quality of care within health care facilities should be agreed 7 Royal College of Midwives and Ugandan Midwives Association. Case study in THET: https://www.thet.org/case-studies/aligning-partner- ship-plans-institutions-strategic-plan-2/ 19PART 1: TPI objectives Partnership development and continued strengthening – Japan and Liberia The Partnership between Nagasaki University Hospital (NUH), Japan, and Tellewayon Memorial Hospital (TMH) in Lofa County, Liberia, was formed in August 2016. At the time, TMH was recovering from the West African Ebola outbreak of 2014 and relying on international support to reactivate its essential health services and moving forward with recovery efforts in alignment with national recovery plans. During the recovery at TMH, it was quickly realized that the impacts of the Ebola response had depleted many resources and that extensive work was needed in order to improve quality. NUH saw that the needs at TMH were extensive and agreed to form a partnership with TMH. The Ministry of Health and the County authorities in Liberia supported this partnership at the onset of the formal TPI agreement. Careful consideration was given to the architecture of the partnership, recognizing the distinct culture and context of the respective partners. Principles and definition of partnerships were carefully considered in recognition that success of the partnership would depend on the foundations developed in the early stages. This proved pivotal in the roll-out of the partnership. Moving forward from this initial partnership, a situational assessment and gap analysis were completed at TMH in October 2016. Following the gap analysis, an official “action planning” meeting took place in December 2016 where both partners agreed to improve infection prevention and control, with specific attention being given to hand hygiene and waste management. It was noted that by improving these two areas, the foundation could be created for overall quality improvement throughout the whole hospital. The partnership undertook two partnership exchange visits in Liberia and Japan respectively. The principles of the partnership were reinforced throughout while the improvement work proceeded. The bi-directionality of the partnership learning was emphasized. For example, the TMH team leader gave a talk about their experience in the Ebola response. NUH stated they benefited greatly from because they learned about the realities of diagnosis and treating Ebola affected patients. 20 Partnership Preparation Package upon. Based on these identified gaps, one or several priority action areas are identified to steer the focus of the partnership. The ultimate aim is to improve the quality of care and overall health outcomes through the successful implementation of interventions using effective improvement methods. Both arms of the partnership need to establish common goals and priorities in order to develop a strong, effective and sustainable partnership. Additionally, when defining areas of improvement, it is necessary for the focus to involve and engage local stakeholders, teams and individuals within the health system who will be the ones to sustain the efforts put forth by the partnership. Objective 2 involves the following necessities. • Both arms of the partnership needing to jointly agree on improvement entry points. This collective approach promotes an atmosphere of ownership, learning and innovation through a safe space supporting an open mind-set, the use of skills and an opportunity to work and learn together. • Achieving common goals set between partners. This includes defining clear targets, agreeing on the best methods of spread, setting clear reporting mechanisms and monitoring standards, methods and ways of working. • Coordinating the implementation of improvement activities through regular contact supported by a communication plan that holds people accountable for their own work. • Testing several changes until a desired process that leads to a desired outcome is achieved, allowing for a certain degree of flexibility, permitting necessary changes and adaptations. The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches to improvement. Areas of improvement can include a variety of service delivery and clinical care areas influenced by the baseline assessment, Improvement “The combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning).” Batalden, P. B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? Quality & Safety in Health Care, 16(1), 2–3. https://qualitysafety.bmj. com/content/16/1/2 21PART 1: TPI objectives such as infection prevention and control (IPC), patient safety, and specific clinical services. Examples abound but the unifying concept is that improvement in service delivery needs to have a direct and lasting impact on the quality of the entire health system8. The linkages between service delivery and health workforce are clearly evident. The inter-relatedness with each of the health system components is highlighted through all partnership action. In the example below, the partnership in Ethiopia illustrated how improvements in both service delivery and clinical care at the facility level have had a direct impact on the wider health system. Ultimately, achieving quality at the facility level can bring balance and improvements to the entire health system. OBJECTIVE 3 – SPREAD Spread allows for sharing and scale-up of improvement experiences and learning within the local and national health system, and beyond (7). This enhances the reach and impact of the partnership by sharing what did and did not work well. When considering Spread, a strategy to help document successful experiences should be developed and early conversations should be held on the following topics: (1) What are the new and creative health service improvements that have been made? Spreading the emerging success stories of improvement can help drive large scale spread. (2) What are the ways in which this improvement will be sustained? A way to sustain improvement is to allow sufficient time for new practice to become fully integrated as the standard (e.g. incorporating new practices in policies, procedures, job description, etc.). (3) How was the improvement made? For example, demonstrating the benefits and advantages arising 8 A health system has traditionally been described by WHO as comprised of six building blocks which include: leadership and governance; health information systems; health financing; essential medical products and technologies; human resources for health; and service delivery. Improvement – Gondar, Ethiopia and Leicester, England The partnership formed between the University of Gondar Hospital, in Ethiopia and the University Hospital of Leicester NHS Trust, in England, aimed to implement the WHO Surgical Safety Checklist in the operating theatres of Gondar Hospital. Through regular audits, staff feedback and multidisciplinary learning sessions, the monitored results showed that the Checklist had successful implementation, compliance and adherence among staff. Additionally, there was consistent focus on joint learning and participation which helped to build research capacity. This resulted in a multi-country research project to look at Checklist implementation in a partnership context. After monitoring the implementation of the Checklist programme, it was found that its use rose from 17% to 53%, with a 100% application in emergency procedures. Multi-professional groups are now trained in its use. Importantly, the research also provided an opportunity to critique the work of the partnership and enable further improvements. Of note, this long-standing partnership benefitted from the support of both THET and WHO (8). 22 Partnership Preparation Package from a new practice encourages both spread and sustainability. (4) Who is the target audience of the Spread? In considering the target audience, it is important to acknowledge if the spread will focus on individual buy-in, whole facility buy-in, or entire health system adoption. These details help to organize and structure a plan to disseminate the information and experiences of success. The work of the partnership, particularly in relation to spread, needs to take careful account of the national strategic direction on quality, where this exists. Many countries are now developing or refining national quality policies and strategies. The formation of these policies and strategies can be informed by experiences that emerge from twinning partnerships. When these national strategies already exist, the work of the twinning partnerships should be carefully aligned with the national direction. This allows the effort of the partnership to have maximal impact by supporting implementation of a nationally owned drive for quality. The initial situational assessment can identify the national quality direction and both arms of the partnership need to be fully aware of this at all stages of the partnership. Spread can be considered in three ways - horizontal, vertical and spontaneous (7)(9). From the onset of the partnership, the following should be considered. 1. As soon as partners begin planning for health facility improvement, spreading this improvement should also be discussed. 2. Consider broadcasting your improvement message through different channels, such as conferences, professional journals, media, word-of-mouth and first-hand accounts. 3. Make it as appealing as possible for others to want to copy your improvement. 4. Build a network to sustain and grow spread. 23PART 1: TPI objectives 5. Finally, consider, at the outset, how the experience arising from this project could be used to feed into learning systems, both at the national and global levels. Horizontal spread refers to spreading improvement across people and organizations within the same level of a health care system. An example of horizontal spread is replicating improvements from one unit in a health facility to another. Vertical spread refers to spreading the information and improvement efforts throughout the national, subnational and local levels of a health system. Vertical spread is particularly important because while national level can drive local change, local can also drive national level change. It is important to collect quantitative data and analysis of the improvements as it lays the groundwork for evidence-based practice and can be a critical component of vertical spread, and thereby influence changes in policy. Spread requires strong connections between quality improvement evidence in conjunction with both facility and national quality policies. This evidence and clear alignment with existing policy could help to facilitate the improvements made from TPI into facility and national quality policies. Spontaneous spread, is not planned for, but can spontaneously occur through informal channels such as social networks, or opinion leaders, which sometimes cross country’s borders. An example of spontaneous spread is the engagement that occurs between partnership facility leaders and key influencers within the health system. The power of human interaction and storytelling – often in informal meetings and gatherings – in achieving change then becomes clearly evident. Of further note is the necessity to consider the spread of ideas, competencies and skills from low-income countries to partners in high-income countries. This is inherently related to concepts of mutuality that are enhanced through partnerships. 24 Partnership Preparation Package The critical role of the community Involving patients and communities can stimulate spread and strengthen implementation and the sustainability of improvement programmes. Connecting with the local community can improve the quality of care and make services more people- centred. This is particularly important in low-resource settings where demand for health care is high. Co- developing health services around the needs of patients and the community, by empowering patients and communities by informing them and giving them the ability to make decisions in order to instigate change, can enhance the patient’s experience, health outcomes, confidence and trust in health care providers (10). Ideally, patient, family and community engagement should be part of all national health plans. In the absence of a formal mechanism to engage patients and the community, health care workers can carry out simple actions to engage them, such as providing practical training (e.g. on hand hygiene, waste management, use of medicines, etc.), invite patients’ representatives or community leaders to participate in orientation meetings and provide on- going support. Advocating for the partnership and the successes achieved will promote the work and lead to further interest within communities. This work can be celebrated and advertised to maintain motivation and create a positive atmosphere. When community spread occurs, the knowledge generated through an improvement process in the health care facility becomes part of normal practice and standards that have positive implications for the population’s health, e.g. hand hygiene improvement. The example below highlights horizontal and vertical spread. Spread - Yagaldo Ouedraogo Hospital, Burkina Faso and Montpellier Hospital, France Yagaldo Ouedraogo Teaching Hospital in Burkina Faso started partnering with the Teaching Hospital of Monpellier in France, and implemented a pilot project to improve hygiene in the neurosurgery ward in 2013. The objective was to meet the standards of hospital hygiene in this specific ward. Four areas were targeted: hand hygiene, waste management, management of nosocomial infections and capacity-building of health workers. The idea was to concentrate efforts on the selected activities in one of the wards of the hospital in order to understand what kind of improvements could then be replicated in other wards and units of the hospital. Improvement was spread horizontally, making the entire facility benefit. Furthermore, convinced of the advantages of partnerships work, Expertise France secured support from the European Commission to spread this improvement to other health care facilities across the country. Nine partnerships involving national and regional hospitals have been implemented since February 2017 with positive implications for the entire health system of Burkina Faso. Thus, horizontal and vertical spread is taking place simultaneously (11).
PART 2: OVERVIEW OF THE 6-STEP CYCLE T he partnership approach is a step-wise approach which facilitates the development of partnerships, the systematic identification of gaps and the development of an action plan and evaluation cycle. 1. Partnership development begins the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions. Both arms of the partnership agree to work together to improve the quality of health care. 2. The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership. 3. The gap analysis involves a review of the needs assessments and reveals key priority areas for action. From the gap analysis, the foundation for action planning is established in a systematic way, in order to help partners to implement a more focused improvement effort. 4. Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long-term targets for the twinning partnership. In this step, it is important to look at communication, spread and budget. 5. Action is the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. 6. Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. A variety of tools and resources are available (Annex 2) to support each step and will guide the partnership implementers throughout the process. PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE A t each step of the cycle, one or more tangible outputs or deliverables to work towards is expected. These outputs are designed to help the TPI partnership move the action forward. To assist partners, a list of supportive tools and resources is provided in annex 2. Implementing organizational and structural change is often complex, because in many cases it involves people and a cultural shift needs to take place. For this reason, when seeking appropriate tools for any given technical action area, it is important to consider how they can support planning for the partnership activities, their implementation, and in addition important cross-cutting themes, such as community engagement, knowledge management and communication/advocacy. It is also important to consider the broader national context, policies, frameworks and national strategic priorities and existing initiatives in planning twinning activities. Technical improvements must align with national policies and strategies. This will be particularly important in achieving objective 3 and spreading the experience from the twinning partnership improvement process both in the short and long term. STEP 1: PARTNERSHIP DEVELOPMENT This is the beginning of the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions (1)(4). Both arms of the partnership agree to work together to improve the quality of health care, focusing on different aspects of service delivery, including clinical care. A requirement of successful partnership implementation is to have a stable funding structure. This has to be defined from the beginning, as the activities that the partners will undertake will depend on the availability of human and financial resources (4). Partnerships established through international cooperation9 can benefit from direct funding of one arm of the partnership. In other cases, partners can agree to share the costs or compete successfully for external funds. This requires the partners working together to identify potential sources of funding and develop joint proposals. Whatever model of funding is applied to implement the activities of the partnership, it is vital that partners agree on clear systems and procedures. Main activities 1. Secure formal management and leadership agreement on both sides of the twinning partnership to take joint action. This can be done through a written statement of understanding across the institutions, such as a letter of commitment. 9 The concept of international cooperation makes reference to the interaction of persons or groups of persons representing various nations, in the pursuit of a common goal or interest. Outputs or deliverables 1. Exchange of letters between institutional management as required (it can be a letter of commitment or a Memorandum of Understanding). 2. Agreement on a definition of the twinning partnership. 3. Team members on each arm of the partnership selected and contact details exchanged. 4. Communication plan drawn up. 5. Kick-off meeting notes indicating potential areas of work, next steps and a tentative date for conducting the needs assessment. 6. Official designation of a lead and deputy trained in the approach using the outline provided in this preparation package. Core resources for Step 1 – Partnership (see annex 2) 30 Partnership Preparation Package 7. Identify a twinning lead and deputy at each partner institution. Ideally the Quality Improvement Officer should be the designated lead. In the absence of a Quality Officer, a focal point responsible for quality and safety can be designated instead. 8. Ensure the engagement of multi-disciplinary staff committed to being part of the “improvement team”. For example, a dedicated person that collects data and monitors evaluation activities. Involving motivated staff will make the change process happen smoothly and positively influence staff who resist change. 9. Consider the suggested definition of partnership; refine and agree on it across the twinning partners as a foundation for moving forward. 10. Negotiate with managers to secure protected time for the improvement team to work on the identified technical action areas. 11. A kick-off meeting with the twinning teams is recommended for the teams to get to know each other. If an in-person meeting is not possible, the alternative is a virtual meeting. 12. Establish a schedule of regular communication (a minimum of once a month is recommended) using a variety of methods (telephone, SMS, text messaging, email, skype, etc.). 13. Establish a budget for the planned activities, including overheads. STEP 2: NEEDS ASSESSMENT The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership.10 10 For an example of a “How To” tool developed for the TPI partnership situational analysis between NUH and TMH, see annex 3. Core resources for Step 2 – Needs assessment (see annex 2) 31PART 3: Digging deep - Putting the 6-Step cycle into practice Main activities 1. Conduct a desk review on existing national, sub- national and institutional documents on quality of health services. Possible documents include: national health sector policy/plan, national quality policy or strategy. 2. Identify experienced and motivated leads to coordinate the assessment, as well as their assessment team members. The composition of the team will depend on the scope of the assessment, the time and resources available. Ideally the team should include a member from the district health management, the health care facility management and an expert of the technical area to be assessed. 3. All members of the assessment team should be briefed before starting the assessment and have an overview of the expected results of the exercise, including the data collection process. 4. Communicate to other facility staff about this exercise as it requires the collaboration of other teams when collecting data, ensure buy-in from the start and discuss confidentiality. 5. Undertake a specific needs assessment within the selected technical area using appropriate assessment tools. Examples of themes that could be assessed are: a. infection prevention and control b. patient safety and health worker safety c. essential surgical care d. waste management e. Water, sanitation and hygiene (WASH) f. maternal and newborn care g. health workforce. 6. Consider the use of a standardized tool to complete the needs assessment. See annex 3, as an example of the tool developed and then used for the TMH needs assessment. Outputs or deliverables Completed baseline and situational analysis report appropriate to technical area of focus. 32 Partnership Preparation Package Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. Core resources for Step 3 – Gap analysis (see annex 2) 33PART 3: Digging deep - Putting the 6-Step cycle into practice Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. 7. Outline specific steps that can be taken to fill the gaps. 8. Organize a meeting with senior leadership to secure endorsement and approval of the findings of the gap analysis and the priority areas identified. Quality Improvement (QI) at the core of TPI The TPI Preparation Package outlines all six steps and provides support and guidance for initiating the partnership and prioritizing which areas in service delivery or care need improvement. In addition to this TPI Preparation Package, a detailed practical field guide entitled “Taking Action: Steps 4 and 5 for Twinning Partnerships for Improvement” can be read alongside the overview of Steps 4 and 5 below. “Taking Action” dives into QI models and approaches and supports the planning, action, implementation, and guidance of QI within partnerships. “Taking Action” reviews the theories of practical application of action in a partnership and can be used by any QI team that has identified a quality challenge, specific needs and current gaps in services; and also that is ready to develop targeted action plans for intervention and improvement in health care setting. The “Taking Action” document also includes a list of common barriers and key factors for successful quality improvement gathered through the WHO Global Learning Laboratory for Quality UHC. The seven countries which provided feedback on common barriers and key factors for success included India, Malawi, Mexico, Nigeria, the United Kingdom, Venezuela and Zimbabwe. The feedback provided critical insights from the front line on the challenges and opportunities for quality improvement at the facility level. For additional information and for the common barriers and key factors, please refer to “Taking Action: Steps 4 & 5 in Twinning Partnerships for Improvement.” For additional information on the WHO Global Learning Laboratory, visit: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/ 34 Partnership Preparation Package STEP 4: ACTION PLANNING Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long- term targets for the twinning partnership (12). In this Step, it is important to also consider matters related to communication, spread and budget.12 Main activities 1. Hold a team meeting at the partnership facility • Identify and confirm the key team members at the partnership facility: • Facility leader or manager to endorse the partnership • QI team leader with dedicated time for the project • Technical/clinical/subject matter expert • Measurement and evaluation leader • Community/patient representative • QI team staff to provide technical and administrative support • Ensure consensus and common understanding of key definitions • Outline preparation activities • Review activities taken to date on Steps 1 to 3 of 6-Step Cycle • Ensure team is prepared with priority areas already identified • Assess ground level interest and capacity • Estimate expected costs in terms of personnel, time and money. 2. Agree on an intervention • Review evidence for possible interventions, focusing on improved outcomes • Seek relevant resources on all relevant 12 For an example of action planning templates, see Annexes 4-6 Core resources for Step 4 – Action Planning (see annex 2) 35PART 3: Digging deep - Putting the 6-Step cycle into practice literature on the subject area • Consult with experts on site and at partnership sites • Consult with other health workers • Select intervention with largest benefit, lowest barriers to use, and greatest potential for sustainability • Carefully consider how technical exchanges can support the intervention • Note sustainability of interventions post-partnership • Break down interventions into necessary behaviours, structural and procedural changes. 3. Outline implementation activities • Outline implementation plans • Summarize roles and responsibilities for implementing various aspects of the intervention • Identify local barriers to implementation and design accordingly13 • Engage stakeholders to identify potential concerns • Identify needs based on local context • Identify potential gains and losses associated with implementation • Evaluate current communication methods and adapt as needed. 4. Outline roles and ensure capacity • Estimate expected expenditure • Estimate costs/time for team members • Estimate costs/time for supplies/ equipment • Estimate amount of inputs and capacity available 13 For a list of common barriers, see Taking Action Steps 4&5. 36 Partnership Preparation Package • Determine roles and responsibilities of each team member and how they will contribute to the improvement aim • Ensure protected time and support for staff • Obtain the necessary approval from the facility leader to protect time for key staff • Designate an administrative support person or other assistance • Ensure clear roles are defined for team members in the partnership institution and communicated clearly across the partnership. 5. Outline monitoring and evaluation activities • Outline monitoring activities • Examine hospital epidemiology and existing measures taken by hospital • Identify key indicators of success in implementation • Identify key methods for collecting evaluation data • Outline evaluation activities • Identify key indicators of outcomes • Identity key methods for collecting evaluation data • Strive for simplicity in evaluation and monitoring • Consider benchmarking success from other hospitals in similar contexts. 6. Complete written action plans • Share preliminary plans – ensure teams in partnership health facilities are in agreement • Schedule a series of partnership visits with defined objectives, including twinning partner, other partners, country/WHO lead (if applicable) • Agree on a schedule of partner progress reports (see annexes 4-6). Outputs or deliverables 1. Complete written 2-year Partnership Plan 2. Complete written 6-month initial short-term action plan. 37PART 3: Digging deep - Putting the 6-Step cycle into practice STEP 5: ACTION Action marks the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. Reviewing progress every six months will allow corrective measures to be taken, if needed. The improvement team should carry out regular and planned monitoring reviews using the indicators previously defined. During this action stage, a method for tracking the budget is advised (12). Main activities 1. Put Partnership Plan into action with partners • Ensure continuous consensus in action between partners • Ensure continued alignment with national and sub-national efforts to strengthen quality of health services • Ensure that partners working within the same facility are continuously aware of improvement activities • Align existing improvement efforts already under way at the facility level • Mark the moment of initial action on both arms of the partnership • Choose a date. 2. Manage the implementation of activities • Set up a regular schedule for the QI team to share updates on progress of the project • Ensure methods are used to make data regularly visible to staff • Ensure involvement across the institution, including staff members not directly involved in the specific improvement intervention • Ensure regularly scheduled communication across the partnership on implementation activities. 38 Partnership Preparation Package 3. Coach the team to implement the QI activities • Provide facilitation and QI methods training for QI team leader • Provide mentoring, coaching and general on-site QI support using all assets available (local- and partnership-based) • Build in time for QI knowledge transfer from the team leader to team during team meetings, with the intention of creating cohorts of health workers who can act as catalysts and mentors. 4. Implement the quality initiatives and test changes • Implement intervention • Measure performance through small test of change – PDSA cycles or other agreed methods • Keep track of progress against the planned activities and budget • Make adjustments to intervention based on information received, e.g. outcomes and feedback in response to small test of change • Document issues that arise in a log, and how they were tackled • Set up rapid response mechanisms for trouble-shooting with partners. 5. Assess and refine the interventions • Implement review every six months • Develop interval reports • Adjust team efforts accordingly • Adjust any changes due to staff turnover, need for capacity-building, or need for re-training or training of additional staff • Report back to the partnership on issues that arise14 14 For an example of a partnership that confronted failure, see annex 1. 39PART 3: Digging deep - Putting the 6-Step cycle into practice • Celebrate small or large victories on both arms of the partnership. 6. Share learning and spread changes • Continuously refine change until ready for implementation on a broader scale • Implement a spread plan, taking careful consideration of sub-national and national contexts • Spread changes, taking a successful implementation process from pilot and replicating change throughout the organization • Identify opportunities to use partnership activities to bring about change in other institutions, encouraging national spread. 7. Document and disseminate the improvements observed • Distil the change stories • Distil learnings on implementation by developing knowledge products15 such as knowledge briefs and action briefs • Synthesize any learning to have emerged from one arm of the partnership that benefitted the other arm, emphasizing the bidirectional nature of learning • Disseminate a progress report using appropriate bodies at national, subnational and local levels to maintain to maintain dialogue and connection to overall national plans. 15 Visit the WHO Global Learning Laboratory for more information on Knowledge Briefs. Outputs or deliverables 1. Develop a series of reports outlining action and progress in partnership plan 2. Conduct mid-term review of implementation activities. 40 Partnership Preparation Package STEP 6: EVALUATION Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work (against their baseline) and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. Monitoring and evaluation are key components for a successful partnership and must be implemented from the outset of the partnership cycle (13). This step marks the closure of the cycle and allows the partners to review and assess how well the partnership has met its objectives, but also the partnership’s true impact. The evaluation is the final stage, but the monitoring has taken place thorough the cycle and the results will inform the overall assessment. In addition to local review meetings and partnership discussions, each twinning partnership provides periodic monitoring reports (6-month reports; 1-year repeated baseline assessment; and a 2-year review). Some suggest an external evaluation by specialists to ensure objectivity and others suggest using the teams within the project to gather optimal learning. A combination of the two approaches can generate better results and partner satisfaction (13). Whatever is decided, the partners should be involved in the exercise; specialists should be responsible for certain aspects of the evaluation, and the evaluation and monitoring process must be planned for at the beginning of the partnership. By including the three objectives as an underpinning structure of the evaluation, a successful evaluation reflects on the strength of the partnership, the priority areas of improvement, along with its spread. Main activities Initial evaluation planning activities should be conducted in earlier parts of the 6-step partnership cycle. This planning activity should include consideration of: Core resources for Step 6 – Evaluation and Review (see annex 2) 41PART 3: Digging deep - Putting the 6-Step cycle into practice • key indicators on the effectiveness of the improvement effort • assessment of partnership strength • spread beyond the partnership • training on evaluation approaches for those involved in the partnership • periodicity of reporting. Evaluation activities are conducted throughout the 6 steps. Step 6 is focused on activities to synthesize findings, as well as conducting any necessary assessments. 1. The partners together review the monitoring reports and decide how to synthesize evaluation (collection of statistical data, interviews, focus group, surveys, etc.) 2. Synthesize findings from key indicators that demonstrate effectiveness of the activities conducted, as well as the long-term impact of the partnership. 3. Prepare an evaluation report based on the actions outlined in the partnership plan (and informed by appropriate evaluation tools). 4. Reflect on the success of the evaluation training. 5. Conduct a repeat of the baseline assessment/ situational analysis to consider progress. 6. Conduct assessment on the strength of the collaboration. 7. Conduct assessment of the spread activities. 8. Synthesize all findings and agree on key lessons learned (consider limiting to top ten). 9. Prepare an evaluation report to demonstrate impact and to advocate for financial support. The reports will focus on the achievement of project outputs and outcomes. 10. Disseminate findings internally and externally. Outputs or deliverables 1. For a 2-year project, three monitoring reports should be generated and shared across the partnership and with hospital leaders outlining action and progress towards achieving the Partnership Plan (at 6 months, 1 year and 2 years). 2. Repeated baseline assessment/ situational analysis. 3. Evaluation report KEEPING THE LEARNING GOING T here have been notable successes among the hospitals and health systems that have participated in partnership-based approaches to improvement. These include sustained partnerships, co-developed products and programmes and spread. It has become clear, that in many cases, neither the technical experts from high-income settings, nor the local providers from low-income institutions have sufficient knowledge and know- how to affect improvements. Strong, trusting, inter- institutional partnerships are therefore needed to co-develop solutions that can lead to success and spread. Linkages with national efforts to enhance quality are key to successful cascading of learning for maximal impact on health outcomes. The 6-Step Partnership Improvement Cycle and the TPI Preparation Package provide a practical blueprint for action. It should be noted, however, that each partnership is different - adaptation will invariably be required. Learning will certainly emerge, and this document will also be improved over time. Quality improvement is still an evolving science, and humility is essential for partners on all sides of the TPI. Indeed, successful partnering is rewarding for all those involved. There is much to be learned about how to apply the principles and practices of quality improvement to strengthen the delivery of health services and build resilient health systems in developing countries, yet, lessons also flow back to the so-called developed world. The prototype partnership between Tellewoyan Memorial Hospital in Liberia and Nagasaki University Hospital in Japan proved invaluable in informing the design of the larger TPI initiative. The experiences from this and other efforts will help refine the different approaches to quality improvement. These experiences can also inform and be informed by wider efforts on quality, which have become increasingly prominent in the context of continued advancement of global efforts to achieve universal health coverage. Resources are limited, and continued global learning about quality improvement will depend on the sharing of knowledge, experiences and ideas. Entities such as the WHO Global Learning Laboratory (GLL) for Quality UHC can foster such sharing. The GLL is also a space where successes can be celebrated and knowledge, experience, and ideas shared. Sometimes there is failure, but resilience is needed to find a way to succeed – a huge body of learning resides in these initial failures. The words of Benjamin Franklin ring true - “Tell me and I forget, teach me and I may remember, involve me and I learn.” That is the power of human interaction that lies at the heart of a partnership. REFERENCES 1. African Partnerships for Patient Safety. Improving Patient Safety Partnership Preparation Package. A resource for all health partnerships committed to strengthening patient safety. Geneva: World Health Organization;2012. (http://www.who.int/patientsafety/ implementation/apps/resources/preparation_package_ EN.pdf?ua=1, accessed 24 June 2018). 2. Twinning Partnerships for Improvement. Recovery Partnership Preparation Package. Building capac- ity to reactivate safe essential health services and sustain health service resilience. Geneva: World Health Organization;2016. (http://apps.who.int/iris/bit- stream/handle/10665/206542/WHO_HIS_SDS_2016.3_eng. pdf;jsessionid=0D0AEC895C8BD6F8D8D192A3236F89B- F?sequence=1, accessed 24 June 2018). 3. Lewis L, Williams C, Jackson L, Caffarella R, edi- tors. Experiential Learning: A New Approach. San Francisco: Jossey-Bass;1994:5-16. 4. Successful partnerships a guide. OECD LEED Forum on partnerships and local gover- nance. (https://www.oecd.org/cfe/ leed/36279186.pdf, accessed 24 June 2018). 5. Partnerships for safer health service delivery: Evaluation of WHO African Partnerships for Patient Safety 2009-2014. Geneva: World Health Organi- zation;2015. (http://www.who.int/ patientsafety/implementation/apps/ evaluation-report/en/, accessed 26 June 2018). 6. Sustainable Development Knowledge Platform. Sustain- able Development Goals. Unit- ed Nations. (https://sustainablede- velopment.un.org/, accessed 24 June 2018). 7. African Partnerships for Pa- tient Safety Spread Pack. Improvement series. Geneva: World Health Organization; 2012. (http://www.who.int/pa- tientsafety/implementation/apps/ resources/APPS_Improv_Spread_ Pack_2012_04_EN.pdf?ua=1, ac- cessed 13 April 2018). 8. African Partnerships for Patient Safety. Building Momentum for Safer Health Care. Gene- va: World Health Organiza- tion;2012. (http://apps.who.int/ iris/bitstream/handle/10665/78043/ WHO_IER_PSP_2012.7_eng.pdf?se- quence=1, accessed 24 June 2018). 9. Greenhalgh T, Robert G, Bate P, Kyriakidou O, Macfarlane F, Pea- cock R. How to Spread Good Ideas. A systematic review of the literature on diffusion, dis- semination and sustainability of innovations in health service delivery and organisation. Re- port for the National Co-ordi- nating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). 2004. (http://www. netscc.ac.uk/hsdr/files/project/ SDO_FR_08-1201-038_V01.pdf, ac- cessed 20 June 2011). 10. WHO Community engage- ment Framework for Quality, People-Centres and Resilient Health Services. Geneva: World Health Organization;2017. (http://apps.who.int/iris/bitstream/ handle/10665/259280/WHO-HIS- SDS-2017.15-eng.pdf?sequence=1, accessed 20 June 2018). 11. Partenariats Africains pour la Sécurité des patients. Rapport d’évaluation des partenariats hospitaliers pour la sécurité des patients entre la France et l’Afrique. Genève: Organisation Mondiale de la Santé;2017 (http://www.who.int/patientsafety/ implementation/apps/evaluation-re- port/fr/, accessed 20 June 2018). 12. Taking action: steps 4 and 5 in twinning partnerships for improvement for health care facility managers, quality im- provement teams and insti- tutional health partnerships. Geneva: World Health Organi- zation;2018. (http://www.who.int/ servicedeliverysafety/twinning-part- nerships/steps4-5/en/, accessed 19 July 2018). 13. EQUAL Partnership Develop- ment toolkit. European Com- mission. Directorate-General for Employment, Social Affairs and Equal Opportunities ; 2005 (http://ec.europa.eu/employment_ social/equal_consolidated/data/doc- ument/pdtoolkit_en.pdf, accessed 13 April 2018). ANNEXES ANNEX 1 Case study - Adjusting action when it’s not working Developing a culture of learning in Malawi16 Partnerships work together to identify what works, what does not and what can be learned from this. The Zomba Mental Health Services (Malawi) partnered with the Department of Health Sciences at the University of York (UK) and worked together on a project designed to strengthen the system of community mental health care in Zomba District, Malawi. The project aimed to develop the role of local village-based health workers, known as health surveillance assistants (HSAs), through training and support, in delivering mental health interventions 16 This partnership was supported by THET. for the first time. Planning and delivery of the project involved key professionals in Zomba from mental health services and district health offices, as well as discussions with the HSAs. To collect data, the project manager of Zomba conducted visits to the village-based HSAs on a monthly basis. This allowed him to capture relevant data and discuss it with them. This process allowed them to engage HSAs in the project as a whole. “It enthused people, kept them motivated and interested, and kept the momentum of the project going. This wouldn’t have happened if we hadn’t built in face-to-face visits”, admitted the project manager. There were practical difficulties and the data required for monitoring and evaluation was not efficiently collected. The project manager of Zomba had planned to capture all data on his laptop on a monthly visits, but this proved too time-consuming. Having realized the data collection system was not working, the team agreed that paper copies of the data would be taken off-site between visits, and that the timescales should be allowed to slip. This affected the progress of the partnership improvements and the colleagues involved agreed to improvise and adjust the action planning. The project manager of Zomba believes that learning has been facilitated by the partners having respect for each other’s views and ideas, and making decisions collectively. “The UK partner was very supportive of our new ideas on the implementation of the work. This has helped the partnership to work better together for one common goal, evidenced in the successful results. In the process, the Malawi partners have gained knowledge and learnt skills, including in relation to good project and financial management, and analysis, interpretation and reporting of data.” Acknowledging problems allows partners to look for solutions and turn challenges into lessons learned. 48 Partnership Preparation Package ANNEX 2. TOOLS AND RESOURCES The tools and resources listed below aim to provide support in the development and execution of your action plan. The resources are diverse and span, not exclusively, advocacy, business/financial, guidance/policies/standards, templates, toolkits and selected academic publications. The resources are included after careful review of WHO materials. Inclusion of a resource is based on its perceived usefulness and also its availability. Inclusion of a resource does not imply endorsement by WHO of any specific organization associated with the resource. Many tools and resources that are applicable in hospitals can be accessed through the WHO website of Hospital of the XXI Century: http://www.who.int/hospitals/en/ Type of resource Location Starting a health partnership (THET) https://www.thet.org/wp-content/uploads/2017/09/How-to-start-a-Health-Partnership.pdf Example of letter of commitment http://www.who.int/patientsafety/implementation/apps/APPS_registration/en/ Example of memorandum of understanding https://www.thet.org/wp-content/uploads/2017/09/Memorandum-of-Understanding-Template. pdf La coopération internationale hospitalière – guide des bonnes pratiques. (French Hospital Federation) https://www.fhf.fr/Europe-International/La-cooperation-internationale/ Guide-cooperation-internationale-hospitaliere Guide de la coopération hospitalière pour l’aide au développement https://www.cultura.com/guide-de-la-cooperation-hospitaliere-pour-l-aide-au- developpement-9782859526849.html Successful partnerships, a guide of OECD https://www.oecd.org/cfe/leed/36279186.pdf Position Statement - Global Catalyst Group for Institutional Health Partnerships http://www.who.int/patientsafety/implementation/apps/global-catalyst-group.pdf Core resources for Step 1 – Partnership development 49Annexes Core resources for Step 2 – Needs assessment The needs assessment tools that you see below are not exhaustive. They were identified from the process undertaken by the partnership prototype between Tellewoyan Memorial Hospital and Nagasaki University Hospital. Type of resource Location Year of publication IPC and patient safety Situational analysis for patient safety. A tool to assess the current level of patient safety in a health care facility based on 12 action areas http://www.who.int/servicedeliverysafety/ twinning-partnerships/tools/en/ 2009, revised in 2015 WHO Hand hygiene Self-Assessment Framework. A critical first step in improving hand hygiene in a health facility is to complete this assessment http://www.who.int/gpsc/country_work/ hhsa_framework_October_2010.pdf 2010 Twinning Partnerships for Improvement. Situational assessment report: quality and patient safety- Tellewoyan Memorial Hospital and Lofa County Health System http://apps.who.int/iris/bitstream/10665/2 53523/1/9789241511872-eng.pdf?ua=1 2017 A tool for Infection prevention and control for supporting national implementation through effective baseline assessment and evaluation http://www.who.int/infection-prevention/ tools/core-components/ICPAT2.pdf 2017 Workforce Human Resource Management Rapid Assessment Tool for Public and Private-Sector Health Organizations http://www.lmgforhealth.org/sites/default/ files/HRM_Rapid_Assessment_Tool_0.pdf 2005 Guidelines: Incentives for health professionals. This underlines both financial and non-financial incentives as critical to ensuring effective recruitment, retention and performance of health workers across the world. http://www.who.int/workforcealliance/doc- uments/Incentives_Guidelines%20EN.pdf 2008 Water, sanitation and hygiene WASH FIT. A practical guide for improving quality of care through water sanitation and hygiene in health care facilities http://www.who.int/water_sanitation_ health/publications/water-and-sanita- tion-for-health-facility-improvement-tool/ en/ 2017 Health service delivery management Service availability and readiness assessment (SARA). A tool to assess and monitor service delivery in terms of availability and readiness of the health sector and to generate evidence to support the planning and managing of a health system http://apps.who.int/iris/bit- stream/10665/104075/1/WHO_HIS_HSI_ RME_2013_1_eng.pdf 2015 Situational analysis of quality improvement in health care, Tanzania. This analysis covers the current status of QI work, standards and their assessment, indicators for QI, methods and approaches in use, progress made, SWOC analysis. http://www.tzdpg.or.tz/fileadmin/ documents/dpg_internal/dpg_work- ing_groups_clusters/cluster_2/ health/Sub_Sector_Group/Quality_ Assurance/11.a_Situation_Analysis_of_ Quality_Improvement_in_Health_Care_ Tanzania_-_Final.pdf 2012 Essential sur- gical care Tool for Situational Analysis to Assess Emergency and Essential Surgical Care http://www.who.int/surgery/publications/ s15986e.pdf?ua=1 2012 50 Partnership Preparation Package Core resources for Step 3 – Gap analysis Type of resource Location Year of publication Gap analysis Implementing a gap analysis framework to im- prove quality of care for your patients. USAID case study showing a gap analysis step-by-step. https://www.usaidassist.org/sites/assist/files/ hci.ghc_gap_framework_workbook.14jun10_1. pdf 2010 Gap analysis AHRQ Quality indicators toolkit – Instructions for doing a gap analysis https://archive.ahrq.gov/professionals/systems/ hospital/qitoolkit/d5-gapanalysis.pdf 2012 Practical resource Twinning Partnerships for Improvement. Japan- Liberia Partner Planning Workshop Report http://www.who.int/servicedeliverysafety/twin- ning-partnerships/partnership-planning-report. pdf 2016 Core resources for Step 4 – Action Planning The WHO Recovery Toolkit, accessible here, is a library of guidance resources in a single place which can be quickly and easily accessed, to guide action. A key purpose of the Recovery Toolkit is to support countries in the reactivation of health services which may have suffered as a result of a large-scale emergency. These services include ongoing programmes such as immunization and vaccinations, maternal and child health services, and noncommunicable diseases. In addition, and because the Toolkit contains core information needed to achieve functioning national health systems, it also supports countries with implementation of their national health plans during the recovery phase following a public health emergency. Type of resource Location Year of publication Knowledge translation Translating evidence into practice: a model for large scale knowledge translation http://www.bmj.com/content/337/bmj. a1714 2008 Planning and implementation WHO planning and implementation of district health services http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 WHO implementation strategy and tools. A guide to implementation of the WHO Multimodal Hand Hygiene Improvement Strategy http://apps.who.int/iris/bit- stream/10665/70030/1/WHO_IER_ PSP_2009.02_eng.pdf?ua=1 2009 Implementation tools and resources for supporting facility and national level implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes http://www.who.int/infection-prevention/ tools/core-components/en/ 2018 Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Evidence-based guideline to support countries as they develop and execute their national antimicrobial resistance (AMR) action plans. http://apps.who.int/iris/bitstream/10 665/251730/1/9789241549929-eng. pdf?ua=1 2017 Planning and implementation of district health services. 10 steps in planning, essential health package, health systems research, disaster preparedness http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 51Annexes Tools for assessing the operationality of district health. A set of tools aimed at district health management teams to generate the information that will serve as a basis for improving the operationality of health districts http://www.who.int/management/dis- trict/assessment/assessment_tool.pdf 2003 WHO Safe management of wastes from health care activities. Provides comprehensive guidance on safe, efficient and environmentally sound methods for the handling and disposal of health care waste in normal situations and also emergencies. http://www.searo.who.int/srilanka/doc- uments/safe_management_of_wastes_ from_healthcare_activities.pdf?ua=1 2014 Sanitation Safety Planning (Implementation tool). Manual for safe use and disposal of wastewater, greywater and excreta. http://apps.who.int/iris/bitstre am/10665/171753/1/9789241549240_ eng.pdf?ua=1 2015 WHO - Workload indicators of Staffing Needs (WISN) – User’s Manual http://www.who.int/hrh/resources/ WISN_Eng_UsersManual.pdf?ua=1 2010 Association for Professionals in Infection Control and Epidemiology (APIC) HAI cost calculator: http://www.apic.org/Resources/ Cost-calculators Core resources for Step 6 – Evaluation and Review Type of resource Location Year of publication Monitoring and evaluation M&E planning tool for both implementing and reviewing M&E plans https://www.thet.org/resources/ hps-monitoring-evaluation-plan/ 2014 Evaluation FAQs Step-by-step guide for health partnerships to effectively carry out an evaluation of their projects and partnerships in the form of frequently asked questions. https://www.thet.org/resources/ health-partnerships-evaluation-faq/ 2014 APPS -Evaluation Handbook A guide to evaluate five domains of a partnership: situational analysis, partnership strength, patient safety improvements, patient safety spread and annual evaluation report http://www.who.int/patientsafe- ty/implementation/apps/ Evaluation-Handbook_EN.pdf?ua=1 2012 Monitoring, evaluation and learning Webinar: sharing of experiences to provide some reflections around M&E https://www.youtube.com/ watch?v=v_oHEvgE_aA 2016 Monitoring and evaluation Health partnership symposium on monitoring, evaluation and learning. Document gathering tips to understand the value of M&E. Examples and exercises are provided. https://www.thet.org/wp-content/ uploads/2017/09/Monitoring-and- Evaluation.pdf 2017 Monitoring and evaluation EFFECt tool stands for EFFective in Embedding Change. This tools focuses on assessing implementation best practice, embedding change and the added benefits to individuals and institutions using a partnership approach https://esther.eu/index.php/effect-tool/ 2017 52 Partnership Preparation Package Core resources for improvement Type of resource Location Year PDSA Cycle (Plan-Do-Study-Act) Systematic process for gaining valuable learning and knowledge for the continual improvement https://deming.org/explore/p-d-s-a 2018 Model for improvement The Model for Improvement, is a simple, yet powerful tool for accelerating improvement http://www.ihi.org/resources/Pages/ HowtoImprove/default.aspx 2018 Confronting staffing issues and turnover of health facility staff Understanding the barriers to setting up a health care quality improvement process in resource- limited settings: a situational analysis at the Medical Department of Kamuzu Central Hospital in Lilongwe, Malawi https://bmchealthservres.biomedcentral.com/ articles/10.1186/1472-6963-14-1 2014 WHO Multimodal Improvement Strategy A one-page visual describing the five-part multimodal strategy to support IPC improvement in a health care facility http://www.who.int/infection-prevention/publi- cations/ipc-cc-mis.pdf?ua=1 2017 53Annexes ANNEX 3. TPI SITUATIONAL ASSESSMENT “HOW TO” TOOL EXAMPLE Step 2: TPI Situational Assessment “How To” Tool The following “how to” tool is presented as a practical guide explaining steps to plan and execute an in-depth situational assessment to inform a twining partnership initiative between two interested partner institutions. This assessment seeks to provide a foundational basis for the co-development of an effective and sustainable twinning partnership between partner institutions. This “how to” tool informs the process of conducting Step 2 of the 6-Step Partnership Improvement Cycle. The “how to” document is to be used together with the TPI Preparation Package and its associated resources. Post-Assessment: Build (4 weeks post-assessment) O B J E C T I V E : T R A N S L A T E F I N D I N G , S H A R E W I T H K E Y S T A K E H O L D E R S A N D I N I T I A T E A C T I O N P L A N N I N G P R O C E S S • Develop and finalize detailed assessment report in collaboration with the thematic lead persons, seeking any approvals where required • Develop short story from assessment highlighting quality improvement and safety opportunities and share with WHO Learning Laboratory for Quality Universal Health Coverage network • Participate in action-planning workshop for the twining partnership initiative presenting summary of the scoping mission findings and recommendations • Co-develop a partnership plan around the focused action areas identified by partner institutions • Use the assessment results to form the basis of the TPI partnership plan development • Provide feedback to WHO TPI team on assessment planning checklist • Discuss opportunities to leverage partner initiatives to support bottlenecks identified at district-/country-level • During Steps 4-6 of TPI cycle, consult quality improvement resources in TPI preparation package for action steps and evaluation/ review. • Conduct evaluation assessment as part of Step 6 of partnership Improvement cycle • Conduct Situational assessment on an annual basis ( as needed) • Align and build monitoring and evaluation system for the partnership with in-country quality of care measurement initiatives • Consult TPI quality improvement resources for hospital partnerships to inform monitoring and evaluation system of the partnership Assessment: Learn (10 days in-country) O B J E C T I V E : B U I L D R E L A T I O N S H I P S A N D L E A R N F R O M F R O N T - L I N E P E R S P E C T I V E S • Conduct team exercise with health facility staff and district health team to gain: • an understanding of the partner institutions • current understanding on quality and safety within local context. • Consult TPI Preparation Package for core technical tools and resources used for Step 2 • Identify key informant(s). Individual(s) should be a respected person amongst his/her peers. • Review interview guide with key informants or group and collectively refine tool to adapt to local context. • Key informant schedules interview times with health worker (HW) cohort. Recommendation for focused group discussions (FGD) with homogenous health worker cohort, if total cohort number exceeds five. Small homogenous groups allow for open discussion and confidentiality • During day of HH and PS assessment, do not hold any FGD. This is to allow limited HW participation in assessment. • Collect, analyse and crosslink data for all five thematic areas daily • Summarize and present preliminary findings to: • Hospital staff and district level staff • WHO Country Office/Ministry of Health • Relevant partners such as funding agency • Summarize preliminary recommendations according to actions needed for different stakeholders: • TPI initiative • Health facility • District health team • Ministry of Health • Hold daily assessment team meeting to debrief from day’s activities, address emerging key issues and prepare for next day Pre-Assessment: Deconstruct (minimum 4 weeks prior to assessment) O B J E C T I V E : R E V I E W I N - C O U N T R Y N A T I O N A L D O C U M E N T S , I D E N T I F Y Q I O P P O R T U N I T I E S A N D R E L E V A N T I N - C O U N T R Y P A R T N E R S • Identify experienced and motivated lead person to coordinate assessment • Inform WHO country office and regional office of impending situational assessment • Conduct desk review of existing national, sub-national and institutional documents on quality and safety. Possible documents include: • National health sector policy/plan • National quality health strategy • District/county-level operational or work plan • Health facility annual plan or workplan • artner coordination mechanisms • In-country quality of care measurement documents/projects • Identify areas you intend to evaluate during the assessment. Ideally, all five assessment thematic areas should be considered: • Quality Improvement • Patient Safety (PS) • Hand Hygiene (HH) • District-level health system • Patient & Community Perspective • Review long-form of interview guide addressing any unanswered questions that arise • Determine situational assessment schedule and share with WCO • WCO country office to schedule meetings in-country and facilitate facility/ district site visit • Identify composition of mission team and assign lead roles for five thematic areas • Ideally, team should include representation from MOH, multiple levels of the organization (if available) and the partner institutions • Ensure availability of relevant skill set, aligned with selected thematic areas • Identify relevant development partners/stakeholders to be consulted • Initiate series of coordination calls and email exchange with assessment team to discuss technical scope of mission and logistics • If funding allows, initiate scoping mission to sensitize Ministry officials and partners in-country ( if funding does not allow, initiate as part of in-country assessment) E X A M P L E S O F H E A L T H W O R K E R C O H O R T FACILITY- LEVEL DISTRICT/COUNTY-LEVEL • Clinical staff: doctor, physician assistant, nurses, midwives, pharmacist, lab technician, aides etc. • Non-clinical staff: maintenance staff, cleaners • Hospital Management • Patient & Community Representatives • Partners within Health Facility • Health Boards • Management Teams • Health Structure Directors • District/County Superintendent, District Commissioners, Traditional chiefs • Partners 55Annexes ANNEX 4. TPI PLANNING TEMPLATE SUMMARY INFORMATION Name of twinning institution 1: Name of lead: Name of twinning institution 2: Name of lead: Name and date of situational analysis/ baseline assessments used: Names of individuals completing the plan: Technical action areas for focus: Partners to consider specific areas to work on, based on situational analysis (experience highlights the need to focus on 2-3 areas maximum) Example: Project 1: Infection prevention and control Project 2: Knowledge and competency on quality improvement. For each action area, complete the template below. Use as many forms as required depending on the additional action areas addressed. Project number and action area • E.g. Project 1: Infection prevention and control Brief description of project • Provide a 1-2 sentence outline of the project Project goals • List the change the project will contribute to in 1- 2 sentences. • Where possible, link to national and/or local policies and plans including the national direction on quality. • Try to emphasize how the goals of the project respond to the needs identified in the baseline assessment. Project outcome(s) • Describe the improvement that you hope will result from the project. • Outcomes often relate to changes in practice or health outcomes. • The outcomes should contribute to the achievement of the goal. Project output(s) • The direct results of the project e.g. 20 people trained in infection control. The outputs should lead to achievement of the outcomes. Main activities • List all planned activities. For each activity, briefly outline what will be done; where and who will be involved on each side of the twinning partnership; how long it will take; methods to be used; and associated costs. • List technical exchange schedule ie. Fortnightly skype connection, monthly leads 1-to-1, 6-monthly visits, ... • Is a visit planned in conjunction with this project? (if yes, list likely human and financial costs.) • Twinning visit plans for year 1 should be thought through in detail. Plans for year 2 may be more general. Include a draft timeline. • What mechanisms are planned to allow receipt of just-in-time input to technical issues? • How will you connect with WHO efforts to support quality improvement? 56 Partnership Preparation Package Beneficiaries • Include information about the people who will benefit (directly and indirectly) from the project e.g. lab technicians; hospital managers; nurses and different groups of patient and community members. • Describe how they will benefit and provide realistic estimates of how many people in each group will benefit. • Will benefits span both sides of the twinning partnership? Stakeholders • Identify the key stakeholders and their interest in the project (e.g. other department, district and national health offices) i.e. any individual or group that may exert influence over the project activities and outcomes (across both arms of the partnership). • Consider the local community and key stakeholders, including patients and families who could contribute and add value to the planned efforts. • Outline which stakeholders the twinning partnership will report to and how often. Monitoring and evaluation • Define key indicators to be used to monitor whether the outcomes of your project have been achieved. • Provide an overview of your monitoring and evaluation plans, providing an outline of methods, who will be involved, how the process will be managed, and how partners will learn together. Sustainability and spread • Describe how long the activities will continue and what the plans are for long-term funding. • What benefits will continue after the initial 2-year project ends and how? • List your plans for building on project achievements. • Describe how you will actively disseminate new information gathered and consider activities to support vertical, horizontal and spontaneous spread opportunities. Risks • Identify potential risks associated with the plan e.g. key personnel moving on, changing institutional priorities, conflict between twinning partners, and how you will manage each of these risks. • List external risks and how you will manage them (e.g. ICT breakdown, problems with visas, political uncertainty). Project management and support • Outline project responsibilities including division of responsibilities across the twinning partnership. • Provide details of the key personnel involved in each arm of the partnership. • Consider key management questions: What systems will be used to manage finances in both locations? Who will have the main responsibility for budgets? How will you ensure that communication is effective and that all partners know what is happening? Approved by Date of approval 57Annexes ANNEX 5. TPI VISIT PROPOSAL TEMPLATE The Visit proposal template should be completed once a visit has been agreed, to ensure that the visit has clear objectives and contributes to the overall partnership planning. Twinning partnership (list both institutions within the partnership): Institution 1: Institution 2: Name of person completing the visit proposal form: Purpose of visit - describe which partnership project(s) the visit relates to: What are the dates of the proposed visit? Start date: End date: Is the visit aligned with existing in-country activity with no duplication of training or policy development work? Yes No Not applicable Does the visit clearly meet the needs of the twinning partner institutions? Yes No Not applicable Briefly describe the expected outcomes of the planned visit (outcomes are clear, realistic and logical): Briefly describe the outputs of the planned visit (outputs are clear, realistic and logical): Briefly describe any risks you think might be associated with the visit: List estimated costs of the visit: Briefly describe how the proposed visit will contribute to monitoring and evaluation of the associated partnership plan: List the number of people involved in the proposed visit and their role in achieving the visit objectives: Has the visit been jointly planned and agreed across the partnership? Yes No Will the visit offer potential benefits to both twinning partners (if yes, de- scribe briefly)? Yes No Not applicable Briefly describe how the visit will help achieve sustainability and spread of effective essential health service delivery. 58 Partnership Preparation Package ANNEX 6. TPI ACTION REPORT TEMPLATE The Action report template allows key outputs of each period of the partnership to be documented, lessons learned and actions arising logged. This is part of developing a strong, effective, action-focused partnership and contributes to partnership governance. Twinning partnership (list both institutions within the partnership): Name of person completing the report and date completed: Time period covered by this progress report: Key actions undertaken: Key achievements resulting from action taken: Key challenges faced: Date of next expected progress report: 59Annexes ANNEX 7: DEFINITIONS Accountability: The obligation to report, or give account of one’s actions – for example, to a governing authority through scrutiny, contract, management, regulation and/or to an electorate. African Partnerships for Patient Safety (APPS) programme: The WHO APPS programme is a hospital- to-hospital focused approach that was results- oriented and co-developed by hospital partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the African Partnerships’ work providing a common relevant goal that everyone was committed to improving. As a result, substantial implementation experience and learning have been achieved in this field across the African Region. The APPS approach demonstrated how working in partnership results in more motivated staff, increased commitment to change, strengthened capacity-building, focused drive and a desire to find appropriate solutions that will impact immediately on the quality and safety of patient care. This in turn can be used to strengthen the delivery of health services to communities globally. Clinical effectiveness: The application of the best knowledge, derived from research, clinical experience and patient preferences to achieve optimal processes and outcomes of care for patients. Community partner: Member of a quality improvement team representing a unit of population, often generally geographically defined, that is the locus of basic political and social responsibility and in which everyday social interactions involving all or most of the spectrum of life activities of the people within it takes place. Continuous Improvement: The process of making something better or of getting better. Integrated People-Centred Health Services (IPCHS) framework: The IPCHS Framework calls for a fundamental shift in the way health services are funded, managed and delivered to respond to these 60 Partnership Preparation Package challenges. The IPCHS vision is that “All people have equal access to quality health services that are co-produced in a way that meets their life course needs, are coordinated across the continuum of care and are comprehensive, safe, effective, timely, efficient and acceptable; and all carers are motivated, skilled and operate in a supportive environment.” WHO recommends five interwoven strategies that need to be implemented in order to achieve IPCHS. Application of the approach can build robust and resilient health services and are critical for progress towards universal health coverage and fulfilling the Sustainable Development Goals. Partnership: A partnership is a collaborative relationship between two or more parties based on trust, equality and mutual understanding for the achievement of a specified goal. Partnerships involve risks as well as benefits, making shared accountability critical. Patient-centredness: Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions. Patient safety: The reduction of risk and unnecessary harm associated with health care to an acceptable minimum. Performance: How well a person, team, project, programme, organization, or policy is being implemented against expected results. Quality: Quality has been defined and understood in different ways around the world. Two of the main definitions are below. • The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. • The totality of characteristics of an entity that bear on its ability to satisfy stated and implied needs. 61Annexes Quality audit: a systematic and independent examination to determine whether quality activities and related results comply with planned arrangements and whether these arrangements are implemented effectively and are suitable to achieve objectives. Quality assurance: all the planned and systematic activities implemented within the quality system, and demonstrated as needed, to provide adequate confidence that an entity will fulfill requirements for quality. Quality control: A process to evaluate actual performance, compare actual performance with quality goals, and take action on the difference. Quality improvement: A process to create beneficial change and attain unprecedented performance. Quality planning: A process to establish quality goals to develop goods and services that meet customer needs. Stakeholder: An individual, group or organization that has an interest in the organization and delivery of health care. BIBLIOGRAPHY Chisholm G. Gree E. Simms B. In our mutual interest. (https://www.thet.org/wp-content/uploads/2017/08/In-Our- Mutual-Interest.pdf, accessed 13 April 2018). Dean L, Njelesani J, Smith H, Bates I. Promoting sustainable research partnerships: a mixedmethod evaluation of a United Kingdom–Africa capacity strengthening award scheme. Health research Policy and Systems .2015. 13:81. (https://doi.org/10.1186/ s12961-015-0071-2, accessed 13 April 2018). Edwards S, Ritman D, Burn E, Dekkers N, Baraitser P. Towards a simple typology of international health partnerships. Globalization and Health. 2015.11:49. (https://doi.org/10.1186/s12992-015-0132-x, accessed 13 April 2018). Health Partnership Scheme: Evaluation synthesis report. Tropical Health Education Trust; 2017 (https://www.gov.uk/government/ publications/evaluationof-health- partnership-scheme, accessed 13 April 2018). Health Partnership Scheme: Impact report 2011-2017. Tropical Health Education Trust; 2017 (https://www.thet.org/wp-content/ uploads/2017/09/Health-Partnership- Scheme-2011-2017-Impact-Report.pdf, accessed 13 April 2018). Jones A. Envisioning a global health partnership movement. Globalization and Health. 2016.12:1. (https://doi.org/10.1186/ s12992-015-0138-4, accessed 13 April 2018). Jones F, Knights D, Sinclair V, Baraitser P. Do health partnerships with organisations in lower income countries benefit the UK partner? A review of the literature. Globalization and Health. 2013. 9:38. (https://doi.org/10.1186/1744- 8603-9-38, accessed 13 April 2018). Kulasabanathan K, Issa H, Bhatti Y, Prime M, Del Castillo J, Darzi A, et al. Do International Health Partnerships contribute to reverse innovation? a mixed methods study of THET-supported partnerships in the UK. Global Health. 2017;18;13(1):25. doi: 10.1186/ s12992-017-0248-2. (https://www. ncbi.nlm.nih.gov/pubmed/28420405, accessed 13 April 2018). Quality improvement made simple. What everyone should know about health care quality improvement. Quick guide. London: The Health Foundation; 2013 (http://www.health. org.uk/publication/quality-improvement- made-simple, accessed 13 April 2018). Reverse innovation in global health systems: learning from low-income countries. In: BMC collections/ reverse innovations [website]. United Kingdom: BioMed Central, 2018 (https://www.biomedcentral. com/collections/reverseinnovations, accessed 22 June 2018). Ritman D. Health partnership research and the assessment of effectiveness. Globalization and Health. 2016.12:43. (https:// doi.org/10.1186/s12992-016-0181-9, accessed 13 April 2018). The European ESTHER Alliance. Bringing together our expertise for capacity building and health care. (https://esther.eu/ wp-content/uploads/2018/01/ BrochureAllianceEsther.pdf, accessed 13 April 2018). WHO Handbook for national quality policy and strategy. Geneva: World Health Organization; 2018 (http:// apps.who.int/iris/bitstream/handle/10 665/272357/9789241565561-eng.pd- f?ua=1, accessed 22 June 2018 ). WORLD HEALTH ORGANIZATION 20 Avenue Appia CH-1211 Geneva 27 Switzerland PLEASE VISIT US AT: http://www.who.int/servicedeliverysafety/ twinning-partnerships/en/
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Printed in Switzerland CONTENTS 8 6 INTRODUCTION ABBREVIATIONS 12 PART 1: TPI OBJECTIVES 26 PART 2: OVERVIEW OF THE 6-STEP CYCLE 28 46 62 PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE ANNEXES BIBLIOGRAPHY 44 REFERENCES 42 KEEPING THE LEARNING GOING ACKNOWLEDGEMENTS The World Health Organization (WHO) would like to acknowledge the support and contribution that many individuals and organizations have made to the development of this document. Katthyana Aparicio, Melissa Kleine-Bingham and Shams Syed (Department of Service Delivery and Safety, WHO) coordinated and led the development and writing of this document. Maki Kajiwara, Nana Mensah Abrampah, Julie Storr (Department of Service Delivery and Safety, WHO) provided significant input to the development and drafting of this document. Special thanks to Sandra Hwang and Albert Wu (Johns Hopkins Bloomberg School of Public Health) for their technical contribution on quality improvement methods. External Peer Review Group Ngormbu Jusu Ballah (Liberia Ministry of Health), Jean Marc Chapplain (Centre Hospitalier Universitaire de Rennes), Graeme Chisholm (Tropical Health Education Trust - THET), Eric de Roodenbeke (International Hospital Federation - IHF), Charlie Evans (American College of Healthcare Executives), Koichi Izumikawa (Nagasaki University Hospital - NHU), Farid Lamara (Expertise France), Emmanuelle Maurin (Expertise France), Sandra Hwang (Johns Hopkins Armstrong Institute for Patient Safety and Quality), Andrew Jones, Samuel Seeigbeh (Tellewayon Memorial Hospital, Liberia) Albert Wu (Johns Hopkins Bloomberg School of Public Health) and ESTHER Alliance for Global Health Partnerships. ABBREVIATIONS AHRQ Agency for Healthcare Research and Quality AMR antimicrobial resistance APIC Association for Professionals in Infection Control APPS African Partnerships for Patient Safety EEA ESTHER Alliance for Global Health Partnerships GLL Global Learning Laboratory HSAs Health Surveillance Assistants IHF International Hospital Federation IPC infection prevention and control LMICs low- and middle-income countries M&E monitoring and evaluation NHS National Health System NUH Nagasaki University Hospital OECD Organisation for Economic Co-operation and Development PDSA Plan-Do-Study-Act QI quality improvement SARA Service Availability and Readiness Assessment SDGs Sustainable Development Goals SMS short message services SWOC Strengths, weaknesses, opportunities and challenges THET Tropical Health Education Trust TMH Tellewayon Memorial Hospital TPI Twinning Partnerships for Improvement UHC universal health coverage USAID United States Agency for International Development WASH water, sanitation and hygiene WISN workload indicators of staffing needs WHO World Health Organization INTRODUCTION BACKGROUND T winning partnerships between health institutions are an innovative approach that can be used to improve various aspects of health service delivery. The WHO Twinning Partnerships for Improvement (TPI) model supports long-term efforts on quality health service delivery within the context of achieving universal health coverage (UHC). The work can contribute to building resilient health systems. Fundamental in the approach is to prioritize alignment with national health plans and strategies, while working to achieve the Sustainable Development Goals (SDGs). TPI builds on the learning from the WHO African Partnerships for Patient Safety (APPS) programme (1). These rich lessons and the subsequent application of twinning partnerships in the recovery effort in Ebola- affected countries have facilitated the design of WHO TPI. The key aim of WHO TPI is to support health care facilities in the improvement and enhancement of the quality of their service delivery, while aligning with the overall national strategic direction on improving quality service delivery. Institutional health partnerships can play a critical role in health systems strengthening. This has been increasingly recognized across the world. Many global health groups1 have highlighted the need to “promote the utility of institutional health partnerships in strengthening health systems and in delivering effective health services.” Recognizing the synergy that comes from a partnership approach, national policy documents over the past decade have also begun to highlight the potential for institutional partnerships as an entry point to strengthen services and health systems. In addition to the APPS programme, TPI also builds on the work undertaken in applying the Twinning model to support recovery from the 2014 West Africa Ebola outbreak. TPI Recovery focused upon building resilient health systems and reactivating safe essential health services in those countries most affected by the outbreak. The aim of TPI Recovery was to rebuild the health services in order to support implementation of national recovery plans (2). Implementation of twinning partnerships involves addressing a variety of service delivery and clinical care areas, including, but not limited to, infection prevention and control (IPC); patient safety; and specific clinical services. Health workforce capacity- building is embedded within the model. TPI can feed into work at the national level to improve the quality 1 For more information on global health groups and to view the consensus statement, please visit WHO’s web site at: http:// www.who.int/patientsafety/implementation/apps/global-catalyst-group. pdf?ua=1 WHO TPI Snapshot • Twinning Partnerships for Improvement focuses on the value of institution-to- institution partnerships in catalyzing health service improvement. • The hospital-to-hospital model developed by ‘African Partnerships for Patient Safety’ (APPS) is the foundation on which TPI has been developed. The emphasis is on a ‘doing while learning” model (3). • As a global network of twinning partners develops there is an opportunity to learn from and share learning across the TPI network. • The approach promotes collaboration, co-development and sharing of both tacit and explicit knowledge thus enhancing spread of successful approaches to improvement. 10 Partnership Preparation Package of service delivery. These partnerships can act as a valuable tool for health improvement strategies and bring real benefit to the front line of service delivery and ultimately to the health of an entire population. The power of twinning partnerships working together can bring effective health improvements beyond what an individual organization or team could achieve alone (4). Furthermore, the work of such twinning partnerships can feed into national strategic efforts to improve quality service delivery elsewhere. PURPOSE OF THE TPI PREPARATION PACKAGE The aim of this document is to provide a practical step-by-step approach for any health institution interested in improving the quality of health service delivery through twinning partnerships. The model is based on a 6-step cycle which begins when two or more partners agree on the establishment of the partnership. TPI guides the partners through a systematic process which involves identifying some specific areas for improvement, developing an action plan to implement improvements, and then evaluating the progression and changes made towards improvement. Institutional health partnerships have the potential not only to work as individual partnerships, but also to collaborate with other partnerships to support a national network of similar partnerships. This can support national efforts through joint problem-solving and sharing experiences in order to develop a body of evidence and experience that can inform national and district authorities. This can further encourage application of the partnership model at all levels of the health system. TARGET AUDIENCE The target audience for this partnership preparation package are those committed to improving the quality of healthcare and service delivery including, but not limited, to those in: TPI brings an opportunity to support improvement in the delivery of care at the local, sub-national and national levels. It can act as a catalyst for change in efforts to enhance quality in the context of UHC. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves (1). 11introduction • health institutions • health facilities • academic/research institutions • professional associations • donor organizations • health authorities • policy making • governments. The TPI preparation package also aims to inform decision-makers and authorities working at the national level that are responsible for planning, developing, implementing and evaluating national health strategies, including WHO country offices and ministries of health. When to use the package The package will be useful to any new or existing twinning health institutions in order to work through a partnership-based approach to improve the quality of health services and embed the effort within long-term service improvement. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves (1). PART 1: TPI OBJECTIVES OVERVIEW OF OBJECTIVES T PI focuses on the value of institution-to-institution partnerships in catalysing health service improvement following a “doing while learning”2 model. TPI takes into account a variety of entities, including health facilities, academic institutions, private institutions, etc.3 It provides the potential for implementing different types of 2 ”Doing while learning” refers to the experiential learning theory where one learns from experience in order to develop skills or new ways of thinking. (Lewis and Williams 1994, p.6) 3 While a variety of entities can be involved in the partnerships, the TPI preparation package will use the generic term institutions to cover all types of entities. partnerships, at local, sub-national and national level, and also across continents. Institutions from high- income countries or from low- and middle-income countries (LMICs) can initiate partnerships to support other institutions within LMICs and thus provide unique opportunities to catalyse the move towards quality health services, all within the context of achieving universal health coverage. Within the TPI model, there are three objectives that each partnership should focus on achieving. 1. The first objective is the development of the partnership. This objective focuses on fostering a strong bi-directional partnership between health institutions. 2. The second objective is improvement through implementing effective interventions based on needs identified at the front lines of service delivery. 3. The third objective is to spread the learning and experience within the local and national health system and also beyond. The ultimate benefits of TPI are bi-directional learning and improvement, motivated and committed staff; strengthened delivery of health services; and better patient and health worker outcomes. The Recovery Toolkit Twinning Partnerships for Improvement - Objectives 14 Partnership Preparation Package The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches towards improvement. As a global network of twinning partners emerges, there is an opportunity to learn from and share learning across the larger TPI network, to promote collaboration, co-development and sharing, and support the spread and replication of improvement. What is co-development? A process that brings together the collective intelligence for a collaborative development and applies joint decision- making that enhances trust. 15PART 1: TPI objectives OBJECTIVE 1 – PARTNERSHIP The formation of a partnership is the first step in the TPI journey. Under the first objective, two or more institutions come together to agree upon a common goal and define the partnership priorities which they hope will result in sustainable improvements at the health facility. Building on the APPS definition of partnership, which encompasses a sociological perspective focusing on the interaction of people, TPI has identified several values essential in building successful partnerships (1). These are: 1. collaborative relationships 2. trust 3. equality 4. mutuality 5. shared accountability 6. transparency. Building on the TPI values and the APPS partnership definition, the TPI principles below can be applied when implementing a partnership4. These principles can provide a foundation for forming and maintaining an effective and sustainable partnership. Shared vision and joint planning • Coordination and mutual agreement in setting objectives, time frames and an approach to evaluation. • Co-developing and establishing partnership plan and activities. • Mutually agreeing on key performance measures to assess impact. 4 These are a set of principles that have emerged from previous part- nerships but should be adapted to the context of each partnership. It is important and useful to recognize similar partnership princi- ples that have been established by a range of organizations (e.g. THET; ESTHER Alliance for Global Health Partnerships). Definition of partnership “A partnership can be defined as a collaborative relationship between two or more parties based on trust, equality and mutual understanding, for the achievement of a jointly agreed goal. Partnerships involve risks as well as benefits, making shared accountability critical.” ~APPS, 2009-2011 16 Partnership Preparation Package Ownership • Ensuring that ownership is supported by each arm of the institution and not individuals. • Involving and engaging stakeholders by developing an effective stakeholder strategy that emphasizes roles, responsibilities and commitments. • Strategizing and planning for the involvement of all levels of the health system. Good relationships • Building relationships based on trust, non- judgement and commitment. • Harnessing the passion and power of individuals. • Respecting and understanding local rules, culture and customs. Good communication • Communicating effectively to facilitate decision- making and information-sharing. • Agree on and securing channels for decision- making. • Clearly identifying focal points5 and the roles of each team member. Ways of working • Nurturing individuals to be self-motivated and considering the value of having a good sense of humour. • Building transparency, flexibility and adaptability into the partnership (while keeping an eye on the changing external environment). • Celebrating what went well and modifying what has not gone well. 5 Focal point can be defined as the designated or referent person serving as a coordinator of information related to a project, a pro- gramme or a specific activity. 17PART 1: TPI objectives The power of partnerships There is a growing understanding that health partnerships work in synergy to yield powerful results – the combined efforts often having greater impact than work in isolation. Both arms of the partnership benefit6 from learning about innovative practices coming from unique and unexpected sources. Sometimes this leads to lower costs for the same or better outcomes. For example, the partnership between Church of Uganda Kisiizi Hospital and Countess of Chester Hospital NHS Foundation Trust maximized the local resources and was able to obtain alcohol from local agriculture to produce hand-sanitizer. This innovative approach exposed and sensitized both arms of the partnership to “out of the box” thinking in order to make improvements. 6 More information about benefits for each partner can be found here: https://www.ache.org/pdf/nonsecure/White-Paper-International-Hos- pital-Partnerships.pdf “We were able to move faster towards our goal than we would have on our own” (5). ~Dr Emanuel Addo- Yobo, Komfe Anokye Teaching Hospital, Ghana APPS Partnership Strength Survey, 2012. SDG 17 Revitalize the global partnership for sustainable development (6). Targets relating to TPI • SDG Target 17.6: “Enhance North-South, South-South and triangular regional and international cooperation on and access to science, technology and innovation and enhance knowledge sharing on mutually agreed terms, including through improved coordination among existing mechanisms, in particular at the United Nations level, and through a global technology facilitation mechanism.” • SDG Target 17.9: “Enhance international support for implementing effective and targeted capacity-building in developing countries to support national plans to implement all the sustainable development goals, including through North-South, South-South and triangular cooperation.” 18 Partnership Preparation Package Partnerships and the global goals The twinning partnership approach provides a link between local institutional change, national health systems and the global arena. The SDGs acknowledge the importance of partnerships (Objective 17) by recognizing that partnerships help to “mobilize and share knowledge, expertise, technology and financial resources.” The SDG goes further to highlight that “a successful sustainable development agenda requires partnerships between governments, the private sector and civil society. These inclusive partnerships built upon principles and values, a shared vision, and shared goals that place people at the centre, are needed at the global, regional, national and local level” (6). Linkages with multiple SDGs are evident, particularly 3.8 on UHC, but a range of others are clearly evident too. For example, a partnership approach can contribute to the reduction of maternal mortality ratio (SDG 3.1) by improving the quality of care for mothers.7 While TPI focuses on local, front-line improvements in the quality of health services, the compounding results from all partnerships around the world can lead towards global cohesion and overall impact. It is important to note that the benefits produced by twinning partnerships not only enhance institutional capacity to deliver improved health services, but also contribute to strengthening of the entire health system, if designed and implemented effectively. OBJECTIVE 2 – IMPROVEMENT Improvement is at the core of the partnership. In general, improvement focuses on the act or process of making something better. In hospital settings, improvement implies organizational and structural change, in addition to a necessary change in attitudes and behaviour, very often - all of which makes this process complex since it involves people and often requires a culture shift. Gaps existing in quality of care within health care facilities should be agreed 7 Royal College of Midwives and Ugandan Midwives Association. Case study in THET: https://www.thet.org/case-studies/aligning-partner- ship-plans-institutions-strategic-plan-2/ 19PART 1: TPI objectives Partnership development and continued strengthening – Japan and Liberia The Partnership between Nagasaki University Hospital (NUH), Japan, and Tellewayon Memorial Hospital (TMH) in Lofa County, Liberia, was formed in August 2016. At the time, TMH was recovering from the West African Ebola outbreak of 2014 and relying on international support to reactivate its essential health services and moving forward with recovery efforts in alignment with national recovery plans. During the recovery at TMH, it was quickly realized that the impacts of the Ebola response had depleted many resources and that extensive work was needed in order to improve quality. NUH saw that the needs at TMH were extensive and agreed to form a partnership with TMH. The Ministry of Health and the County authorities in Liberia supported this partnership at the onset of the formal TPI agreement. Careful consideration was given to the architecture of the partnership, recognizing the distinct culture and context of the respective partners. Principles and definition of partnerships were carefully considered in recognition that success of the partnership would depend on the foundations developed in the early stages. This proved pivotal in the roll-out of the partnership. Moving forward from this initial partnership, a situational assessment and gap analysis were completed at TMH in October 2016. Following the gap analysis, an official “action planning” meeting took place in December 2016 where both partners agreed to improve infection prevention and control, with specific attention being given to hand hygiene and waste management. It was noted that by improving these two areas, the foundation could be created for overall quality improvement throughout the whole hospital. The partnership undertook two partnership exchange visits in Liberia and Japan respectively. The principles of the partnership were reinforced throughout while the improvement work proceeded. The bi-directionality of the partnership learning was emphasized. For example, the TMH team leader gave a talk about their experience in the Ebola response. NUH stated they benefited greatly from because they learned about the realities of diagnosis and treating Ebola affected patients. 20 Partnership Preparation Package upon. Based on these identified gaps, one or several priority action areas are identified to steer the focus of the partnership. The ultimate aim is to improve the quality of care and overall health outcomes through the successful implementation of interventions using effective improvement methods. Both arms of the partnership need to establish common goals and priorities in order to develop a strong, effective and sustainable partnership. Additionally, when defining areas of improvement, it is necessary for the focus to involve and engage local stakeholders, teams and individuals within the health system who will be the ones to sustain the efforts put forth by the partnership. Objective 2 involves the following necessities. • Both arms of the partnership needing to jointly agree on improvement entry points. This collective approach promotes an atmosphere of ownership, learning and innovation through a safe space supporting an open mind-set, the use of skills and an opportunity to work and learn together. • Achieving common goals set between partners. This includes defining clear targets, agreeing on the best methods of spread, setting clear reporting mechanisms and monitoring standards, methods and ways of working. • Coordinating the implementation of improvement activities through regular contact supported by a communication plan that holds people accountable for their own work. • Testing several changes until a desired process that leads to a desired outcome is achieved, allowing for a certain degree of flexibility, permitting necessary changes and adaptations. The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches to improvement. Areas of improvement can include a variety of service delivery and clinical care areas influenced by the baseline assessment, Improvement “The combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning).” Batalden, P. B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? Quality & Safety in Health Care, 16(1), 2–3. https://qualitysafety.bmj. com/content/16/1/2 21PART 1: TPI objectives such as infection prevention and control (IPC), patient safety, and specific clinical services. Examples abound but the unifying concept is that improvement in service delivery needs to have a direct and lasting impact on the quality of the entire health system8. The linkages between service delivery and health workforce are clearly evident. The inter-relatedness with each of the health system components is highlighted through all partnership action. In the example below, the partnership in Ethiopia illustrated how improvements in both service delivery and clinical care at the facility level have had a direct impact on the wider health system. Ultimately, achieving quality at the facility level can bring balance and improvements to the entire health system. OBJECTIVE 3 – SPREAD Spread allows for sharing and scale-up of improvement experiences and learning within the local and national health system, and beyond (7). This enhances the reach and impact of the partnership by sharing what did and did not work well. When considering Spread, a strategy to help document successful experiences should be developed and early conversations should be held on the following topics: (1) What are the new and creative health service improvements that have been made? Spreading the emerging success stories of improvement can help drive large scale spread. (2) What are the ways in which this improvement will be sustained? A way to sustain improvement is to allow sufficient time for new practice to become fully integrated as the standard (e.g. incorporating new practices in policies, procedures, job description, etc.). (3) How was the improvement made? For example, demonstrating the benefits and advantages arising 8 A health system has traditionally been described by WHO as comprised of six building blocks which include: leadership and governance; health information systems; health financing; essential medical products and technologies; human resources for health; and service delivery. Improvement – Gondar, Ethiopia and Leicester, England The partnership formed between the University of Gondar Hospital, in Ethiopia and the University Hospital of Leicester NHS Trust, in England, aimed to implement the WHO Surgical Safety Checklist in the operating theatres of Gondar Hospital. Through regular audits, staff feedback and multidisciplinary learning sessions, the monitored results showed that the Checklist had successful implementation, compliance and adherence among staff. Additionally, there was consistent focus on joint learning and participation which helped to build research capacity. This resulted in a multi-country research project to look at Checklist implementation in a partnership context. After monitoring the implementation of the Checklist programme, it was found that its use rose from 17% to 53%, with a 100% application in emergency procedures. Multi-professional groups are now trained in its use. Importantly, the research also provided an opportunity to critique the work of the partnership and enable further improvements. Of note, this long-standing partnership benefitted from the support of both THET and WHO (8). 22 Partnership Preparation Package from a new practice encourages both spread and sustainability. (4) Who is the target audience of the Spread? In considering the target audience, it is important to acknowledge if the spread will focus on individual buy-in, whole facility buy-in, or entire health system adoption. These details help to organize and structure a plan to disseminate the information and experiences of success. The work of the partnership, particularly in relation to spread, needs to take careful account of the national strategic direction on quality, where this exists. Many countries are now developing or refining national quality policies and strategies. The formation of these policies and strategies can be informed by experiences that emerge from twinning partnerships. When these national strategies already exist, the work of the twinning partnerships should be carefully aligned with the national direction. This allows the effort of the partnership to have maximal impact by supporting implementation of a nationally owned drive for quality. The initial situational assessment can identify the national quality direction and both arms of the partnership need to be fully aware of this at all stages of the partnership. Spread can be considered in three ways - horizontal, vertical and spontaneous (7)(9). From the onset of the partnership, the following should be considered. 1. As soon as partners begin planning for health facility improvement, spreading this improvement should also be discussed. 2. Consider broadcasting your improvement message through different channels, such as conferences, professional journals, media, word-of-mouth and first-hand accounts. 3. Make it as appealing as possible for others to want to copy your improvement. 4. Build a network to sustain and grow spread. 23PART 1: TPI objectives 5. Finally, consider, at the outset, how the experience arising from this project could be used to feed into learning systems, both at the national and global levels. Horizontal spread refers to spreading improvement across people and organizations within the same level of a health care system. An example of horizontal spread is replicating improvements from one unit in a health facility to another. Vertical spread refers to spreading the information and improvement efforts throughout the national, subnational and local levels of a health system. Vertical spread is particularly important because while national level can drive local change, local can also drive national level change. It is important to collect quantitative data and analysis of the improvements as it lays the groundwork for evidence-based practice and can be a critical component of vertical spread, and thereby influence changes in policy. Spread requires strong connections between quality improvement evidence in conjunction with both facility and national quality policies. This evidence and clear alignment with existing policy could help to facilitate the improvements made from TPI into facility and national quality policies. Spontaneous spread, is not planned for, but can spontaneously occur through informal channels such as social networks, or opinion leaders, which sometimes cross country’s borders. An example of spontaneous spread is the engagement that occurs between partnership facility leaders and key influencers within the health system. The power of human interaction and storytelling – often in informal meetings and gatherings – in achieving change then becomes clearly evident. Of further note is the necessity to consider the spread of ideas, competencies and skills from low-income countries to partners in high-income countries. This is inherently related to concepts of mutuality that are enhanced through partnerships. 24 Partnership Preparation Package The critical role of the community Involving patients and communities can stimulate spread and strengthen implementation and the sustainability of improvement programmes. Connecting with the local community can improve the quality of care and make services more people- centred. This is particularly important in low-resource settings where demand for health care is high. Co- developing health services around the needs of patients and the community, by empowering patients and communities by informing them and giving them the ability to make decisions in order to instigate change, can enhance the patient’s experience, health outcomes, confidence and trust in health care providers (10). Ideally, patient, family and community engagement should be part of all national health plans. In the absence of a formal mechanism to engage patients and the community, health care workers can carry out simple actions to engage them, such as providing practical training (e.g. on hand hygiene, waste management, use of medicines, etc.), invite patients’ representatives or community leaders to participate in orientation meetings and provide on- going support. Advocating for the partnership and the successes achieved will promote the work and lead to further interest within communities. This work can be celebrated and advertised to maintain motivation and create a positive atmosphere. When community spread occurs, the knowledge generated through an improvement process in the health care facility becomes part of normal practice and standards that have positive implications for the population’s health, e.g. hand hygiene improvement. The example below highlights horizontal and vertical spread. Spread - Yagaldo Ouedraogo Hospital, Burkina Faso and Montpellier Hospital, France Yagaldo Ouedraogo Teaching Hospital in Burkina Faso started partnering with the Teaching Hospital of Monpellier in France, and implemented a pilot project to improve hygiene in the neurosurgery ward in 2013. The objective was to meet the standards of hospital hygiene in this specific ward. Four areas were targeted: hand hygiene, waste management, management of nosocomial infections and capacity-building of health workers. The idea was to concentrate efforts on the selected activities in one of the wards of the hospital in order to understand what kind of improvements could then be replicated in other wards and units of the hospital. Improvement was spread horizontally, making the entire facility benefit. Furthermore, convinced of the advantages of partnerships work, Expertise France secured support from the European Commission to spread this improvement to other health care facilities across the country. Nine partnerships involving national and regional hospitals have been implemented since February 2017 with positive implications for the entire health system of Burkina Faso. Thus, horizontal and vertical spread is taking place simultaneously (11).
PART 2: OVERVIEW OF THE 6-STEP CYCLE T he partnership approach is a step-wise approach which facilitates the development of partnerships, the systematic identification of gaps and the development of an action plan and evaluation cycle. 1. Partnership development begins the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions. Both arms of the partnership agree to work together to improve the quality of health care. 2. The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership. 3. The gap analysis involves a review of the needs assessments and reveals key priority areas for action. From the gap analysis, the foundation for action planning is established in a systematic way, in order to help partners to implement a more focused improvement effort. 4. Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long-term targets for the twinning partnership. In this step, it is important to look at communication, spread and budget. 5. Action is the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. 6. Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. A variety of tools and resources are available (Annex 2) to support each step and will guide the partnership implementers throughout the process. PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE A t each step of the cycle, one or more tangible outputs or deliverables to work towards is expected. These outputs are designed to help the TPI partnership move the action forward. To assist partners, a list of supportive tools and resources is provided in annex 2. Implementing organizational and structural change is often complex, because in many cases it involves people and a cultural shift needs to take place. For this reason, when seeking appropriate tools for any given technical action area, it is important to consider how they can support planning for the partnership activities, their implementation, and in addition important cross-cutting themes, such as community engagement, knowledge management and communication/advocacy. It is also important to consider the broader national context, policies, frameworks and national strategic priorities and existing initiatives in planning twinning activities. Technical improvements must align with national policies and strategies. This will be particularly important in achieving objective 3 and spreading the experience from the twinning partnership improvement process both in the short and long term. STEP 1: PARTNERSHIP DEVELOPMENT This is the beginning of the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions (1)(4). Both arms of the partnership agree to work together to improve the quality of health care, focusing on different aspects of service delivery, including clinical care. A requirement of successful partnership implementation is to have a stable funding structure. This has to be defined from the beginning, as the activities that the partners will undertake will depend on the availability of human and financial resources (4). Partnerships established through international cooperation9 can benefit from direct funding of one arm of the partnership. In other cases, partners can agree to share the costs or compete successfully for external funds. This requires the partners working together to identify potential sources of funding and develop joint proposals. Whatever model of funding is applied to implement the activities of the partnership, it is vital that partners agree on clear systems and procedures. Main activities 1. Secure formal management and leadership agreement on both sides of the twinning partnership to take joint action. This can be done through a written statement of understanding across the institutions, such as a letter of commitment. 9 The concept of international cooperation makes reference to the interaction of persons or groups of persons representing various nations, in the pursuit of a common goal or interest. Outputs or deliverables 1. Exchange of letters between institutional management as required (it can be a letter of commitment or a Memorandum of Understanding). 2. Agreement on a definition of the twinning partnership. 3. Team members on each arm of the partnership selected and contact details exchanged. 4. Communication plan drawn up. 5. Kick-off meeting notes indicating potential areas of work, next steps and a tentative date for conducting the needs assessment. 6. Official designation of a lead and deputy trained in the approach using the outline provided in this preparation package. Core resources for Step 1 – Partnership (see annex 2) 30 Partnership Preparation Package 7. Identify a twinning lead and deputy at each partner institution. Ideally the Quality Improvement Officer should be the designated lead. In the absence of a Quality Officer, a focal point responsible for quality and safety can be designated instead. 8. Ensure the engagement of multi-disciplinary staff committed to being part of the “improvement team”. For example, a dedicated person that collects data and monitors evaluation activities. Involving motivated staff will make the change process happen smoothly and positively influence staff who resist change. 9. Consider the suggested definition of partnership; refine and agree on it across the twinning partners as a foundation for moving forward. 10. Negotiate with managers to secure protected time for the improvement team to work on the identified technical action areas. 11. A kick-off meeting with the twinning teams is recommended for the teams to get to know each other. If an in-person meeting is not possible, the alternative is a virtual meeting. 12. Establish a schedule of regular communication (a minimum of once a month is recommended) using a variety of methods (telephone, SMS, text messaging, email, skype, etc.). 13. Establish a budget for the planned activities, including overheads. STEP 2: NEEDS ASSESSMENT The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership.10 10 For an example of a “How To” tool developed for the TPI partnership situational analysis between NUH and TMH, see annex 3. Core resources for Step 2 – Needs assessment (see annex 2) 31PART 3: Digging deep - Putting the 6-Step cycle into practice Main activities 1. Conduct a desk review on existing national, sub- national and institutional documents on quality of health services. Possible documents include: national health sector policy/plan, national quality policy or strategy. 2. Identify experienced and motivated leads to coordinate the assessment, as well as their assessment team members. The composition of the team will depend on the scope of the assessment, the time and resources available. Ideally the team should include a member from the district health management, the health care facility management and an expert of the technical area to be assessed. 3. All members of the assessment team should be briefed before starting the assessment and have an overview of the expected results of the exercise, including the data collection process. 4. Communicate to other facility staff about this exercise as it requires the collaboration of other teams when collecting data, ensure buy-in from the start and discuss confidentiality. 5. Undertake a specific needs assessment within the selected technical area using appropriate assessment tools. Examples of themes that could be assessed are: a. infection prevention and control b. patient safety and health worker safety c. essential surgical care d. waste management e. Water, sanitation and hygiene (WASH) f. maternal and newborn care g. health workforce. 6. Consider the use of a standardized tool to complete the needs assessment. See annex 3, as an example of the tool developed and then used for the TMH needs assessment. Outputs or deliverables Completed baseline and situational analysis report appropriate to technical area of focus. 32 Partnership Preparation Package Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. Core resources for Step 3 – Gap analysis (see annex 2) 33PART 3: Digging deep - Putting the 6-Step cycle into practice Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. 7. Outline specific steps that can be taken to fill the gaps. 8. Organize a meeting with senior leadership to secure endorsement and approval of the findings of the gap analysis and the priority areas identified. Quality Improvement (QI) at the core of TPI The TPI Preparation Package outlines all six steps and provides support and guidance for initiating the partnership and prioritizing which areas in service delivery or care need improvement. In addition to this TPI Preparation Package, a detailed practical field guide entitled “Taking Action: Steps 4 and 5 for Twinning Partnerships for Improvement” can be read alongside the overview of Steps 4 and 5 below. “Taking Action” dives into QI models and approaches and supports the planning, action, implementation, and guidance of QI within partnerships. “Taking Action” reviews the theories of practical application of action in a partnership and can be used by any QI team that has identified a quality challenge, specific needs and current gaps in services; and also that is ready to develop targeted action plans for intervention and improvement in health care setting. The “Taking Action” document also includes a list of common barriers and key factors for successful quality improvement gathered through the WHO Global Learning Laboratory for Quality UHC. The seven countries which provided feedback on common barriers and key factors for success included India, Malawi, Mexico, Nigeria, the United Kingdom, Venezuela and Zimbabwe. The feedback provided critical insights from the front line on the challenges and opportunities for quality improvement at the facility level. For additional information and for the common barriers and key factors, please refer to “Taking Action: Steps 4 & 5 in Twinning Partnerships for Improvement.” For additional information on the WHO Global Learning Laboratory, visit: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/ 34 Partnership Preparation Package STEP 4: ACTION PLANNING Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long- term targets for the twinning partnership (12). In this Step, it is important to also consider matters related to communication, spread and budget.12 Main activities 1. Hold a team meeting at the partnership facility • Identify and confirm the key team members at the partnership facility: • Facility leader or manager to endorse the partnership • QI team leader with dedicated time for the project • Technical/clinical/subject matter expert • Measurement and evaluation leader • Community/patient representative • QI team staff to provide technical and administrative support • Ensure consensus and common understanding of key definitions • Outline preparation activities • Review activities taken to date on Steps 1 to 3 of 6-Step Cycle • Ensure team is prepared with priority areas already identified • Assess ground level interest and capacity • Estimate expected costs in terms of personnel, time and money. 2. Agree on an intervention • Review evidence for possible interventions, focusing on improved outcomes • Seek relevant resources on all relevant 12 For an example of action planning templates, see Annexes 4-6 Core resources for Step 4 – Action Planning (see annex 2) 35PART 3: Digging deep - Putting the 6-Step cycle into practice literature on the subject area • Consult with experts on site and at partnership sites • Consult with other health workers • Select intervention with largest benefit, lowest barriers to use, and greatest potential for sustainability • Carefully consider how technical exchanges can support the intervention • Note sustainability of interventions post-partnership • Break down interventions into necessary behaviours, structural and procedural changes. 3. Outline implementation activities • Outline implementation plans • Summarize roles and responsibilities for implementing various aspects of the intervention • Identify local barriers to implementation and design accordingly13 • Engage stakeholders to identify potential concerns • Identify needs based on local context • Identify potential gains and losses associated with implementation • Evaluate current communication methods and adapt as needed. 4. Outline roles and ensure capacity • Estimate expected expenditure • Estimate costs/time for team members • Estimate costs/time for supplies/ equipment • Estimate amount of inputs and capacity available 13 For a list of common barriers, see Taking Action Steps 4&5. 36 Partnership Preparation Package • Determine roles and responsibilities of each team member and how they will contribute to the improvement aim • Ensure protected time and support for staff • Obtain the necessary approval from the facility leader to protect time for key staff • Designate an administrative support person or other assistance • Ensure clear roles are defined for team members in the partnership institution and communicated clearly across the partnership. 5. Outline monitoring and evaluation activities • Outline monitoring activities • Examine hospital epidemiology and existing measures taken by hospital • Identify key indicators of success in implementation • Identify key methods for collecting evaluation data • Outline evaluation activities • Identify key indicators of outcomes • Identity key methods for collecting evaluation data • Strive for simplicity in evaluation and monitoring • Consider benchmarking success from other hospitals in similar contexts. 6. Complete written action plans • Share preliminary plans – ensure teams in partnership health facilities are in agreement • Schedule a series of partnership visits with defined objectives, including twinning partner, other partners, country/WHO lead (if applicable) • Agree on a schedule of partner progress reports (see annexes 4-6). Outputs or deliverables 1. Complete written 2-year Partnership Plan 2. Complete written 6-month initial short-term action plan. 37PART 3: Digging deep - Putting the 6-Step cycle into practice STEP 5: ACTION Action marks the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. Reviewing progress every six months will allow corrective measures to be taken, if needed. The improvement team should carry out regular and planned monitoring reviews using the indicators previously defined. During this action stage, a method for tracking the budget is advised (12). Main activities 1. Put Partnership Plan into action with partners • Ensure continuous consensus in action between partners • Ensure continued alignment with national and sub-national efforts to strengthen quality of health services • Ensure that partners working within the same facility are continuously aware of improvement activities • Align existing improvement efforts already under way at the facility level • Mark the moment of initial action on both arms of the partnership • Choose a date. 2. Manage the implementation of activities • Set up a regular schedule for the QI team to share updates on progress of the project • Ensure methods are used to make data regularly visible to staff • Ensure involvement across the institution, including staff members not directly involved in the specific improvement intervention • Ensure regularly scheduled communication across the partnership on implementation activities. 38 Partnership Preparation Package 3. Coach the team to implement the QI activities • Provide facilitation and QI methods training for QI team leader • Provide mentoring, coaching and general on-site QI support using all assets available (local- and partnership-based) • Build in time for QI knowledge transfer from the team leader to team during team meetings, with the intention of creating cohorts of health workers who can act as catalysts and mentors. 4. Implement the quality initiatives and test changes • Implement intervention • Measure performance through small test of change – PDSA cycles or other agreed methods • Keep track of progress against the planned activities and budget • Make adjustments to intervention based on information received, e.g. outcomes and feedback in response to small test of change • Document issues that arise in a log, and how they were tackled • Set up rapid response mechanisms for trouble-shooting with partners. 5. Assess and refine the interventions • Implement review every six months • Develop interval reports • Adjust team efforts accordingly • Adjust any changes due to staff turnover, need for capacity-building, or need for re-training or training of additional staff • Report back to the partnership on issues that arise14 14 For an example of a partnership that confronted failure, see annex 1. 39PART 3: Digging deep - Putting the 6-Step cycle into practice • Celebrate small or large victories on both arms of the partnership. 6. Share learning and spread changes • Continuously refine change until ready for implementation on a broader scale • Implement a spread plan, taking careful consideration of sub-national and national contexts • Spread changes, taking a successful implementation process from pilot and replicating change throughout the organization • Identify opportunities to use partnership activities to bring about change in other institutions, encouraging national spread. 7. Document and disseminate the improvements observed • Distil the change stories • Distil learnings on implementation by developing knowledge products15 such as knowledge briefs and action briefs • Synthesize any learning to have emerged from one arm of the partnership that benefitted the other arm, emphasizing the bidirectional nature of learning • Disseminate a progress report using appropriate bodies at national, subnational and local levels to maintain to maintain dialogue and connection to overall national plans. 15 Visit the WHO Global Learning Laboratory for more information on Knowledge Briefs. Outputs or deliverables 1. Develop a series of reports outlining action and progress in partnership plan 2. Conduct mid-term review of implementation activities. 40 Partnership Preparation Package STEP 6: EVALUATION Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work (against their baseline) and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. Monitoring and evaluation are key components for a successful partnership and must be implemented from the outset of the partnership cycle (13). This step marks the closure of the cycle and allows the partners to review and assess how well the partnership has met its objectives, but also the partnership’s true impact. The evaluation is the final stage, but the monitoring has taken place thorough the cycle and the results will inform the overall assessment. In addition to local review meetings and partnership discussions, each twinning partnership provides periodic monitoring reports (6-month reports; 1-year repeated baseline assessment; and a 2-year review). Some suggest an external evaluation by specialists to ensure objectivity and others suggest using the teams within the project to gather optimal learning. A combination of the two approaches can generate better results and partner satisfaction (13). Whatever is decided, the partners should be involved in the exercise; specialists should be responsible for certain aspects of the evaluation, and the evaluation and monitoring process must be planned for at the beginning of the partnership. By including the three objectives as an underpinning structure of the evaluation, a successful evaluation reflects on the strength of the partnership, the priority areas of improvement, along with its spread. Main activities Initial evaluation planning activities should be conducted in earlier parts of the 6-step partnership cycle. This planning activity should include consideration of: Core resources for Step 6 – Evaluation and Review (see annex 2) 41PART 3: Digging deep - Putting the 6-Step cycle into practice • key indicators on the effectiveness of the improvement effort • assessment of partnership strength • spread beyond the partnership • training on evaluation approaches for those involved in the partnership • periodicity of reporting. Evaluation activities are conducted throughout the 6 steps. Step 6 is focused on activities to synthesize findings, as well as conducting any necessary assessments. 1. The partners together review the monitoring reports and decide how to synthesize evaluation (collection of statistical data, interviews, focus group, surveys, etc.) 2. Synthesize findings from key indicators that demonstrate effectiveness of the activities conducted, as well as the long-term impact of the partnership. 3. Prepare an evaluation report based on the actions outlined in the partnership plan (and informed by appropriate evaluation tools). 4. Reflect on the success of the evaluation training. 5. Conduct a repeat of the baseline assessment/ situational analysis to consider progress. 6. Conduct assessment on the strength of the collaboration. 7. Conduct assessment of the spread activities. 8. Synthesize all findings and agree on key lessons learned (consider limiting to top ten). 9. Prepare an evaluation report to demonstrate impact and to advocate for financial support. The reports will focus on the achievement of project outputs and outcomes. 10. Disseminate findings internally and externally. Outputs or deliverables 1. For a 2-year project, three monitoring reports should be generated and shared across the partnership and with hospital leaders outlining action and progress towards achieving the Partnership Plan (at 6 months, 1 year and 2 years). 2. Repeated baseline assessment/ situational analysis. 3. Evaluation report KEEPING THE LEARNING GOING T here have been notable successes among the hospitals and health systems that have participated in partnership-based approaches to improvement. These include sustained partnerships, co-developed products and programmes and spread. It has become clear, that in many cases, neither the technical experts from high-income settings, nor the local providers from low-income institutions have sufficient knowledge and know- how to affect improvements. Strong, trusting, inter- institutional partnerships are therefore needed to co-develop solutions that can lead to success and spread. Linkages with national efforts to enhance quality are key to successful cascading of learning for maximal impact on health outcomes. The 6-Step Partnership Improvement Cycle and the TPI Preparation Package provide a practical blueprint for action. It should be noted, however, that each partnership is different - adaptation will invariably be required. Learning will certainly emerge, and this document will also be improved over time. Quality improvement is still an evolving science, and humility is essential for partners on all sides of the TPI. Indeed, successful partnering is rewarding for all those involved. There is much to be learned about how to apply the principles and practices of quality improvement to strengthen the delivery of health services and build resilient health systems in developing countries, yet, lessons also flow back to the so-called developed world. The prototype partnership between Tellewoyan Memorial Hospital in Liberia and Nagasaki University Hospital in Japan proved invaluable in informing the design of the larger TPI initiative. The experiences from this and other efforts will help refine the different approaches to quality improvement. These experiences can also inform and be informed by wider efforts on quality, which have become increasingly prominent in the context of continued advancement of global efforts to achieve universal health coverage. Resources are limited, and continued global learning about quality improvement will depend on the sharing of knowledge, experiences and ideas. Entities such as the WHO Global Learning Laboratory (GLL) for Quality UHC can foster such sharing. The GLL is also a space where successes can be celebrated and knowledge, experience, and ideas shared. Sometimes there is failure, but resilience is needed to find a way to succeed – a huge body of learning resides in these initial failures. The words of Benjamin Franklin ring true - “Tell me and I forget, teach me and I may remember, involve me and I learn.” That is the power of human interaction that lies at the heart of a partnership. REFERENCES 1. African Partnerships for Patient Safety. Improving Patient Safety Partnership Preparation Package. A resource for all health partnerships committed to strengthening patient safety. Geneva: World Health Organization;2012. (http://www.who.int/patientsafety/ implementation/apps/resources/preparation_package_ EN.pdf?ua=1, accessed 24 June 2018). 2. Twinning Partnerships for Improvement. Recovery Partnership Preparation Package. Building capac- ity to reactivate safe essential health services and sustain health service resilience. Geneva: World Health Organization;2016. (http://apps.who.int/iris/bit- stream/handle/10665/206542/WHO_HIS_SDS_2016.3_eng. pdf;jsessionid=0D0AEC895C8BD6F8D8D192A3236F89B- F?sequence=1, accessed 24 June 2018). 3. Lewis L, Williams C, Jackson L, Caffarella R, edi- tors. Experiential Learning: A New Approach. San Francisco: Jossey-Bass;1994:5-16. 4. Successful partnerships a guide. OECD LEED Forum on partnerships and local gover- nance. (https://www.oecd.org/cfe/ leed/36279186.pdf, accessed 24 June 2018). 5. Partnerships for safer health service delivery: Evaluation of WHO African Partnerships for Patient Safety 2009-2014. Geneva: World Health Organi- zation;2015. (http://www.who.int/ patientsafety/implementation/apps/ evaluation-report/en/, accessed 26 June 2018). 6. Sustainable Development Knowledge Platform. Sustain- able Development Goals. Unit- ed Nations. (https://sustainablede- velopment.un.org/, accessed 24 June 2018). 7. African Partnerships for Pa- tient Safety Spread Pack. Improvement series. Geneva: World Health Organization; 2012. (http://www.who.int/pa- tientsafety/implementation/apps/ resources/APPS_Improv_Spread_ Pack_2012_04_EN.pdf?ua=1, ac- cessed 13 April 2018). 8. African Partnerships for Patient Safety. Building Momentum for Safer Health Care. Gene- va: World Health Organiza- tion;2012. (http://apps.who.int/ iris/bitstream/handle/10665/78043/ WHO_IER_PSP_2012.7_eng.pdf?se- quence=1, accessed 24 June 2018). 9. Greenhalgh T, Robert G, Bate P, Kyriakidou O, Macfarlane F, Pea- cock R. How to Spread Good Ideas. A systematic review of the literature on diffusion, dis- semination and sustainability of innovations in health service delivery and organisation. Re- port for the National Co-ordi- nating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). 2004. (http://www. netscc.ac.uk/hsdr/files/project/ SDO_FR_08-1201-038_V01.pdf, ac- cessed 20 June 2011). 10. WHO Community engage- ment Framework for Quality, People-Centres and Resilient Health Services. Geneva: World Health Organization;2017. (http://apps.who.int/iris/bitstream/ handle/10665/259280/WHO-HIS- SDS-2017.15-eng.pdf?sequence=1, accessed 20 June 2018). 11. Partenariats Africains pour la Sécurité des patients. Rapport d’évaluation des partenariats hospitaliers pour la sécurité des patients entre la France et l’Afrique. Genève: Organisation Mondiale de la Santé;2017 (http://www.who.int/patientsafety/ implementation/apps/evaluation-re- port/fr/, accessed 20 June 2018). 12. Taking action: steps 4 and 5 in twinning partnerships for improvement for health care facility managers, quality im- provement teams and insti- tutional health partnerships. Geneva: World Health Organi- zation;2018. (http://www.who.int/ servicedeliverysafety/twinning-part- nerships/steps4-5/en/, accessed 19 July 2018). 13. EQUAL Partnership Develop- ment toolkit. European Com- mission. Directorate-General for Employment, Social Affairs and Equal Opportunities ; 2005 (http://ec.europa.eu/employment_ social/equal_consolidated/data/doc- ument/pdtoolkit_en.pdf, accessed 13 April 2018). ANNEXES ANNEX 1 Case study - Adjusting action when it’s not working Developing a culture of learning in Malawi16 Partnerships work together to identify what works, what does not and what can be learned from this. The Zomba Mental Health Services (Malawi) partnered with the Department of Health Sciences at the University of York (UK) and worked together on a project designed to strengthen the system of community mental health care in Zomba District, Malawi. The project aimed to develop the role of local village-based health workers, known as health surveillance assistants (HSAs), through training and support, in delivering mental health interventions 16 This partnership was supported by THET. for the first time. Planning and delivery of the project involved key professionals in Zomba from mental health services and district health offices, as well as discussions with the HSAs. To collect data, the project manager of Zomba conducted visits to the village-based HSAs on a monthly basis. This allowed him to capture relevant data and discuss it with them. This process allowed them to engage HSAs in the project as a whole. “It enthused people, kept them motivated and interested, and kept the momentum of the project going. This wouldn’t have happened if we hadn’t built in face-to-face visits”, admitted the project manager. There were practical difficulties and the data required for monitoring and evaluation was not efficiently collected. The project manager of Zomba had planned to capture all data on his laptop on a monthly visits, but this proved too time-consuming. Having realized the data collection system was not working, the team agreed that paper copies of the data would be taken off-site between visits, and that the timescales should be allowed to slip. This affected the progress of the partnership improvements and the colleagues involved agreed to improvise and adjust the action planning. The project manager of Zomba believes that learning has been facilitated by the partners having respect for each other’s views and ideas, and making decisions collectively. “The UK partner was very supportive of our new ideas on the implementation of the work. This has helped the partnership to work better together for one common goal, evidenced in the successful results. In the process, the Malawi partners have gained knowledge and learnt skills, including in relation to good project and financial management, and analysis, interpretation and reporting of data.” Acknowledging problems allows partners to look for solutions and turn challenges into lessons learned. 48 Partnership Preparation Package ANNEX 2. TOOLS AND RESOURCES The tools and resources listed below aim to provide support in the development and execution of your action plan. The resources are diverse and span, not exclusively, advocacy, business/financial, guidance/policies/standards, templates, toolkits and selected academic publications. The resources are included after careful review of WHO materials. Inclusion of a resource is based on its perceived usefulness and also its availability. Inclusion of a resource does not imply endorsement by WHO of any specific organization associated with the resource. Many tools and resources that are applicable in hospitals can be accessed through the WHO website of Hospital of the XXI Century: http://www.who.int/hospitals/en/ Type of resource Location Starting a health partnership (THET) https://www.thet.org/wp-content/uploads/2017/09/How-to-start-a-Health-Partnership.pdf Example of letter of commitment http://www.who.int/patientsafety/implementation/apps/APPS_registration/en/ Example of memorandum of understanding https://www.thet.org/wp-content/uploads/2017/09/Memorandum-of-Understanding-Template. pdf La coopération internationale hospitalière – guide des bonnes pratiques. (French Hospital Federation) https://www.fhf.fr/Europe-International/La-cooperation-internationale/ Guide-cooperation-internationale-hospitaliere Guide de la coopération hospitalière pour l’aide au développement https://www.cultura.com/guide-de-la-cooperation-hospitaliere-pour-l-aide-au- developpement-9782859526849.html Successful partnerships, a guide of OECD https://www.oecd.org/cfe/leed/36279186.pdf Position Statement - Global Catalyst Group for Institutional Health Partnerships http://www.who.int/patientsafety/implementation/apps/global-catalyst-group.pdf Core resources for Step 1 – Partnership development 49Annexes Core resources for Step 2 – Needs assessment The needs assessment tools that you see below are not exhaustive. They were identified from the process undertaken by the partnership prototype between Tellewoyan Memorial Hospital and Nagasaki University Hospital. Type of resource Location Year of publication IPC and patient safety Situational analysis for patient safety. A tool to assess the current level of patient safety in a health care facility based on 12 action areas http://www.who.int/servicedeliverysafety/ twinning-partnerships/tools/en/ 2009, revised in 2015 WHO Hand hygiene Self-Assessment Framework. A critical first step in improving hand hygiene in a health facility is to complete this assessment http://www.who.int/gpsc/country_work/ hhsa_framework_October_2010.pdf 2010 Twinning Partnerships for Improvement. Situational assessment report: quality and patient safety- Tellewoyan Memorial Hospital and Lofa County Health System http://apps.who.int/iris/bitstream/10665/2 53523/1/9789241511872-eng.pdf?ua=1 2017 A tool for Infection prevention and control for supporting national implementation through effective baseline assessment and evaluation http://www.who.int/infection-prevention/ tools/core-components/ICPAT2.pdf 2017 Workforce Human Resource Management Rapid Assessment Tool for Public and Private-Sector Health Organizations http://www.lmgforhealth.org/sites/default/ files/HRM_Rapid_Assessment_Tool_0.pdf 2005 Guidelines: Incentives for health professionals. This underlines both financial and non-financial incentives as critical to ensuring effective recruitment, retention and performance of health workers across the world. http://www.who.int/workforcealliance/doc- uments/Incentives_Guidelines%20EN.pdf 2008 Water, sanitation and hygiene WASH FIT. A practical guide for improving quality of care through water sanitation and hygiene in health care facilities http://www.who.int/water_sanitation_ health/publications/water-and-sanita- tion-for-health-facility-improvement-tool/ en/ 2017 Health service delivery management Service availability and readiness assessment (SARA). A tool to assess and monitor service delivery in terms of availability and readiness of the health sector and to generate evidence to support the planning and managing of a health system http://apps.who.int/iris/bit- stream/10665/104075/1/WHO_HIS_HSI_ RME_2013_1_eng.pdf 2015 Situational analysis of quality improvement in health care, Tanzania. This analysis covers the current status of QI work, standards and their assessment, indicators for QI, methods and approaches in use, progress made, SWOC analysis. http://www.tzdpg.or.tz/fileadmin/ documents/dpg_internal/dpg_work- ing_groups_clusters/cluster_2/ health/Sub_Sector_Group/Quality_ Assurance/11.a_Situation_Analysis_of_ Quality_Improvement_in_Health_Care_ Tanzania_-_Final.pdf 2012 Essential sur- gical care Tool for Situational Analysis to Assess Emergency and Essential Surgical Care http://www.who.int/surgery/publications/ s15986e.pdf?ua=1 2012 50 Partnership Preparation Package Core resources for Step 3 – Gap analysis Type of resource Location Year of publication Gap analysis Implementing a gap analysis framework to im- prove quality of care for your patients. USAID case study showing a gap analysis step-by-step. https://www.usaidassist.org/sites/assist/files/ hci.ghc_gap_framework_workbook.14jun10_1. pdf 2010 Gap analysis AHRQ Quality indicators toolkit – Instructions for doing a gap analysis https://archive.ahrq.gov/professionals/systems/ hospital/qitoolkit/d5-gapanalysis.pdf 2012 Practical resource Twinning Partnerships for Improvement. Japan- Liberia Partner Planning Workshop Report http://www.who.int/servicedeliverysafety/twin- ning-partnerships/partnership-planning-report. pdf 2016 Core resources for Step 4 – Action Planning The WHO Recovery Toolkit, accessible here, is a library of guidance resources in a single place which can be quickly and easily accessed, to guide action. A key purpose of the Recovery Toolkit is to support countries in the reactivation of health services which may have suffered as a result of a large-scale emergency. These services include ongoing programmes such as immunization and vaccinations, maternal and child health services, and noncommunicable diseases. In addition, and because the Toolkit contains core information needed to achieve functioning national health systems, it also supports countries with implementation of their national health plans during the recovery phase following a public health emergency. Type of resource Location Year of publication Knowledge translation Translating evidence into practice: a model for large scale knowledge translation http://www.bmj.com/content/337/bmj. a1714 2008 Planning and implementation WHO planning and implementation of district health services http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 WHO implementation strategy and tools. A guide to implementation of the WHO Multimodal Hand Hygiene Improvement Strategy http://apps.who.int/iris/bit- stream/10665/70030/1/WHO_IER_ PSP_2009.02_eng.pdf?ua=1 2009 Implementation tools and resources for supporting facility and national level implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes http://www.who.int/infection-prevention/ tools/core-components/en/ 2018 Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Evidence-based guideline to support countries as they develop and execute their national antimicrobial resistance (AMR) action plans. http://apps.who.int/iris/bitstream/10 665/251730/1/9789241549929-eng. pdf?ua=1 2017 Planning and implementation of district health services. 10 steps in planning, essential health package, health systems research, disaster preparedness http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 51Annexes Tools for assessing the operationality of district health. A set of tools aimed at district health management teams to generate the information that will serve as a basis for improving the operationality of health districts http://www.who.int/management/dis- trict/assessment/assessment_tool.pdf 2003 WHO Safe management of wastes from health care activities. Provides comprehensive guidance on safe, efficient and environmentally sound methods for the handling and disposal of health care waste in normal situations and also emergencies. http://www.searo.who.int/srilanka/doc- uments/safe_management_of_wastes_ from_healthcare_activities.pdf?ua=1 2014 Sanitation Safety Planning (Implementation tool). Manual for safe use and disposal of wastewater, greywater and excreta. http://apps.who.int/iris/bitstre am/10665/171753/1/9789241549240_ eng.pdf?ua=1 2015 WHO - Workload indicators of Staffing Needs (WISN) – User’s Manual http://www.who.int/hrh/resources/ WISN_Eng_UsersManual.pdf?ua=1 2010 Association for Professionals in Infection Control and Epidemiology (APIC) HAI cost calculator: http://www.apic.org/Resources/ Cost-calculators Core resources for Step 6 – Evaluation and Review Type of resource Location Year of publication Monitoring and evaluation M&E planning tool for both implementing and reviewing M&E plans https://www.thet.org/resources/ hps-monitoring-evaluation-plan/ 2014 Evaluation FAQs Step-by-step guide for health partnerships to effectively carry out an evaluation of their projects and partnerships in the form of frequently asked questions. https://www.thet.org/resources/ health-partnerships-evaluation-faq/ 2014 APPS -Evaluation Handbook A guide to evaluate five domains of a partnership: situational analysis, partnership strength, patient safety improvements, patient safety spread and annual evaluation report http://www.who.int/patientsafe- ty/implementation/apps/ Evaluation-Handbook_EN.pdf?ua=1 2012 Monitoring, evaluation and learning Webinar: sharing of experiences to provide some reflections around M&E https://www.youtube.com/ watch?v=v_oHEvgE_aA 2016 Monitoring and evaluation Health partnership symposium on monitoring, evaluation and learning. Document gathering tips to understand the value of M&E. Examples and exercises are provided. https://www.thet.org/wp-content/ uploads/2017/09/Monitoring-and- Evaluation.pdf 2017 Monitoring and evaluation EFFECt tool stands for EFFective in Embedding Change. This tools focuses on assessing implementation best practice, embedding change and the added benefits to individuals and institutions using a partnership approach https://esther.eu/index.php/effect-tool/ 2017 52 Partnership Preparation Package Core resources for improvement Type of resource Location Year PDSA Cycle (Plan-Do-Study-Act) Systematic process for gaining valuable learning and knowledge for the continual improvement https://deming.org/explore/p-d-s-a 2018 Model for improvement The Model for Improvement, is a simple, yet powerful tool for accelerating improvement http://www.ihi.org/resources/Pages/ HowtoImprove/default.aspx 2018 Confronting staffing issues and turnover of health facility staff Understanding the barriers to setting up a health care quality improvement process in resource- limited settings: a situational analysis at the Medical Department of Kamuzu Central Hospital in Lilongwe, Malawi https://bmchealthservres.biomedcentral.com/ articles/10.1186/1472-6963-14-1 2014 WHO Multimodal Improvement Strategy A one-page visual describing the five-part multimodal strategy to support IPC improvement in a health care facility http://www.who.int/infection-prevention/publi- cations/ipc-cc-mis.pdf?ua=1 2017 53Annexes ANNEX 3. TPI SITUATIONAL ASSESSMENT “HOW TO” TOOL EXAMPLE Step 2: TPI Situational Assessment “How To” Tool The following “how to” tool is presented as a practical guide explaining steps to plan and execute an in-depth situational assessment to inform a twining partnership initiative between two interested partner institutions. This assessment seeks to provide a foundational basis for the co-development of an effective and sustainable twinning partnership between partner institutions. This “how to” tool informs the process of conducting Step 2 of the 6-Step Partnership Improvement Cycle. The “how to” document is to be used together with the TPI Preparation Package and its associated resources. Post-Assessment: Build (4 weeks post-assessment) O B J E C T I V E : T R A N S L A T E F I N D I N G , S H A R E W I T H K E Y S T A K E H O L D E R S A N D I N I T I A T E A C T I O N P L A N N I N G P R O C E S S • Develop and finalize detailed assessment report in collaboration with the thematic lead persons, seeking any approvals where required • Develop short story from assessment highlighting quality improvement and safety opportunities and share with WHO Learning Laboratory for Quality Universal Health Coverage network • Participate in action-planning workshop for the twining partnership initiative presenting summary of the scoping mission findings and recommendations • Co-develop a partnership plan around the focused action areas identified by partner institutions • Use the assessment results to form the basis of the TPI partnership plan development • Provide feedback to WHO TPI team on assessment planning checklist • Discuss opportunities to leverage partner initiatives to support bottlenecks identified at district-/country-level • During Steps 4-6 of TPI cycle, consult quality improvement resources in TPI preparation package for action steps and evaluation/ review. • Conduct evaluation assessment as part of Step 6 of partnership Improvement cycle • Conduct Situational assessment on an annual basis ( as needed) • Align and build monitoring and evaluation system for the partnership with in-country quality of care measurement initiatives • Consult TPI quality improvement resources for hospital partnerships to inform monitoring and evaluation system of the partnership Assessment: Learn (10 days in-country) O B J E C T I V E : B U I L D R E L A T I O N S H I P S A N D L E A R N F R O M F R O N T - L I N E P E R S P E C T I V E S • Conduct team exercise with health facility staff and district health team to gain: • an understanding of the partner institutions • current understanding on quality and safety within local context. • Consult TPI Preparation Package for core technical tools and resources used for Step 2 • Identify key informant(s). Individual(s) should be a respected person amongst his/her peers. • Review interview guide with key informants or group and collectively refine tool to adapt to local context. • Key informant schedules interview times with health worker (HW) cohort. Recommendation for focused group discussions (FGD) with homogenous health worker cohort, if total cohort number exceeds five. Small homogenous groups allow for open discussion and confidentiality • During day of HH and PS assessment, do not hold any FGD. This is to allow limited HW participation in assessment. • Collect, analyse and crosslink data for all five thematic areas daily • Summarize and present preliminary findings to: • Hospital staff and district level staff • WHO Country Office/Ministry of Health • Relevant partners such as funding agency • Summarize preliminary recommendations according to actions needed for different stakeholders: • TPI initiative • Health facility • District health team • Ministry of Health • Hold daily assessment team meeting to debrief from day’s activities, address emerging key issues and prepare for next day Pre-Assessment: Deconstruct (minimum 4 weeks prior to assessment) O B J E C T I V E : R E V I E W I N - C O U N T R Y N A T I O N A L D O C U M E N T S , I D E N T I F Y Q I O P P O R T U N I T I E S A N D R E L E V A N T I N - C O U N T R Y P A R T N E R S • Identify experienced and motivated lead person to coordinate assessment • Inform WHO country office and regional office of impending situational assessment • Conduct desk review of existing national, sub-national and institutional documents on quality and safety. Possible documents include: • National health sector policy/plan • National quality health strategy • District/county-level operational or work plan • Health facility annual plan or workplan • artner coordination mechanisms • In-country quality of care measurement documents/projects • Identify areas you intend to evaluate during the assessment. Ideally, all five assessment thematic areas should be considered: • Quality Improvement • Patient Safety (PS) • Hand Hygiene (HH) • District-level health system • Patient & Community Perspective • Review long-form of interview guide addressing any unanswered questions that arise • Determine situational assessment schedule and share with WCO • WCO country office to schedule meetings in-country and facilitate facility/ district site visit • Identify composition of mission team and assign lead roles for five thematic areas • Ideally, team should include representation from MOH, multiple levels of the organization (if available) and the partner institutions • Ensure availability of relevant skill set, aligned with selected thematic areas • Identify relevant development partners/stakeholders to be consulted • Initiate series of coordination calls and email exchange with assessment team to discuss technical scope of mission and logistics • If funding allows, initiate scoping mission to sensitize Ministry officials and partners in-country ( if funding does not allow, initiate as part of in-country assessment) E X A M P L E S O F H E A L T H W O R K E R C O H O R T FACILITY- LEVEL DISTRICT/COUNTY-LEVEL • Clinical staff: doctor, physician assistant, nurses, midwives, pharmacist, lab technician, aides etc. • Non-clinical staff: maintenance staff, cleaners • Hospital Management • Patient & Community Representatives • Partners within Health Facility • Health Boards • Management Teams • Health Structure Directors • District/County Superintendent, District Commissioners, Traditional chiefs • Partners 55Annexes ANNEX 4. TPI PLANNING TEMPLATE SUMMARY INFORMATION Name of twinning institution 1: Name of lead: Name of twinning institution 2: Name of lead: Name and date of situational analysis/ baseline assessments used: Names of individuals completing the plan: Technical action areas for focus: Partners to consider specific areas to work on, based on situational analysis (experience highlights the need to focus on 2-3 areas maximum) Example: Project 1: Infection prevention and control Project 2: Knowledge and competency on quality improvement. For each action area, complete the template below. Use as many forms as required depending on the additional action areas addressed. Project number and action area • E.g. Project 1: Infection prevention and control Brief description of project • Provide a 1-2 sentence outline of the project Project goals • List the change the project will contribute to in 1- 2 sentences. • Where possible, link to national and/or local policies and plans including the national direction on quality. • Try to emphasize how the goals of the project respond to the needs identified in the baseline assessment. Project outcome(s) • Describe the improvement that you hope will result from the project. • Outcomes often relate to changes in practice or health outcomes. • The outcomes should contribute to the achievement of the goal. Project output(s) • The direct results of the project e.g. 20 people trained in infection control. The outputs should lead to achievement of the outcomes. Main activities • List all planned activities. For each activity, briefly outline what will be done; where and who will be involved on each side of the twinning partnership; how long it will take; methods to be used; and associated costs. • List technical exchange schedule ie. Fortnightly skype connection, monthly leads 1-to-1, 6-monthly visits, ... • Is a visit planned in conjunction with this project? (if yes, list likely human and financial costs.) • Twinning visit plans for year 1 should be thought through in detail. Plans for year 2 may be more general. Include a draft timeline. • What mechanisms are planned to allow receipt of just-in-time input to technical issues? • How will you connect with WHO efforts to support quality improvement? 56 Partnership Preparation Package Beneficiaries • Include information about the people who will benefit (directly and indirectly) from the project e.g. lab technicians; hospital managers; nurses and different groups of patient and community members. • Describe how they will benefit and provide realistic estimates of how many people in each group will benefit. • Will benefits span both sides of the twinning partnership? Stakeholders • Identify the key stakeholders and their interest in the project (e.g. other department, district and national health offices) i.e. any individual or group that may exert influence over the project activities and outcomes (across both arms of the partnership). • Consider the local community and key stakeholders, including patients and families who could contribute and add value to the planned efforts. • Outline which stakeholders the twinning partnership will report to and how often. Monitoring and evaluation • Define key indicators to be used to monitor whether the outcomes of your project have been achieved. • Provide an overview of your monitoring and evaluation plans, providing an outline of methods, who will be involved, how the process will be managed, and how partners will learn together. Sustainability and spread • Describe how long the activities will continue and what the plans are for long-term funding. • What benefits will continue after the initial 2-year project ends and how? • List your plans for building on project achievements. • Describe how you will actively disseminate new information gathered and consider activities to support vertical, horizontal and spontaneous spread opportunities. Risks • Identify potential risks associated with the plan e.g. key personnel moving on, changing institutional priorities, conflict between twinning partners, and how you will manage each of these risks. • List external risks and how you will manage them (e.g. ICT breakdown, problems with visas, political uncertainty). Project management and support • Outline project responsibilities including division of responsibilities across the twinning partnership. • Provide details of the key personnel involved in each arm of the partnership. • Consider key management questions: What systems will be used to manage finances in both locations? Who will have the main responsibility for budgets? How will you ensure that communication is effective and that all partners know what is happening? Approved by Date of approval 57Annexes ANNEX 5. TPI VISIT PROPOSAL TEMPLATE The Visit proposal template should be completed once a visit has been agreed, to ensure that the visit has clear objectives and contributes to the overall partnership planning. Twinning partnership (list both institutions within the partnership): Institution 1: Institution 2: Name of person completing the visit proposal form: Purpose of visit - describe which partnership project(s) the visit relates to: What are the dates of the proposed visit? Start date: End date: Is the visit aligned with existing in-country activity with no duplication of training or policy development work? Yes No Not applicable Does the visit clearly meet the needs of the twinning partner institutions? Yes No Not applicable Briefly describe the expected outcomes of the planned visit (outcomes are clear, realistic and logical): Briefly describe the outputs of the planned visit (outputs are clear, realistic and logical): Briefly describe any risks you think might be associated with the visit: List estimated costs of the visit: Briefly describe how the proposed visit will contribute to monitoring and evaluation of the associated partnership plan: List the number of people involved in the proposed visit and their role in achieving the visit objectives: Has the visit been jointly planned and agreed across the partnership? Yes No Will the visit offer potential benefits to both twinning partners (if yes, de- scribe briefly)? Yes No Not applicable Briefly describe how the visit will help achieve sustainability and spread of effective essential health service delivery. 58 Partnership Preparation Package ANNEX 6. TPI ACTION REPORT TEMPLATE The Action report template allows key outputs of each period of the partnership to be documented, lessons learned and actions arising logged. This is part of developing a strong, effective, action-focused partnership and contributes to partnership governance. Twinning partnership (list both institutions within the partnership): Name of person completing the report and date completed: Time period covered by this progress report: Key actions undertaken: Key achievements resulting from action taken: Key challenges faced: Date of next expected progress report: 59Annexes ANNEX 7: DEFINITIONS Accountability: The obligation to report, or give account of one’s actions – for example, to a governing authority through scrutiny, contract, management, regulation and/or to an electorate. African Partnerships for Patient Safety (APPS) programme: The WHO APPS programme is a hospital- to-hospital focused approach that was results- oriented and co-developed by hospital partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the African Partnerships’ work providing a common relevant goal that everyone was committed to improving. As a result, substantial implementation experience and learning have been achieved in this field across the African Region. The APPS approach demonstrated how working in partnership results in more motivated staff, increased commitment to change, strengthened capacity-building, focused drive and a desire to find appropriate solutions that will impact immediately on the quality and safety of patient care. This in turn can be used to strengthen the delivery of health services to communities globally. Clinical effectiveness: The application of the best knowledge, derived from research, clinical experience and patient preferences to achieve optimal processes and outcomes of care for patients. Community partner: Member of a quality improvement team representing a unit of population, often generally geographically defined, that is the locus of basic political and social responsibility and in which everyday social interactions involving all or most of the spectrum of life activities of the people within it takes place. Continuous Improvement: The process of making something better or of getting better. Integrated People-Centred Health Services (IPCHS) framework: The IPCHS Framework calls for a fundamental shift in the way health services are funded, managed and delivered to respond to these 60 Partnership Preparation Package challenges. The IPCHS vision is that “All people have equal access to quality health services that are co-produced in a way that meets their life course needs, are coordinated across the continuum of care and are comprehensive, safe, effective, timely, efficient and acceptable; and all carers are motivated, skilled and operate in a supportive environment.” WHO recommends five interwoven strategies that need to be implemented in order to achieve IPCHS. Application of the approach can build robust and resilient health services and are critical for progress towards universal health coverage and fulfilling the Sustainable Development Goals. Partnership: A partnership is a collaborative relationship between two or more parties based on trust, equality and mutual understanding for the achievement of a specified goal. Partnerships involve risks as well as benefits, making shared accountability critical. Patient-centredness: Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions. Patient safety: The reduction of risk and unnecessary harm associated with health care to an acceptable minimum. Performance: How well a person, team, project, programme, organization, or policy is being implemented against expected results. Quality: Quality has been defined and understood in different ways around the world. Two of the main definitions are below. • The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. • The totality of characteristics of an entity that bear on its ability to satisfy stated and implied needs. 61Annexes Quality audit: a systematic and independent examination to determine whether quality activities and related results comply with planned arrangements and whether these arrangements are implemented effectively and are suitable to achieve objectives. Quality assurance: all the planned and systematic activities implemented within the quality system, and demonstrated as needed, to provide adequate confidence that an entity will fulfill requirements for quality. Quality control: A process to evaluate actual performance, compare actual performance with quality goals, and take action on the difference. 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Printed in Switzerland CONTENTS 8 6 INTRODUCTION ABBREVIATIONS 12 PART 1: TPI OBJECTIVES 26 PART 2: OVERVIEW OF THE 6-STEP CYCLE 28 46 62 PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE ANNEXES BIBLIOGRAPHY 44 REFERENCES 42 KEEPING THE LEARNING GOING ACKNOWLEDGEMENTS The World Health Organization (WHO) would like to acknowledge the support and contribution that many individuals and organizations have made to the development of this document. Katthyana Aparicio, Melissa Kleine-Bingham and Shams Syed (Department of Service Delivery and Safety, WHO) coordinated and led the development and writing of this document. Maki Kajiwara, Nana Mensah Abrampah, Julie Storr (Department of Service Delivery and Safety, WHO) provided significant input to the development and drafting of this document. Special thanks to Sandra Hwang and Albert Wu (Johns Hopkins Bloomberg School of Public Health) for their technical contribution on quality improvement methods. External Peer Review Group Ngormbu Jusu Ballah (Liberia Ministry of Health), Jean Marc Chapplain (Centre Hospitalier Universitaire de Rennes), Graeme Chisholm (Tropical Health Education Trust - THET), Eric de Roodenbeke (International Hospital Federation - IHF), Charlie Evans (American College of Healthcare Executives), Koichi Izumikawa (Nagasaki University Hospital - NHU), Farid Lamara (Expertise France), Emmanuelle Maurin (Expertise France), Sandra Hwang (Johns Hopkins Armstrong Institute for Patient Safety and Quality), Andrew Jones, Samuel Seeigbeh (Tellewayon Memorial Hospital, Liberia) Albert Wu (Johns Hopkins Bloomberg School of Public Health) and ESTHER Alliance for Global Health Partnerships. ABBREVIATIONS AHRQ Agency for Healthcare Research and Quality AMR antimicrobial resistance APIC Association for Professionals in Infection Control APPS African Partnerships for Patient Safety EEA ESTHER Alliance for Global Health Partnerships GLL Global Learning Laboratory HSAs Health Surveillance Assistants IHF International Hospital Federation IPC infection prevention and control LMICs low- and middle-income countries M&E monitoring and evaluation NHS National Health System NUH Nagasaki University Hospital OECD Organisation for Economic Co-operation and Development PDSA Plan-Do-Study-Act QI quality improvement SARA Service Availability and Readiness Assessment SDGs Sustainable Development Goals SMS short message services SWOC Strengths, weaknesses, opportunities and challenges THET Tropical Health Education Trust TMH Tellewayon Memorial Hospital TPI Twinning Partnerships for Improvement UHC universal health coverage USAID United States Agency for International Development WASH water, sanitation and hygiene WISN workload indicators of staffing needs WHO World Health Organization INTRODUCTION BACKGROUND T winning partnerships between health institutions are an innovative approach that can be used to improve various aspects of health service delivery. The WHO Twinning Partnerships for Improvement (TPI) model supports long-term efforts on quality health service delivery within the context of achieving universal health coverage (UHC). The work can contribute to building resilient health systems. Fundamental in the approach is to prioritize alignment with national health plans and strategies, while working to achieve the Sustainable Development Goals (SDGs). TPI builds on the learning from the WHO African Partnerships for Patient Safety (APPS) programme (1). These rich lessons and the subsequent application of twinning partnerships in the recovery effort in Ebola- affected countries have facilitated the design of WHO TPI. The key aim of WHO TPI is to support health care facilities in the improvement and enhancement of the quality of their service delivery, while aligning with the overall national strategic direction on improving quality service delivery. Institutional health partnerships can play a critical role in health systems strengthening. This has been increasingly recognized across the world. Many global health groups1 have highlighted the need to “promote the utility of institutional health partnerships in strengthening health systems and in delivering effective health services.” Recognizing the synergy that comes from a partnership approach, national policy documents over the past decade have also begun to highlight the potential for institutional partnerships as an entry point to strengthen services and health systems. In addition to the APPS programme, TPI also builds on the work undertaken in applying the Twinning model to support recovery from the 2014 West Africa Ebola outbreak. TPI Recovery focused upon building resilient health systems and reactivating safe essential health services in those countries most affected by the outbreak. The aim of TPI Recovery was to rebuild the health services in order to support implementation of national recovery plans (2). Implementation of twinning partnerships involves addressing a variety of service delivery and clinical care areas, including, but not limited to, infection prevention and control (IPC); patient safety; and specific clinical services. Health workforce capacity- building is embedded within the model. TPI can feed into work at the national level to improve the quality 1 For more information on global health groups and to view the consensus statement, please visit WHO’s web site at: http:// www.who.int/patientsafety/implementation/apps/global-catalyst-group. pdf?ua=1 WHO TPI Snapshot • Twinning Partnerships for Improvement focuses on the value of institution-to- institution partnerships in catalyzing health service improvement. • The hospital-to-hospital model developed by ‘African Partnerships for Patient Safety’ (APPS) is the foundation on which TPI has been developed. The emphasis is on a ‘doing while learning” model (3). • As a global network of twinning partners develops there is an opportunity to learn from and share learning across the TPI network. • The approach promotes collaboration, co-development and sharing of both tacit and explicit knowledge thus enhancing spread of successful approaches to improvement. 10 Partnership Preparation Package of service delivery. These partnerships can act as a valuable tool for health improvement strategies and bring real benefit to the front line of service delivery and ultimately to the health of an entire population. The power of twinning partnerships working together can bring effective health improvements beyond what an individual organization or team could achieve alone (4). Furthermore, the work of such twinning partnerships can feed into national strategic efforts to improve quality service delivery elsewhere. PURPOSE OF THE TPI PREPARATION PACKAGE The aim of this document is to provide a practical step-by-step approach for any health institution interested in improving the quality of health service delivery through twinning partnerships. The model is based on a 6-step cycle which begins when two or more partners agree on the establishment of the partnership. TPI guides the partners through a systematic process which involves identifying some specific areas for improvement, developing an action plan to implement improvements, and then evaluating the progression and changes made towards improvement. Institutional health partnerships have the potential not only to work as individual partnerships, but also to collaborate with other partnerships to support a national network of similar partnerships. This can support national efforts through joint problem-solving and sharing experiences in order to develop a body of evidence and experience that can inform national and district authorities. This can further encourage application of the partnership model at all levels of the health system. TARGET AUDIENCE The target audience for this partnership preparation package are those committed to improving the quality of healthcare and service delivery including, but not limited, to those in: TPI brings an opportunity to support improvement in the delivery of care at the local, sub-national and national levels. It can act as a catalyst for change in efforts to enhance quality in the context of UHC. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves (1). 11introduction • health institutions • health facilities • academic/research institutions • professional associations • donor organizations • health authorities • policy making • governments. The TPI preparation package also aims to inform decision-makers and authorities working at the national level that are responsible for planning, developing, implementing and evaluating national health strategies, including WHO country offices and ministries of health. When to use the package The package will be useful to any new or existing twinning health institutions in order to work through a partnership-based approach to improve the quality of health services and embed the effort within long-term service improvement. Who benefits from TPI? • Health workers • Hospitals • Health facilities • Patients • Communities • Quality strategists • National policy-makers What is APPS? The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to- hospital approach to improvement. The emphasis of APPS was on the joint development of solutions based on mutually beneficial partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the APPS partnership work providing a common goal. APPS resulted in a range of implementation experience across the participating countries and reinforced the value of partnerships in motivating staff, increasing commitment to change, strengthening capacity-building and ultimately impacting on the quality and safety of patient care. The APPS approach is an example of how partnerships have the potential to strengthen the delivery of health services for the benefit of the wider community, as well as the participating health facilities themselves (1). PART 1: TPI OBJECTIVES OVERVIEW OF OBJECTIVES T PI focuses on the value of institution-to-institution partnerships in catalysing health service improvement following a “doing while learning”2 model. TPI takes into account a variety of entities, including health facilities, academic institutions, private institutions, etc.3 It provides the potential for implementing different types of 2 ”Doing while learning” refers to the experiential learning theory where one learns from experience in order to develop skills or new ways of thinking. (Lewis and Williams 1994, p.6) 3 While a variety of entities can be involved in the partnerships, the TPI preparation package will use the generic term institutions to cover all types of entities. partnerships, at local, sub-national and national level, and also across continents. Institutions from high- income countries or from low- and middle-income countries (LMICs) can initiate partnerships to support other institutions within LMICs and thus provide unique opportunities to catalyse the move towards quality health services, all within the context of achieving universal health coverage. Within the TPI model, there are three objectives that each partnership should focus on achieving. 1. The first objective is the development of the partnership. This objective focuses on fostering a strong bi-directional partnership between health institutions. 2. The second objective is improvement through implementing effective interventions based on needs identified at the front lines of service delivery. 3. The third objective is to spread the learning and experience within the local and national health system and also beyond. The ultimate benefits of TPI are bi-directional learning and improvement, motivated and committed staff; strengthened delivery of health services; and better patient and health worker outcomes. The Recovery Toolkit Twinning Partnerships for Improvement - Objectives 14 Partnership Preparation Package The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches towards improvement. As a global network of twinning partners emerges, there is an opportunity to learn from and share learning across the larger TPI network, to promote collaboration, co-development and sharing, and support the spread and replication of improvement. What is co-development? A process that brings together the collective intelligence for a collaborative development and applies joint decision- making that enhances trust. 15PART 1: TPI objectives OBJECTIVE 1 – PARTNERSHIP The formation of a partnership is the first step in the TPI journey. Under the first objective, two or more institutions come together to agree upon a common goal and define the partnership priorities which they hope will result in sustainable improvements at the health facility. Building on the APPS definition of partnership, which encompasses a sociological perspective focusing on the interaction of people, TPI has identified several values essential in building successful partnerships (1). These are: 1. collaborative relationships 2. trust 3. equality 4. mutuality 5. shared accountability 6. transparency. Building on the TPI values and the APPS partnership definition, the TPI principles below can be applied when implementing a partnership4. These principles can provide a foundation for forming and maintaining an effective and sustainable partnership. Shared vision and joint planning • Coordination and mutual agreement in setting objectives, time frames and an approach to evaluation. • Co-developing and establishing partnership plan and activities. • Mutually agreeing on key performance measures to assess impact. 4 These are a set of principles that have emerged from previous part- nerships but should be adapted to the context of each partnership. It is important and useful to recognize similar partnership princi- ples that have been established by a range of organizations (e.g. THET; ESTHER Alliance for Global Health Partnerships). Definition of partnership “A partnership can be defined as a collaborative relationship between two or more parties based on trust, equality and mutual understanding, for the achievement of a jointly agreed goal. Partnerships involve risks as well as benefits, making shared accountability critical.” ~APPS, 2009-2011 16 Partnership Preparation Package Ownership • Ensuring that ownership is supported by each arm of the institution and not individuals. • Involving and engaging stakeholders by developing an effective stakeholder strategy that emphasizes roles, responsibilities and commitments. • Strategizing and planning for the involvement of all levels of the health system. Good relationships • Building relationships based on trust, non- judgement and commitment. • Harnessing the passion and power of individuals. • Respecting and understanding local rules, culture and customs. Good communication • Communicating effectively to facilitate decision- making and information-sharing. • Agree on and securing channels for decision- making. • Clearly identifying focal points5 and the roles of each team member. Ways of working • Nurturing individuals to be self-motivated and considering the value of having a good sense of humour. • Building transparency, flexibility and adaptability into the partnership (while keeping an eye on the changing external environment). • Celebrating what went well and modifying what has not gone well. 5 Focal point can be defined as the designated or referent person serving as a coordinator of information related to a project, a pro- gramme or a specific activity. 17PART 1: TPI objectives The power of partnerships There is a growing understanding that health partnerships work in synergy to yield powerful results – the combined efforts often having greater impact than work in isolation. Both arms of the partnership benefit6 from learning about innovative practices coming from unique and unexpected sources. Sometimes this leads to lower costs for the same or better outcomes. For example, the partnership between Church of Uganda Kisiizi Hospital and Countess of Chester Hospital NHS Foundation Trust maximized the local resources and was able to obtain alcohol from local agriculture to produce hand-sanitizer. This innovative approach exposed and sensitized both arms of the partnership to “out of the box” thinking in order to make improvements. 6 More information about benefits for each partner can be found here: https://www.ache.org/pdf/nonsecure/White-Paper-International-Hos- pital-Partnerships.pdf “We were able to move faster towards our goal than we would have on our own” (5). ~Dr Emanuel Addo- Yobo, Komfe Anokye Teaching Hospital, Ghana APPS Partnership Strength Survey, 2012. SDG 17 Revitalize the global partnership for sustainable development (6). Targets relating to TPI • SDG Target 17.6: “Enhance North-South, South-South and triangular regional and international cooperation on and access to science, technology and innovation and enhance knowledge sharing on mutually agreed terms, including through improved coordination among existing mechanisms, in particular at the United Nations level, and through a global technology facilitation mechanism.” • SDG Target 17.9: “Enhance international support for implementing effective and targeted capacity-building in developing countries to support national plans to implement all the sustainable development goals, including through North-South, South-South and triangular cooperation.” 18 Partnership Preparation Package Partnerships and the global goals The twinning partnership approach provides a link between local institutional change, national health systems and the global arena. The SDGs acknowledge the importance of partnerships (Objective 17) by recognizing that partnerships help to “mobilize and share knowledge, expertise, technology and financial resources.” The SDG goes further to highlight that “a successful sustainable development agenda requires partnerships between governments, the private sector and civil society. These inclusive partnerships built upon principles and values, a shared vision, and shared goals that place people at the centre, are needed at the global, regional, national and local level” (6). Linkages with multiple SDGs are evident, particularly 3.8 on UHC, but a range of others are clearly evident too. For example, a partnership approach can contribute to the reduction of maternal mortality ratio (SDG 3.1) by improving the quality of care for mothers.7 While TPI focuses on local, front-line improvements in the quality of health services, the compounding results from all partnerships around the world can lead towards global cohesion and overall impact. It is important to note that the benefits produced by twinning partnerships not only enhance institutional capacity to deliver improved health services, but also contribute to strengthening of the entire health system, if designed and implemented effectively. OBJECTIVE 2 – IMPROVEMENT Improvement is at the core of the partnership. In general, improvement focuses on the act or process of making something better. In hospital settings, improvement implies organizational and structural change, in addition to a necessary change in attitudes and behaviour, very often - all of which makes this process complex since it involves people and often requires a culture shift. Gaps existing in quality of care within health care facilities should be agreed 7 Royal College of Midwives and Ugandan Midwives Association. Case study in THET: https://www.thet.org/case-studies/aligning-partner- ship-plans-institutions-strategic-plan-2/ 19PART 1: TPI objectives Partnership development and continued strengthening – Japan and Liberia The Partnership between Nagasaki University Hospital (NUH), Japan, and Tellewayon Memorial Hospital (TMH) in Lofa County, Liberia, was formed in August 2016. At the time, TMH was recovering from the West African Ebola outbreak of 2014 and relying on international support to reactivate its essential health services and moving forward with recovery efforts in alignment with national recovery plans. During the recovery at TMH, it was quickly realized that the impacts of the Ebola response had depleted many resources and that extensive work was needed in order to improve quality. NUH saw that the needs at TMH were extensive and agreed to form a partnership with TMH. The Ministry of Health and the County authorities in Liberia supported this partnership at the onset of the formal TPI agreement. Careful consideration was given to the architecture of the partnership, recognizing the distinct culture and context of the respective partners. Principles and definition of partnerships were carefully considered in recognition that success of the partnership would depend on the foundations developed in the early stages. This proved pivotal in the roll-out of the partnership. Moving forward from this initial partnership, a situational assessment and gap analysis were completed at TMH in October 2016. Following the gap analysis, an official “action planning” meeting took place in December 2016 where both partners agreed to improve infection prevention and control, with specific attention being given to hand hygiene and waste management. It was noted that by improving these two areas, the foundation could be created for overall quality improvement throughout the whole hospital. The partnership undertook two partnership exchange visits in Liberia and Japan respectively. The principles of the partnership were reinforced throughout while the improvement work proceeded. The bi-directionality of the partnership learning was emphasized. For example, the TMH team leader gave a talk about their experience in the Ebola response. NUH stated they benefited greatly from because they learned about the realities of diagnosis and treating Ebola affected patients. 20 Partnership Preparation Package upon. Based on these identified gaps, one or several priority action areas are identified to steer the focus of the partnership. The ultimate aim is to improve the quality of care and overall health outcomes through the successful implementation of interventions using effective improvement methods. Both arms of the partnership need to establish common goals and priorities in order to develop a strong, effective and sustainable partnership. Additionally, when defining areas of improvement, it is necessary for the focus to involve and engage local stakeholders, teams and individuals within the health system who will be the ones to sustain the efforts put forth by the partnership. Objective 2 involves the following necessities. • Both arms of the partnership needing to jointly agree on improvement entry points. This collective approach promotes an atmosphere of ownership, learning and innovation through a safe space supporting an open mind-set, the use of skills and an opportunity to work and learn together. • Achieving common goals set between partners. This includes defining clear targets, agreeing on the best methods of spread, setting clear reporting mechanisms and monitoring standards, methods and ways of working. • Coordinating the implementation of improvement activities through regular contact supported by a communication plan that holds people accountable for their own work. • Testing several changes until a desired process that leads to a desired outcome is achieved, allowing for a certain degree of flexibility, permitting necessary changes and adaptations. The TPI approach provides a measurable improvement process that uses a validated set of tools. By participating in TPI, partners gain knowledge, cultural awareness and share learning on innovative approaches to improvement. Areas of improvement can include a variety of service delivery and clinical care areas influenced by the baseline assessment, Improvement “The combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning).” Batalden, P. B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? Quality & Safety in Health Care, 16(1), 2–3. https://qualitysafety.bmj. com/content/16/1/2 21PART 1: TPI objectives such as infection prevention and control (IPC), patient safety, and specific clinical services. Examples abound but the unifying concept is that improvement in service delivery needs to have a direct and lasting impact on the quality of the entire health system8. The linkages between service delivery and health workforce are clearly evident. The inter-relatedness with each of the health system components is highlighted through all partnership action. In the example below, the partnership in Ethiopia illustrated how improvements in both service delivery and clinical care at the facility level have had a direct impact on the wider health system. Ultimately, achieving quality at the facility level can bring balance and improvements to the entire health system. OBJECTIVE 3 – SPREAD Spread allows for sharing and scale-up of improvement experiences and learning within the local and national health system, and beyond (7). This enhances the reach and impact of the partnership by sharing what did and did not work well. When considering Spread, a strategy to help document successful experiences should be developed and early conversations should be held on the following topics: (1) What are the new and creative health service improvements that have been made? Spreading the emerging success stories of improvement can help drive large scale spread. (2) What are the ways in which this improvement will be sustained? A way to sustain improvement is to allow sufficient time for new practice to become fully integrated as the standard (e.g. incorporating new practices in policies, procedures, job description, etc.). (3) How was the improvement made? For example, demonstrating the benefits and advantages arising 8 A health system has traditionally been described by WHO as comprised of six building blocks which include: leadership and governance; health information systems; health financing; essential medical products and technologies; human resources for health; and service delivery. Improvement – Gondar, Ethiopia and Leicester, England The partnership formed between the University of Gondar Hospital, in Ethiopia and the University Hospital of Leicester NHS Trust, in England, aimed to implement the WHO Surgical Safety Checklist in the operating theatres of Gondar Hospital. Through regular audits, staff feedback and multidisciplinary learning sessions, the monitored results showed that the Checklist had successful implementation, compliance and adherence among staff. Additionally, there was consistent focus on joint learning and participation which helped to build research capacity. This resulted in a multi-country research project to look at Checklist implementation in a partnership context. After monitoring the implementation of the Checklist programme, it was found that its use rose from 17% to 53%, with a 100% application in emergency procedures. Multi-professional groups are now trained in its use. Importantly, the research also provided an opportunity to critique the work of the partnership and enable further improvements. Of note, this long-standing partnership benefitted from the support of both THET and WHO (8). 22 Partnership Preparation Package from a new practice encourages both spread and sustainability. (4) Who is the target audience of the Spread? In considering the target audience, it is important to acknowledge if the spread will focus on individual buy-in, whole facility buy-in, or entire health system adoption. These details help to organize and structure a plan to disseminate the information and experiences of success. The work of the partnership, particularly in relation to spread, needs to take careful account of the national strategic direction on quality, where this exists. Many countries are now developing or refining national quality policies and strategies. The formation of these policies and strategies can be informed by experiences that emerge from twinning partnerships. When these national strategies already exist, the work of the twinning partnerships should be carefully aligned with the national direction. This allows the effort of the partnership to have maximal impact by supporting implementation of a nationally owned drive for quality. The initial situational assessment can identify the national quality direction and both arms of the partnership need to be fully aware of this at all stages of the partnership. Spread can be considered in three ways - horizontal, vertical and spontaneous (7)(9). From the onset of the partnership, the following should be considered. 1. As soon as partners begin planning for health facility improvement, spreading this improvement should also be discussed. 2. Consider broadcasting your improvement message through different channels, such as conferences, professional journals, media, word-of-mouth and first-hand accounts. 3. Make it as appealing as possible for others to want to copy your improvement. 4. Build a network to sustain and grow spread. 23PART 1: TPI objectives 5. Finally, consider, at the outset, how the experience arising from this project could be used to feed into learning systems, both at the national and global levels. Horizontal spread refers to spreading improvement across people and organizations within the same level of a health care system. An example of horizontal spread is replicating improvements from one unit in a health facility to another. Vertical spread refers to spreading the information and improvement efforts throughout the national, subnational and local levels of a health system. Vertical spread is particularly important because while national level can drive local change, local can also drive national level change. It is important to collect quantitative data and analysis of the improvements as it lays the groundwork for evidence-based practice and can be a critical component of vertical spread, and thereby influence changes in policy. Spread requires strong connections between quality improvement evidence in conjunction with both facility and national quality policies. This evidence and clear alignment with existing policy could help to facilitate the improvements made from TPI into facility and national quality policies. Spontaneous spread, is not planned for, but can spontaneously occur through informal channels such as social networks, or opinion leaders, which sometimes cross country’s borders. An example of spontaneous spread is the engagement that occurs between partnership facility leaders and key influencers within the health system. The power of human interaction and storytelling – often in informal meetings and gatherings – in achieving change then becomes clearly evident. Of further note is the necessity to consider the spread of ideas, competencies and skills from low-income countries to partners in high-income countries. This is inherently related to concepts of mutuality that are enhanced through partnerships. 24 Partnership Preparation Package The critical role of the community Involving patients and communities can stimulate spread and strengthen implementation and the sustainability of improvement programmes. Connecting with the local community can improve the quality of care and make services more people- centred. This is particularly important in low-resource settings where demand for health care is high. Co- developing health services around the needs of patients and the community, by empowering patients and communities by informing them and giving them the ability to make decisions in order to instigate change, can enhance the patient’s experience, health outcomes, confidence and trust in health care providers (10). Ideally, patient, family and community engagement should be part of all national health plans. In the absence of a formal mechanism to engage patients and the community, health care workers can carry out simple actions to engage them, such as providing practical training (e.g. on hand hygiene, waste management, use of medicines, etc.), invite patients’ representatives or community leaders to participate in orientation meetings and provide on- going support. Advocating for the partnership and the successes achieved will promote the work and lead to further interest within communities. This work can be celebrated and advertised to maintain motivation and create a positive atmosphere. When community spread occurs, the knowledge generated through an improvement process in the health care facility becomes part of normal practice and standards that have positive implications for the population’s health, e.g. hand hygiene improvement. The example below highlights horizontal and vertical spread. Spread - Yagaldo Ouedraogo Hospital, Burkina Faso and Montpellier Hospital, France Yagaldo Ouedraogo Teaching Hospital in Burkina Faso started partnering with the Teaching Hospital of Monpellier in France, and implemented a pilot project to improve hygiene in the neurosurgery ward in 2013. The objective was to meet the standards of hospital hygiene in this specific ward. Four areas were targeted: hand hygiene, waste management, management of nosocomial infections and capacity-building of health workers. The idea was to concentrate efforts on the selected activities in one of the wards of the hospital in order to understand what kind of improvements could then be replicated in other wards and units of the hospital. Improvement was spread horizontally, making the entire facility benefit. Furthermore, convinced of the advantages of partnerships work, Expertise France secured support from the European Commission to spread this improvement to other health care facilities across the country. Nine partnerships involving national and regional hospitals have been implemented since February 2017 with positive implications for the entire health system of Burkina Faso. Thus, horizontal and vertical spread is taking place simultaneously (11).
PART 2: OVERVIEW OF THE 6-STEP CYCLE T he partnership approach is a step-wise approach which facilitates the development of partnerships, the systematic identification of gaps and the development of an action plan and evaluation cycle. 1. Partnership development begins the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions. Both arms of the partnership agree to work together to improve the quality of health care. 2. The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership. 3. The gap analysis involves a review of the needs assessments and reveals key priority areas for action. From the gap analysis, the foundation for action planning is established in a systematic way, in order to help partners to implement a more focused improvement effort. 4. Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long-term targets for the twinning partnership. In this step, it is important to look at communication, spread and budget. 5. Action is the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. 6. Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. A variety of tools and resources are available (Annex 2) to support each step and will guide the partnership implementers throughout the process. PART 3: DIGGING DEEP - PUTTING THE 6-STEP CYCLE INTO PRACTICE A t each step of the cycle, one or more tangible outputs or deliverables to work towards is expected. These outputs are designed to help the TPI partnership move the action forward. To assist partners, a list of supportive tools and resources is provided in annex 2. Implementing organizational and structural change is often complex, because in many cases it involves people and a cultural shift needs to take place. For this reason, when seeking appropriate tools for any given technical action area, it is important to consider how they can support planning for the partnership activities, their implementation, and in addition important cross-cutting themes, such as community engagement, knowledge management and communication/advocacy. It is also important to consider the broader national context, policies, frameworks and national strategic priorities and existing initiatives in planning twinning activities. Technical improvements must align with national policies and strategies. This will be particularly important in achieving objective 3 and spreading the experience from the twinning partnership improvement process both in the short and long term. STEP 1: PARTNERSHIP DEVELOPMENT This is the beginning of the formal establishment of a fully functioning, communicative twinning relation between two or more health institutions (1)(4). Both arms of the partnership agree to work together to improve the quality of health care, focusing on different aspects of service delivery, including clinical care. A requirement of successful partnership implementation is to have a stable funding structure. This has to be defined from the beginning, as the activities that the partners will undertake will depend on the availability of human and financial resources (4). Partnerships established through international cooperation9 can benefit from direct funding of one arm of the partnership. In other cases, partners can agree to share the costs or compete successfully for external funds. This requires the partners working together to identify potential sources of funding and develop joint proposals. Whatever model of funding is applied to implement the activities of the partnership, it is vital that partners agree on clear systems and procedures. Main activities 1. Secure formal management and leadership agreement on both sides of the twinning partnership to take joint action. This can be done through a written statement of understanding across the institutions, such as a letter of commitment. 9 The concept of international cooperation makes reference to the interaction of persons or groups of persons representing various nations, in the pursuit of a common goal or interest. Outputs or deliverables 1. Exchange of letters between institutional management as required (it can be a letter of commitment or a Memorandum of Understanding). 2. Agreement on a definition of the twinning partnership. 3. Team members on each arm of the partnership selected and contact details exchanged. 4. Communication plan drawn up. 5. Kick-off meeting notes indicating potential areas of work, next steps and a tentative date for conducting the needs assessment. 6. Official designation of a lead and deputy trained in the approach using the outline provided in this preparation package. Core resources for Step 1 – Partnership (see annex 2) 30 Partnership Preparation Package 7. Identify a twinning lead and deputy at each partner institution. Ideally the Quality Improvement Officer should be the designated lead. In the absence of a Quality Officer, a focal point responsible for quality and safety can be designated instead. 8. Ensure the engagement of multi-disciplinary staff committed to being part of the “improvement team”. For example, a dedicated person that collects data and monitors evaluation activities. Involving motivated staff will make the change process happen smoothly and positively influence staff who resist change. 9. Consider the suggested definition of partnership; refine and agree on it across the twinning partners as a foundation for moving forward. 10. Negotiate with managers to secure protected time for the improvement team to work on the identified technical action areas. 11. A kick-off meeting with the twinning teams is recommended for the teams to get to know each other. If an in-person meeting is not possible, the alternative is a virtual meeting. 12. Establish a schedule of regular communication (a minimum of once a month is recommended) using a variety of methods (telephone, SMS, text messaging, email, skype, etc.). 13. Establish a budget for the planned activities, including overheads. STEP 2: NEEDS ASSESSMENT The needs assessment allows for the baseline needs of the health facility to be identified and understood. This forms the basis for the gap analysis and ultimately, guides all future improvement activities of the partnership.10 10 For an example of a “How To” tool developed for the TPI partnership situational analysis between NUH and TMH, see annex 3. Core resources for Step 2 – Needs assessment (see annex 2) 31PART 3: Digging deep - Putting the 6-Step cycle into practice Main activities 1. Conduct a desk review on existing national, sub- national and institutional documents on quality of health services. Possible documents include: national health sector policy/plan, national quality policy or strategy. 2. Identify experienced and motivated leads to coordinate the assessment, as well as their assessment team members. The composition of the team will depend on the scope of the assessment, the time and resources available. Ideally the team should include a member from the district health management, the health care facility management and an expert of the technical area to be assessed. 3. All members of the assessment team should be briefed before starting the assessment and have an overview of the expected results of the exercise, including the data collection process. 4. Communicate to other facility staff about this exercise as it requires the collaboration of other teams when collecting data, ensure buy-in from the start and discuss confidentiality. 5. Undertake a specific needs assessment within the selected technical area using appropriate assessment tools. Examples of themes that could be assessed are: a. infection prevention and control b. patient safety and health worker safety c. essential surgical care d. waste management e. Water, sanitation and hygiene (WASH) f. maternal and newborn care g. health workforce. 6. Consider the use of a standardized tool to complete the needs assessment. See annex 3, as an example of the tool developed and then used for the TMH needs assessment. Outputs or deliverables Completed baseline and situational analysis report appropriate to technical area of focus. 32 Partnership Preparation Package Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. Core resources for Step 3 – Gap analysis (see annex 2) 33PART 3: Digging deep - Putting the 6-Step cycle into practice Consider any assessments that have been undertaken in any of these areas in the past 6-12 months and gather together assessment results and expertise that can be a source of valuable learning. STEP 3. GAP ANALYSIS The Gap analysis is a review of the needs assessments and reveals key priority areas for improvement action. The systematic gap analysis is the foundation for action planning that can help partners to implement a more focused improvement effort. While analysis can reveal several gaps, not all of them would be appropriate for addressing within the context of the partnership. It is recommended to choose two or three areas of priority intervention to ensure that the desired improvements can be made.11 Main activities 1. Organize a face-to-face or virtual meeting with the improvement teams of each arm of the partnership to discuss the results of the situational analysis conducted in Step 2. 2. Analyse and interpret the data and information collected. 3. Using the findings of the baseline and situational analysis, develop a list of gaps that require improvement action and whenever possible, the causes of the gaps. 4. From the list of gaps, identify priority areas based on urgency and the human and financial resources available. 5. Define the indicators to be included in the improvement plan. 6. Focus on small-scale, simple actions. 11 In completing the gap analysis following Step 2, the TPI between TMH and NUH conducted a Partnership Planning Workshop to review the gaps and determine the priorities moving forward. For a full report, see Step 3 of Annex 2. Outputs or deliverables 1. A gap analysis report containing the current situation and desired improvements. This report should outline what constitutes the gap and the factors contributing to it. 2. A list of priorities and indicators based on the capacities of both arms of the partnership to address the gaps identified. 7. Outline specific steps that can be taken to fill the gaps. 8. Organize a meeting with senior leadership to secure endorsement and approval of the findings of the gap analysis and the priority areas identified. Quality Improvement (QI) at the core of TPI The TPI Preparation Package outlines all six steps and provides support and guidance for initiating the partnership and prioritizing which areas in service delivery or care need improvement. In addition to this TPI Preparation Package, a detailed practical field guide entitled “Taking Action: Steps 4 and 5 for Twinning Partnerships for Improvement” can be read alongside the overview of Steps 4 and 5 below. “Taking Action” dives into QI models and approaches and supports the planning, action, implementation, and guidance of QI within partnerships. “Taking Action” reviews the theories of practical application of action in a partnership and can be used by any QI team that has identified a quality challenge, specific needs and current gaps in services; and also that is ready to develop targeted action plans for intervention and improvement in health care setting. The “Taking Action” document also includes a list of common barriers and key factors for successful quality improvement gathered through the WHO Global Learning Laboratory for Quality UHC. The seven countries which provided feedback on common barriers and key factors for success included India, Malawi, Mexico, Nigeria, the United Kingdom, Venezuela and Zimbabwe. The feedback provided critical insights from the front line on the challenges and opportunities for quality improvement at the facility level. For additional information and for the common barriers and key factors, please refer to “Taking Action: Steps 4 & 5 in Twinning Partnerships for Improvement.” For additional information on the WHO Global Learning Laboratory, visit: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/ 34 Partnership Preparation Package STEP 4: ACTION PLANNING Action planning brings partners to a jointly agreed written plan of action. This action plan is grounded in the gap analysis and sets clear short-term and long- term targets for the twinning partnership (12). In this Step, it is important to also consider matters related to communication, spread and budget.12 Main activities 1. Hold a team meeting at the partnership facility • Identify and confirm the key team members at the partnership facility: • Facility leader or manager to endorse the partnership • QI team leader with dedicated time for the project • Technical/clinical/subject matter expert • Measurement and evaluation leader • Community/patient representative • QI team staff to provide technical and administrative support • Ensure consensus and common understanding of key definitions • Outline preparation activities • Review activities taken to date on Steps 1 to 3 of 6-Step Cycle • Ensure team is prepared with priority areas already identified • Assess ground level interest and capacity • Estimate expected costs in terms of personnel, time and money. 2. Agree on an intervention • Review evidence for possible interventions, focusing on improved outcomes • Seek relevant resources on all relevant 12 For an example of action planning templates, see Annexes 4-6 Core resources for Step 4 – Action Planning (see annex 2) 35PART 3: Digging deep - Putting the 6-Step cycle into practice literature on the subject area • Consult with experts on site and at partnership sites • Consult with other health workers • Select intervention with largest benefit, lowest barriers to use, and greatest potential for sustainability • Carefully consider how technical exchanges can support the intervention • Note sustainability of interventions post-partnership • Break down interventions into necessary behaviours, structural and procedural changes. 3. Outline implementation activities • Outline implementation plans • Summarize roles and responsibilities for implementing various aspects of the intervention • Identify local barriers to implementation and design accordingly13 • Engage stakeholders to identify potential concerns • Identify needs based on local context • Identify potential gains and losses associated with implementation • Evaluate current communication methods and adapt as needed. 4. Outline roles and ensure capacity • Estimate expected expenditure • Estimate costs/time for team members • Estimate costs/time for supplies/ equipment • Estimate amount of inputs and capacity available 13 For a list of common barriers, see Taking Action Steps 4&5. 36 Partnership Preparation Package • Determine roles and responsibilities of each team member and how they will contribute to the improvement aim • Ensure protected time and support for staff • Obtain the necessary approval from the facility leader to protect time for key staff • Designate an administrative support person or other assistance • Ensure clear roles are defined for team members in the partnership institution and communicated clearly across the partnership. 5. Outline monitoring and evaluation activities • Outline monitoring activities • Examine hospital epidemiology and existing measures taken by hospital • Identify key indicators of success in implementation • Identify key methods for collecting evaluation data • Outline evaluation activities • Identify key indicators of outcomes • Identity key methods for collecting evaluation data • Strive for simplicity in evaluation and monitoring • Consider benchmarking success from other hospitals in similar contexts. 6. Complete written action plans • Share preliminary plans – ensure teams in partnership health facilities are in agreement • Schedule a series of partnership visits with defined objectives, including twinning partner, other partners, country/WHO lead (if applicable) • Agree on a schedule of partner progress reports (see annexes 4-6). Outputs or deliverables 1. Complete written 2-year Partnership Plan 2. Complete written 6-month initial short-term action plan. 37PART 3: Digging deep - Putting the 6-Step cycle into practice STEP 5: ACTION Action marks the start of implementing the agreed improvement activities set forth by the action plan. By this stage, partners have established and strategized about methods of action and have secured communication channels for ongoing partnership action. Reviewing progress every six months will allow corrective measures to be taken, if needed. The improvement team should carry out regular and planned monitoring reviews using the indicators previously defined. During this action stage, a method for tracking the budget is advised (12). Main activities 1. Put Partnership Plan into action with partners • Ensure continuous consensus in action between partners • Ensure continued alignment with national and sub-national efforts to strengthen quality of health services • Ensure that partners working within the same facility are continuously aware of improvement activities • Align existing improvement efforts already under way at the facility level • Mark the moment of initial action on both arms of the partnership • Choose a date. 2. Manage the implementation of activities • Set up a regular schedule for the QI team to share updates on progress of the project • Ensure methods are used to make data regularly visible to staff • Ensure involvement across the institution, including staff members not directly involved in the specific improvement intervention • Ensure regularly scheduled communication across the partnership on implementation activities. 38 Partnership Preparation Package 3. Coach the team to implement the QI activities • Provide facilitation and QI methods training for QI team leader • Provide mentoring, coaching and general on-site QI support using all assets available (local- and partnership-based) • Build in time for QI knowledge transfer from the team leader to team during team meetings, with the intention of creating cohorts of health workers who can act as catalysts and mentors. 4. Implement the quality initiatives and test changes • Implement intervention • Measure performance through small test of change – PDSA cycles or other agreed methods • Keep track of progress against the planned activities and budget • Make adjustments to intervention based on information received, e.g. outcomes and feedback in response to small test of change • Document issues that arise in a log, and how they were tackled • Set up rapid response mechanisms for trouble-shooting with partners. 5. Assess and refine the interventions • Implement review every six months • Develop interval reports • Adjust team efforts accordingly • Adjust any changes due to staff turnover, need for capacity-building, or need for re-training or training of additional staff • Report back to the partnership on issues that arise14 14 For an example of a partnership that confronted failure, see annex 1. 39PART 3: Digging deep - Putting the 6-Step cycle into practice • Celebrate small or large victories on both arms of the partnership. 6. Share learning and spread changes • Continuously refine change until ready for implementation on a broader scale • Implement a spread plan, taking careful consideration of sub-national and national contexts • Spread changes, taking a successful implementation process from pilot and replicating change throughout the organization • Identify opportunities to use partnership activities to bring about change in other institutions, encouraging national spread. 7. Document and disseminate the improvements observed • Distil the change stories • Distil learnings on implementation by developing knowledge products15 such as knowledge briefs and action briefs • Synthesize any learning to have emerged from one arm of the partnership that benefitted the other arm, emphasizing the bidirectional nature of learning • Disseminate a progress report using appropriate bodies at national, subnational and local levels to maintain to maintain dialogue and connection to overall national plans. 15 Visit the WHO Global Learning Laboratory for more information on Knowledge Briefs. Outputs or deliverables 1. Develop a series of reports outlining action and progress in partnership plan 2. Conduct mid-term review of implementation activities. 40 Partnership Preparation Package STEP 6: EVALUATION Evaluation and review enables twinning partnerships to assess the impact of both their technical improvement work (against their baseline) and the strength and functioning of their twinning relations. This reflects on the strengths and gaps of the partnerships so that refinements can be made. Monitoring and evaluation are key components for a successful partnership and must be implemented from the outset of the partnership cycle (13). This step marks the closure of the cycle and allows the partners to review and assess how well the partnership has met its objectives, but also the partnership’s true impact. The evaluation is the final stage, but the monitoring has taken place thorough the cycle and the results will inform the overall assessment. In addition to local review meetings and partnership discussions, each twinning partnership provides periodic monitoring reports (6-month reports; 1-year repeated baseline assessment; and a 2-year review). Some suggest an external evaluation by specialists to ensure objectivity and others suggest using the teams within the project to gather optimal learning. A combination of the two approaches can generate better results and partner satisfaction (13). Whatever is decided, the partners should be involved in the exercise; specialists should be responsible for certain aspects of the evaluation, and the evaluation and monitoring process must be planned for at the beginning of the partnership. By including the three objectives as an underpinning structure of the evaluation, a successful evaluation reflects on the strength of the partnership, the priority areas of improvement, along with its spread. Main activities Initial evaluation planning activities should be conducted in earlier parts of the 6-step partnership cycle. This planning activity should include consideration of: Core resources for Step 6 – Evaluation and Review (see annex 2) 41PART 3: Digging deep - Putting the 6-Step cycle into practice • key indicators on the effectiveness of the improvement effort • assessment of partnership strength • spread beyond the partnership • training on evaluation approaches for those involved in the partnership • periodicity of reporting. Evaluation activities are conducted throughout the 6 steps. Step 6 is focused on activities to synthesize findings, as well as conducting any necessary assessments. 1. The partners together review the monitoring reports and decide how to synthesize evaluation (collection of statistical data, interviews, focus group, surveys, etc.) 2. Synthesize findings from key indicators that demonstrate effectiveness of the activities conducted, as well as the long-term impact of the partnership. 3. Prepare an evaluation report based on the actions outlined in the partnership plan (and informed by appropriate evaluation tools). 4. Reflect on the success of the evaluation training. 5. Conduct a repeat of the baseline assessment/ situational analysis to consider progress. 6. Conduct assessment on the strength of the collaboration. 7. Conduct assessment of the spread activities. 8. Synthesize all findings and agree on key lessons learned (consider limiting to top ten). 9. Prepare an evaluation report to demonstrate impact and to advocate for financial support. The reports will focus on the achievement of project outputs and outcomes. 10. Disseminate findings internally and externally. Outputs or deliverables 1. For a 2-year project, three monitoring reports should be generated and shared across the partnership and with hospital leaders outlining action and progress towards achieving the Partnership Plan (at 6 months, 1 year and 2 years). 2. Repeated baseline assessment/ situational analysis. 3. Evaluation report KEEPING THE LEARNING GOING T here have been notable successes among the hospitals and health systems that have participated in partnership-based approaches to improvement. These include sustained partnerships, co-developed products and programmes and spread. It has become clear, that in many cases, neither the technical experts from high-income settings, nor the local providers from low-income institutions have sufficient knowledge and know- how to affect improvements. Strong, trusting, inter- institutional partnerships are therefore needed to co-develop solutions that can lead to success and spread. Linkages with national efforts to enhance quality are key to successful cascading of learning for maximal impact on health outcomes. The 6-Step Partnership Improvement Cycle and the TPI Preparation Package provide a practical blueprint for action. It should be noted, however, that each partnership is different - adaptation will invariably be required. Learning will certainly emerge, and this document will also be improved over time. Quality improvement is still an evolving science, and humility is essential for partners on all sides of the TPI. Indeed, successful partnering is rewarding for all those involved. There is much to be learned about how to apply the principles and practices of quality improvement to strengthen the delivery of health services and build resilient health systems in developing countries, yet, lessons also flow back to the so-called developed world. The prototype partnership between Tellewoyan Memorial Hospital in Liberia and Nagasaki University Hospital in Japan proved invaluable in informing the design of the larger TPI initiative. The experiences from this and other efforts will help refine the different approaches to quality improvement. These experiences can also inform and be informed by wider efforts on quality, which have become increasingly prominent in the context of continued advancement of global efforts to achieve universal health coverage. Resources are limited, and continued global learning about quality improvement will depend on the sharing of knowledge, experiences and ideas. Entities such as the WHO Global Learning Laboratory (GLL) for Quality UHC can foster such sharing. The GLL is also a space where successes can be celebrated and knowledge, experience, and ideas shared. Sometimes there is failure, but resilience is needed to find a way to succeed – a huge body of learning resides in these initial failures. The words of Benjamin Franklin ring true - “Tell me and I forget, teach me and I may remember, involve me and I learn.” That is the power of human interaction that lies at the heart of a partnership. REFERENCES 1. African Partnerships for Patient Safety. Improving Patient Safety Partnership Preparation Package. A resource for all health partnerships committed to strengthening patient safety. Geneva: World Health Organization;2012. (http://www.who.int/patientsafety/ implementation/apps/resources/preparation_package_ EN.pdf?ua=1, accessed 24 June 2018). 2. Twinning Partnerships for Improvement. Recovery Partnership Preparation Package. Building capac- ity to reactivate safe essential health services and sustain health service resilience. Geneva: World Health Organization;2016. (http://apps.who.int/iris/bit- stream/handle/10665/206542/WHO_HIS_SDS_2016.3_eng. pdf;jsessionid=0D0AEC895C8BD6F8D8D192A3236F89B- F?sequence=1, accessed 24 June 2018). 3. Lewis L, Williams C, Jackson L, Caffarella R, edi- tors. Experiential Learning: A New Approach. San Francisco: Jossey-Bass;1994:5-16. 4. Successful partnerships a guide. OECD LEED Forum on partnerships and local gover- nance. (https://www.oecd.org/cfe/ leed/36279186.pdf, accessed 24 June 2018). 5. Partnerships for safer health service delivery: Evaluation of WHO African Partnerships for Patient Safety 2009-2014. Geneva: World Health Organi- zation;2015. (http://www.who.int/ patientsafety/implementation/apps/ evaluation-report/en/, accessed 26 June 2018). 6. Sustainable Development Knowledge Platform. Sustain- able Development Goals. Unit- ed Nations. (https://sustainablede- velopment.un.org/, accessed 24 June 2018). 7. African Partnerships for Pa- tient Safety Spread Pack. Improvement series. Geneva: World Health Organization; 2012. (http://www.who.int/pa- tientsafety/implementation/apps/ resources/APPS_Improv_Spread_ Pack_2012_04_EN.pdf?ua=1, ac- cessed 13 April 2018). 8. African Partnerships for Patient Safety. Building Momentum for Safer Health Care. Gene- va: World Health Organiza- tion;2012. (http://apps.who.int/ iris/bitstream/handle/10665/78043/ WHO_IER_PSP_2012.7_eng.pdf?se- quence=1, accessed 24 June 2018). 9. Greenhalgh T, Robert G, Bate P, Kyriakidou O, Macfarlane F, Pea- cock R. How to Spread Good Ideas. A systematic review of the literature on diffusion, dis- semination and sustainability of innovations in health service delivery and organisation. Re- port for the National Co-ordi- nating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). 2004. (http://www. netscc.ac.uk/hsdr/files/project/ SDO_FR_08-1201-038_V01.pdf, ac- cessed 20 June 2011). 10. WHO Community engage- ment Framework for Quality, People-Centres and Resilient Health Services. Geneva: World Health Organization;2017. (http://apps.who.int/iris/bitstream/ handle/10665/259280/WHO-HIS- SDS-2017.15-eng.pdf?sequence=1, accessed 20 June 2018). 11. Partenariats Africains pour la Sécurité des patients. Rapport d’évaluation des partenariats hospitaliers pour la sécurité des patients entre la France et l’Afrique. Genève: Organisation Mondiale de la Santé;2017 (http://www.who.int/patientsafety/ implementation/apps/evaluation-re- port/fr/, accessed 20 June 2018). 12. Taking action: steps 4 and 5 in twinning partnerships for improvement for health care facility managers, quality im- provement teams and insti- tutional health partnerships. Geneva: World Health Organi- zation;2018. (http://www.who.int/ servicedeliverysafety/twinning-part- nerships/steps4-5/en/, accessed 19 July 2018). 13. EQUAL Partnership Develop- ment toolkit. European Com- mission. Directorate-General for Employment, Social Affairs and Equal Opportunities ; 2005 (http://ec.europa.eu/employment_ social/equal_consolidated/data/doc- ument/pdtoolkit_en.pdf, accessed 13 April 2018). ANNEXES ANNEX 1 Case study - Adjusting action when it’s not working Developing a culture of learning in Malawi16 Partnerships work together to identify what works, what does not and what can be learned from this. The Zomba Mental Health Services (Malawi) partnered with the Department of Health Sciences at the University of York (UK) and worked together on a project designed to strengthen the system of community mental health care in Zomba District, Malawi. The project aimed to develop the role of local village-based health workers, known as health surveillance assistants (HSAs), through training and support, in delivering mental health interventions 16 This partnership was supported by THET. for the first time. Planning and delivery of the project involved key professionals in Zomba from mental health services and district health offices, as well as discussions with the HSAs. To collect data, the project manager of Zomba conducted visits to the village-based HSAs on a monthly basis. This allowed him to capture relevant data and discuss it with them. This process allowed them to engage HSAs in the project as a whole. “It enthused people, kept them motivated and interested, and kept the momentum of the project going. This wouldn’t have happened if we hadn’t built in face-to-face visits”, admitted the project manager. There were practical difficulties and the data required for monitoring and evaluation was not efficiently collected. The project manager of Zomba had planned to capture all data on his laptop on a monthly visits, but this proved too time-consuming. Having realized the data collection system was not working, the team agreed that paper copies of the data would be taken off-site between visits, and that the timescales should be allowed to slip. This affected the progress of the partnership improvements and the colleagues involved agreed to improvise and adjust the action planning. The project manager of Zomba believes that learning has been facilitated by the partners having respect for each other’s views and ideas, and making decisions collectively. “The UK partner was very supportive of our new ideas on the implementation of the work. This has helped the partnership to work better together for one common goal, evidenced in the successful results. In the process, the Malawi partners have gained knowledge and learnt skills, including in relation to good project and financial management, and analysis, interpretation and reporting of data.” Acknowledging problems allows partners to look for solutions and turn challenges into lessons learned. 48 Partnership Preparation Package ANNEX 2. TOOLS AND RESOURCES The tools and resources listed below aim to provide support in the development and execution of your action plan. The resources are diverse and span, not exclusively, advocacy, business/financial, guidance/policies/standards, templates, toolkits and selected academic publications. The resources are included after careful review of WHO materials. Inclusion of a resource is based on its perceived usefulness and also its availability. Inclusion of a resource does not imply endorsement by WHO of any specific organization associated with the resource. Many tools and resources that are applicable in hospitals can be accessed through the WHO website of Hospital of the XXI Century: http://www.who.int/hospitals/en/ Type of resource Location Starting a health partnership (THET) https://www.thet.org/wp-content/uploads/2017/09/How-to-start-a-Health-Partnership.pdf Example of letter of commitment http://www.who.int/patientsafety/implementation/apps/APPS_registration/en/ Example of memorandum of understanding https://www.thet.org/wp-content/uploads/2017/09/Memorandum-of-Understanding-Template. pdf La coopération internationale hospitalière – guide des bonnes pratiques. (French Hospital Federation) https://www.fhf.fr/Europe-International/La-cooperation-internationale/ Guide-cooperation-internationale-hospitaliere Guide de la coopération hospitalière pour l’aide au développement https://www.cultura.com/guide-de-la-cooperation-hospitaliere-pour-l-aide-au- developpement-9782859526849.html Successful partnerships, a guide of OECD https://www.oecd.org/cfe/leed/36279186.pdf Position Statement - Global Catalyst Group for Institutional Health Partnerships http://www.who.int/patientsafety/implementation/apps/global-catalyst-group.pdf Core resources for Step 1 – Partnership development 49Annexes Core resources for Step 2 – Needs assessment The needs assessment tools that you see below are not exhaustive. They were identified from the process undertaken by the partnership prototype between Tellewoyan Memorial Hospital and Nagasaki University Hospital. Type of resource Location Year of publication IPC and patient safety Situational analysis for patient safety. A tool to assess the current level of patient safety in a health care facility based on 12 action areas http://www.who.int/servicedeliverysafety/ twinning-partnerships/tools/en/ 2009, revised in 2015 WHO Hand hygiene Self-Assessment Framework. A critical first step in improving hand hygiene in a health facility is to complete this assessment http://www.who.int/gpsc/country_work/ hhsa_framework_October_2010.pdf 2010 Twinning Partnerships for Improvement. Situational assessment report: quality and patient safety- Tellewoyan Memorial Hospital and Lofa County Health System http://apps.who.int/iris/bitstream/10665/2 53523/1/9789241511872-eng.pdf?ua=1 2017 A tool for Infection prevention and control for supporting national implementation through effective baseline assessment and evaluation http://www.who.int/infection-prevention/ tools/core-components/ICPAT2.pdf 2017 Workforce Human Resource Management Rapid Assessment Tool for Public and Private-Sector Health Organizations http://www.lmgforhealth.org/sites/default/ files/HRM_Rapid_Assessment_Tool_0.pdf 2005 Guidelines: Incentives for health professionals. This underlines both financial and non-financial incentives as critical to ensuring effective recruitment, retention and performance of health workers across the world. http://www.who.int/workforcealliance/doc- uments/Incentives_Guidelines%20EN.pdf 2008 Water, sanitation and hygiene WASH FIT. A practical guide for improving quality of care through water sanitation and hygiene in health care facilities http://www.who.int/water_sanitation_ health/publications/water-and-sanita- tion-for-health-facility-improvement-tool/ en/ 2017 Health service delivery management Service availability and readiness assessment (SARA). A tool to assess and monitor service delivery in terms of availability and readiness of the health sector and to generate evidence to support the planning and managing of a health system http://apps.who.int/iris/bit- stream/10665/104075/1/WHO_HIS_HSI_ RME_2013_1_eng.pdf 2015 Situational analysis of quality improvement in health care, Tanzania. This analysis covers the current status of QI work, standards and their assessment, indicators for QI, methods and approaches in use, progress made, SWOC analysis. http://www.tzdpg.or.tz/fileadmin/ documents/dpg_internal/dpg_work- ing_groups_clusters/cluster_2/ health/Sub_Sector_Group/Quality_ Assurance/11.a_Situation_Analysis_of_ Quality_Improvement_in_Health_Care_ Tanzania_-_Final.pdf 2012 Essential sur- gical care Tool for Situational Analysis to Assess Emergency and Essential Surgical Care http://www.who.int/surgery/publications/ s15986e.pdf?ua=1 2012 50 Partnership Preparation Package Core resources for Step 3 – Gap analysis Type of resource Location Year of publication Gap analysis Implementing a gap analysis framework to im- prove quality of care for your patients. USAID case study showing a gap analysis step-by-step. https://www.usaidassist.org/sites/assist/files/ hci.ghc_gap_framework_workbook.14jun10_1. pdf 2010 Gap analysis AHRQ Quality indicators toolkit – Instructions for doing a gap analysis https://archive.ahrq.gov/professionals/systems/ hospital/qitoolkit/d5-gapanalysis.pdf 2012 Practical resource Twinning Partnerships for Improvement. Japan- Liberia Partner Planning Workshop Report http://www.who.int/servicedeliverysafety/twin- ning-partnerships/partnership-planning-report. pdf 2016 Core resources for Step 4 – Action Planning The WHO Recovery Toolkit, accessible here, is a library of guidance resources in a single place which can be quickly and easily accessed, to guide action. A key purpose of the Recovery Toolkit is to support countries in the reactivation of health services which may have suffered as a result of a large-scale emergency. These services include ongoing programmes such as immunization and vaccinations, maternal and child health services, and noncommunicable diseases. In addition, and because the Toolkit contains core information needed to achieve functioning national health systems, it also supports countries with implementation of their national health plans during the recovery phase following a public health emergency. Type of resource Location Year of publication Knowledge translation Translating evidence into practice: a model for large scale knowledge translation http://www.bmj.com/content/337/bmj. a1714 2008 Planning and implementation WHO planning and implementation of district health services http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 WHO implementation strategy and tools. A guide to implementation of the WHO Multimodal Hand Hygiene Improvement Strategy http://apps.who.int/iris/bit- stream/10665/70030/1/WHO_IER_ PSP_2009.02_eng.pdf?ua=1 2009 Implementation tools and resources for supporting facility and national level implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes http://www.who.int/infection-prevention/ tools/core-components/en/ 2018 Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Evidence-based guideline to support countries as they develop and execute their national antimicrobial resistance (AMR) action plans. http://apps.who.int/iris/bitstream/10 665/251730/1/9789241549929-eng. pdf?ua=1 2017 Planning and implementation of district health services. 10 steps in planning, essential health package, health systems research, disaster preparedness http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 51Annexes Tools for assessing the operationality of district health. A set of tools aimed at district health management teams to generate the information that will serve as a basis for improving the operationality of health districts http://www.who.int/management/dis- trict/assessment/assessment_tool.pdf 2003 WHO Safe management of wastes from health care activities. Provides comprehensive guidance on safe, efficient and environmentally sound methods for the handling and disposal of health care waste in normal situations and also emergencies. http://www.searo.who.int/srilanka/doc- uments/safe_management_of_wastes_ from_healthcare_activities.pdf?ua=1 2014 Sanitation Safety Planning (Implementation tool). Manual for safe use and disposal of wastewater, greywater and excreta. http://apps.who.int/iris/bitstre am/10665/171753/1/9789241549240_ eng.pdf?ua=1 2015 WHO - Workload indicators of Staffing Needs (WISN) – User’s Manual http://www.who.int/hrh/resources/ WISN_Eng_UsersManual.pdf?ua=1 2010 Association for Professionals in Infection Control and Epidemiology (APIC) HAI cost calculator: http://www.apic.org/Resources/ Cost-calculators Core resources for Step 6 – Evaluation and Review Type of resource Location Year of publication Monitoring and evaluation M&E planning tool for both implementing and reviewing M&E plans https://www.thet.org/resources/ hps-monitoring-evaluation-plan/ 2014 Evaluation FAQs Step-by-step guide for health partnerships to effectively carry out an evaluation of their projects and partnerships in the form of frequently asked questions. https://www.thet.org/resources/ health-partnerships-evaluation-faq/ 2014 APPS -Evaluation Handbook A guide to evaluate five domains of a partnership: situational analysis, partnership strength, patient safety improvements, patient safety spread and annual evaluation report http://www.who.int/patientsafe- ty/implementation/apps/ Evaluation-Handbook_EN.pdf?ua=1 2012 Monitoring, evaluation and learning Webinar: sharing of experiences to provide some reflections around M&E https://www.youtube.com/ watch?v=v_oHEvgE_aA 2016 Monitoring and evaluation Health partnership symposium on monitoring, evaluation and learning. Document gathering tips to understand the value of M&E. Examples and exercises are provided. https://www.thet.org/wp-content/ uploads/2017/09/Monitoring-and- Evaluation.pdf 2017 Monitoring and evaluation EFFECt tool stands for EFFective in Embedding Change. This tools focuses on assessing implementation best practice, embedding change and the added benefits to individuals and institutions using a partnership approach https://esther.eu/index.php/effect-tool/ 2017 52 Partnership Preparation Package Core resources for improvement Type of resource Location Year PDSA Cycle (Plan-Do-Study-Act) Systematic process for gaining valuable learning and knowledge for the continual improvement https://deming.org/explore/p-d-s-a 2018 Model for improvement The Model for Improvement, is a simple, yet powerful tool for accelerating improvement http://www.ihi.org/resources/Pages/ HowtoImprove/default.aspx 2018 Confronting staffing issues and turnover of health facility staff Understanding the barriers to setting up a health care quality improvement process in resource- limited settings: a situational analysis at the Medical Department of Kamuzu Central Hospital in Lilongwe, Malawi https://bmchealthservres.biomedcentral.com/ articles/10.1186/1472-6963-14-1 2014 WHO Multimodal Improvement Strategy A one-page visual describing the five-part multimodal strategy to support IPC improvement in a health care facility http://www.who.int/infection-prevention/publi- cations/ipc-cc-mis.pdf?ua=1 2017 53Annexes ANNEX 3. TPI SITUATIONAL ASSESSMENT “HOW TO” TOOL EXAMPLE Step 2: TPI Situational Assessment “How To” Tool The following “how to” tool is presented as a practical guide explaining steps to plan and execute an in-depth situational assessment to inform a twining partnership initiative between two interested partner institutions. This assessment seeks to provide a foundational basis for the co-development of an effective and sustainable twinning partnership between partner institutions. This “how to” tool informs the process of conducting Step 2 of the 6-Step Partnership Improvement Cycle. The “how to” document is to be used together with the TPI Preparation Package and its associated resources. Post-Assessment: Build (4 weeks post-assessment) O B J E C T I V E : T R A N S L A T E F I N D I N G , S H A R E W I T H K E Y S T A K E H O L D E R S A N D I N I T I A T E A C T I O N P L A N N I N G P R O C E S S • Develop and finalize detailed assessment report in collaboration with the thematic lead persons, seeking any approvals where required • Develop short story from assessment highlighting quality improvement and safety opportunities and share with WHO Learning Laboratory for Quality Universal Health Coverage network • Participate in action-planning workshop for the twining partnership initiative presenting summary of the scoping mission findings and recommendations • Co-develop a partnership plan around the focused action areas identified by partner institutions • Use the assessment results to form the basis of the TPI partnership plan development • Provide feedback to WHO TPI team on assessment planning checklist • Discuss opportunities to leverage partner initiatives to support bottlenecks identified at district-/country-level • During Steps 4-6 of TPI cycle, consult quality improvement resources in TPI preparation package for action steps and evaluation/ review. • Conduct evaluation assessment as part of Step 6 of partnership Improvement cycle • Conduct Situational assessment on an annual basis ( as needed) • Align and build monitoring and evaluation system for the partnership with in-country quality of care measurement initiatives • Consult TPI quality improvement resources for hospital partnerships to inform monitoring and evaluation system of the partnership Assessment: Learn (10 days in-country) O B J E C T I V E : B U I L D R E L A T I O N S H I P S A N D L E A R N F R O M F R O N T - L I N E P E R S P E C T I V E S • Conduct team exercise with health facility staff and district health team to gain: • an understanding of the partner institutions • current understanding on quality and safety within local context. • Consult TPI Preparation Package for core technical tools and resources used for Step 2 • Identify key informant(s). Individual(s) should be a respected person amongst his/her peers. • Review interview guide with key informants or group and collectively refine tool to adapt to local context. • Key informant schedules interview times with health worker (HW) cohort. Recommendation for focused group discussions (FGD) with homogenous health worker cohort, if total cohort number exceeds five. Small homogenous groups allow for open discussion and confidentiality • During day of HH and PS assessment, do not hold any FGD. This is to allow limited HW participation in assessment. • Collect, analyse and crosslink data for all five thematic areas daily • Summarize and present preliminary findings to: • Hospital staff and district level staff • WHO Country Office/Ministry of Health • Relevant partners such as funding agency • Summarize preliminary recommendations according to actions needed for different stakeholders: • TPI initiative • Health facility • District health team • Ministry of Health • Hold daily assessment team meeting to debrief from day’s activities, address emerging key issues and prepare for next day Pre-Assessment: Deconstruct (minimum 4 weeks prior to assessment) O B J E C T I V E : R E V I E W I N - C O U N T R Y N A T I O N A L D O C U M E N T S , I D E N T I F Y Q I O P P O R T U N I T I E S A N D R E L E V A N T I N - C O U N T R Y P A R T N E R S • Identify experienced and motivated lead person to coordinate assessment • Inform WHO country office and regional office of impending situational assessment • Conduct desk review of existing national, sub-national and institutional documents on quality and safety. Possible documents include: • National health sector policy/plan • National quality health strategy • District/county-level operational or work plan • Health facility annual plan or workplan • artner coordination mechanisms • In-country quality of care measurement documents/projects • Identify areas you intend to evaluate during the assessment. Ideally, all five assessment thematic areas should be considered: • Quality Improvement • Patient Safety (PS) • Hand Hygiene (HH) • District-level health system • Patient & Community Perspective • Review long-form of interview guide addressing any unanswered questions that arise • Determine situational assessment schedule and share with WCO • WCO country office to schedule meetings in-country and facilitate facility/ district site visit • Identify composition of mission team and assign lead roles for five thematic areas • Ideally, team should include representation from MOH, multiple levels of the organization (if available) and the partner institutions • Ensure availability of relevant skill set, aligned with selected thematic areas • Identify relevant development partners/stakeholders to be consulted • Initiate series of coordination calls and email exchange with assessment team to discuss technical scope of mission and logistics • If funding allows, initiate scoping mission to sensitize Ministry officials and partners in-country ( if funding does not allow, initiate as part of in-country assessment) E X A M P L E S O F H E A L T H W O R K E R C O H O R T FACILITY- LEVEL DISTRICT/COUNTY-LEVEL • Clinical staff: doctor, physician assistant, nurses, midwives, pharmacist, lab technician, aides etc. • Non-clinical staff: maintenance staff, cleaners • Hospital Management • Patient & Community Representatives • Partners within Health Facility • Health Boards • Management Teams • Health Structure Directors • District/County Superintendent, District Commissioners, Traditional chiefs • Partners 55Annexes ANNEX 4. TPI PLANNING TEMPLATE SUMMARY INFORMATION Name of twinning institution 1: Name of lead: Name of twinning institution 2: Name of lead: Name and date of situational analysis/ baseline assessments used: Names of individuals completing the plan: Technical action areas for focus: Partners to consider specific areas to work on, based on situational analysis (experience highlights the need to focus on 2-3 areas maximum) Example: Project 1: Infection prevention and control Project 2: Knowledge and competency on quality improvement. For each action area, complete the template below. Use as many forms as required depending on the additional action areas addressed. Project number and action area • E.g. Project 1: Infection prevention and control Brief description of project • Provide a 1-2 sentence outline of the project Project goals • List the change the project will contribute to in 1- 2 sentences. • Where possible, link to national and/or local policies and plans including the national direction on quality. • Try to emphasize how the goals of the project respond to the needs identified in the baseline assessment. Project outcome(s) • Describe the improvement that you hope will result from the project. • Outcomes often relate to changes in practice or health outcomes. • The outcomes should contribute to the achievement of the goal. Project output(s) • The direct results of the project e.g. 20 people trained in infection control. The outputs should lead to achievement of the outcomes. Main activities • List all planned activities. For each activity, briefly outline what will be done; where and who will be involved on each side of the twinning partnership; how long it will take; methods to be used; and associated costs. • List technical exchange schedule ie. Fortnightly skype connection, monthly leads 1-to-1, 6-monthly visits, ... • Is a visit planned in conjunction with this project? (if yes, list likely human and financial costs.) • Twinning visit plans for year 1 should be thought through in detail. Plans for year 2 may be more general. Include a draft timeline. • What mechanisms are planned to allow receipt of just-in-time input to technical issues? • How will you connect with WHO efforts to support quality improvement? 56 Partnership Preparation Package Beneficiaries • Include information about the people who will benefit (directly and indirectly) from the project e.g. lab technicians; hospital managers; nurses and different groups of patient and community members. • Describe how they will benefit and provide realistic estimates of how many people in each group will benefit. • Will benefits span both sides of the twinning partnership? Stakeholders • Identify the key stakeholders and their interest in the project (e.g. other department, district and national health offices) i.e. any individual or group that may exert influence over the project activities and outcomes (across both arms of the partnership). • Consider the local community and key stakeholders, including patients and families who could contribute and add value to the planned efforts. • Outline which stakeholders the twinning partnership will report to and how often. Monitoring and evaluation • Define key indicators to be used to monitor whether the outcomes of your project have been achieved. • Provide an overview of your monitoring and evaluation plans, providing an outline of methods, who will be involved, how the process will be managed, and how partners will learn together. Sustainability and spread • Describe how long the activities will continue and what the plans are for long-term funding. • What benefits will continue after the initial 2-year project ends and how? • List your plans for building on project achievements. • Describe how you will actively disseminate new information gathered and consider activities to support vertical, horizontal and spontaneous spread opportunities. Risks • Identify potential risks associated with the plan e.g. key personnel moving on, changing institutional priorities, conflict between twinning partners, and how you will manage each of these risks. • List external risks and how you will manage them (e.g. ICT breakdown, problems with visas, political uncertainty). Project management and support • Outline project responsibilities including division of responsibilities across the twinning partnership. • Provide details of the key personnel involved in each arm of the partnership. • Consider key management questions: What systems will be used to manage finances in both locations? Who will have the main responsibility for budgets? How will you ensure that communication is effective and that all partners know what is happening? Approved by Date of approval 57Annexes ANNEX 5. TPI VISIT PROPOSAL TEMPLATE The Visit proposal template should be completed once a visit has been agreed, to ensure that the visit has clear objectives and contributes to the overall partnership planning. Twinning partnership (list both institutions within the partnership): Institution 1: Institution 2: Name of person completing the visit proposal form: Purpose of visit - describe which partnership project(s) the visit relates to: What are the dates of the proposed visit? Start date: End date: Is the visit aligned with existing in-country activity with no duplication of training or policy development work? Yes No Not applicable Does the visit clearly meet the needs of the twinning partner institutions? Yes No Not applicable Briefly describe the expected outcomes of the planned visit (outcomes are clear, realistic and logical): Briefly describe the outputs of the planned visit (outputs are clear, realistic and logical): Briefly describe any risks you think might be associated with the visit: List estimated costs of the visit: Briefly describe how the proposed visit will contribute to monitoring and evaluation of the associated partnership plan: List the number of people involved in the proposed visit and their role in achieving the visit objectives: Has the visit been jointly planned and agreed across the partnership? Yes No Will the visit offer potential benefits to both twinning partners (if yes, de- scribe briefly)? Yes No Not applicable Briefly describe how the visit will help achieve sustainability and spread of effective essential health service delivery. 58 Partnership Preparation Package ANNEX 6. TPI ACTION REPORT TEMPLATE The Action report template allows key outputs of each period of the partnership to be documented, lessons learned and actions arising logged. This is part of developing a strong, effective, action-focused partnership and contributes to partnership governance. Twinning partnership (list both institutions within the partnership): Name of person completing the report and date completed: Time period covered by this progress report: Key actions undertaken: Key achievements resulting from action taken: Key challenges faced: Date of next expected progress report: 59Annexes ANNEX 7: DEFINITIONS Accountability: The obligation to report, or give account of one’s actions – for example, to a governing authority through scrutiny, contract, management, regulation and/or to an electorate. African Partnerships for Patient Safety (APPS) programme: The WHO APPS programme is a hospital- to-hospital focused approach that was results- oriented and co-developed by hospital partnerships. Infection prevention and control, safe surgery, waste management and health worker safety were central elements of the African Partnerships’ work providing a common relevant goal that everyone was committed to improving. As a result, substantial implementation experience and learning have been achieved in this field across the African Region. The APPS approach demonstrated how working in partnership results in more motivated staff, increased commitment to change, strengthened capacity-building, focused drive and a desire to find appropriate solutions that will impact immediately on the quality and safety of patient care. This in turn can be used to strengthen the delivery of health services to communities globally. Clinical effectiveness: The application of the best knowledge, derived from research, clinical experience and patient preferences to achieve optimal processes and outcomes of care for patients. Community partner: Member of a quality improvement team representing a unit of population, often generally geographically defined, that is the locus of basic political and social responsibility and in which everyday social interactions involving all or most of the spectrum of life activities of the people within it takes place. Continuous Improvement: The process of making something better or of getting better. Integrated People-Centred Health Services (IPCHS) framework: The IPCHS Framework calls for a fundamental shift in the way health services are funded, managed and delivered to respond to these 60 Partnership Preparation Package challenges. The IPCHS vision is that “All people have equal access to quality health services that are co-produced in a way that meets their life course needs, are coordinated across the continuum of care and are comprehensive, safe, effective, timely, efficient and acceptable; and all carers are motivated, skilled and operate in a supportive environment.” WHO recommends five interwoven strategies that need to be implemented in order to achieve IPCHS. Application of the approach can build robust and resilient health services and are critical for progress towards universal health coverage and fulfilling the Sustainable Development Goals. Partnership: A partnership is a collaborative relationship between two or more parties based on trust, equality and mutual understanding for the achievement of a specified goal. Partnerships involve risks as well as benefits, making shared accountability critical. Patient-centredness: Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions. Patient safety: The reduction of risk and unnecessary harm associated with health care to an acceptable minimum. Performance: How well a person, team, project, programme, organization, or policy is being implemented against expected results. Quality: Quality has been defined and understood in different ways around the world. Two of the main definitions are below. • The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. • The totality of characteristics of an entity that bear on its ability to satisfy stated and implied needs. 61Annexes Quality audit: a systematic and independent examination to determine whether quality activities and related results comply with planned arrangements and whether these arrangements are implemented effectively and are suitable to achieve objectives. Quality assurance: all the planned and systematic activities implemented within the quality system, and demonstrated as needed, to provide adequate confidence that an entity will fulfill requirements for quality. Quality control: A process to evaluate actual performance, compare actual performance with quality goals, and take action on the difference. 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(https:// doi.org/10.1186/s12992-016-0181-9, accessed 13 April 2018). The European ESTHER Alliance. Bringing together our expertise for capacity building and health care. (https://esther.eu/ wp-content/uploads/2018/01/ BrochureAllianceEsther.pdf, accessed 13 April 2018). WHO Handbook for national quality policy and strategy. Geneva: World Health Organization; 2018 (http:// apps.who.int/iris/bitstream/handle/10 665/272357/9789241565561-eng.pd- f?ua=1, accessed 22 June 2018 ). WORLD HEALTH ORGANIZATION 20 Avenue Appia CH-1211 Geneva 27 Switzerland PLEASE VISIT US AT: http://www.who.int/servicedeliverysafety/ twinning-partnerships/en/
世卫组织结对促 进伙伴关系 实施结对伙伴 关系实用指南 筹备结对促进 伙伴关系的 一 揽子措施 WHO Twinning Partnerships for Improvement A practical document to implement twinning partnerships Partnership preparation package 世卫组织结对促进伙伴关系 实施结对伙伴关系实用指南 筹备结对促进伙伴关系的 一 揽子措施 2 筹备伙伴关系措施 WHO/HIS/SDS/2018.13 © 世界卫生组织2019年 保留部分版权。本作品可在知识共享署名——非商业性使用——相同方式共享3.0政府间组织 （CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo/deed.zh） 许 可协议下使用。 根据该许可协议条款，可为非商业目的复制、重新分发和改写本作品，但须按以下说明妥善引 用。在对本作品进行任何使用时，均不得暗示世卫组织认可任何特定组织、产品或服务。不允许 使用世卫组织的标识。如果改写本作品，则必须根据相同或同等的知识共享许可协议对改写后 的作品发放许可。如果对本作品进行翻译，则应与建议的引用格式一道添加下述免责声明：“本 译文不由世界卫生组织（世卫组织）翻译，世卫组织不对此译文的内容或准确性负责。原始英文 版本为应遵守的正本。” 与许可协议下出现的争端有关的任何调解应根据世界知识产权组织调解规则进行。 建议的引用格式。筹备结对促进伙伴关系的一揽子措施 - 实施结对伙伴关系实用指南。 日内瓦：世界卫生组织；2019 (WHO/HIS/SDS/2018.13)。许可协议：CC BY-NC-SA 3.0 IGO。 在版编目（CIP）数据。在版编目数据可查阅http://apps.who.int/iris/。 销售、版权和许可。购买世卫组织出版物，参见http://apps.who.int/bookorders。提交商业使用请 求和查询版权及许可情况，参见http://www.who.int/about/licensing。 第三方材料。如果希望重新使用本作品中属于第三方的材料，如表格、图形或图像等，应自行决 定这种重新使用是否需要获得许可，并相应从版权所有方获取这一许可。因侵犯本作品中任何 属于第三方所有的内容而导致的索赔风险完全由使用者承担。 一般免责声明。本出版物采用的名称和陈述的材料并不代表世卫组织对任何国家、领地、城市 或地区或其当局的合法地位，或关于边界或分界线的规定有任何意见。地图上的虚线表示可能 尚未完全达成一致的大致边界线。 凡提及某些公司或某些制造商的产品时，并不意味着它们已为世卫组织所认可或推荐，或比其 它未提及的同类公司或产品更好。除差错和疏忽外，凡专利产品名称均冠以大写字母，以示区 别。 世卫组织已采取一切合理的预防措施来核实本出版物中包含的信息。但是，已出版材料的分发 无任何明确或含蓄的保证。解释和使用材料的责任取决于读者。世卫组织对于因使用这些材料 造成的损失不承担责任。 由Ana Beatriz Dominguez Organero排版和设计。 Printed in Switzerland 目录 8 6 序言 缩略语 12 第1部分： 结对促进伙伴关系的目标 24 第2部分： 六步循环简介 26 44 60 第3部分： 深入挖掘 – 实践六步循环 附件 参考书目 42 参考文献 40 保持学习势头 致谢 世界卫生组织感谢诸多个人和组织为编写本文件提供支持和做出贡献。 Katthyana Aparicio、Melissa Kleine-Bingham和Shams Syed（世卫组织服务交 付与安全司）协调并领导了本文件的编写和成稿。Maki Kajiwara、Nana Mensah Abrampah和Julie Storr（世卫组织服务交付与安全司）为文件编写和起草提供重 要素材。 特别感谢Sandra Hwang和Albert Wu（约翰·霍普金斯大学彭博公共卫生学院）就 质量改进方法提出的技术意见。 外部同行评审小组 Ngormbu Jusu Ballah（利比里亚卫生部）、Jean Marc Chapplain（雷恩大学中心 医院）、Graeme Chisholm（热带卫生教育信托基金）、Eric de Roodenbeke（国际 医院联合会）、Charlie Evans（美国医疗管理者学会）、Koichi Izumikawa（长崎大 学医院）、Farid Lamara（法国专业技术促进会）、Emmanuelle Maurin（法国专业 技术促进会）、Sandra Hwang（约翰·霍普金斯大学阿姆斯特朗患者安全与质量研 究所）、Andrew Jones、Samuel Seeigbeh（利比里亚特莱沃恩纪念医院）、Albert Wu（约翰·霍普金斯大学彭博公共卫生学院）。促进全球卫生伙伴关系ESTHER联盟 成员。 缩略语 AHRQ 卫生保健研究和质量促进机构 AMR 抗微生物药物耐药性 APIC 感染控制和流行病学专业人员协会 APPS 非洲患者安全伙伴关系 EEA 欧洲ESTHER联盟 GLL 全球学习实验室 IHF 国际医院联合会 IPC 感染预防和控制 LMICs 低收入和中等收入国家 M&E 监测和评价 NHS 国家卫生系统 NUH 长崎大学医院 OECD 经济合作与发展组织 PDSA PDSA循环（计划-执行-学习-行动） QI 质量改进 SARA 服务可用性和就绪程度评估 SDGs 可持续发展目标 SMS 短信服务 SWOC 态势分析法（优势、劣势、机遇和挑战分析） THET 热带卫生教育信托基金 TMH 特莱沃恩纪念医院 TPI 结对促进伙伴关系 UHC 全民健康覆盖 USAID 美国国际开发署 WASH 水、卫生设施和个人卫生 WISN 人员配备需求的工作量指标 WHO 世界卫生组织 序言 背景 卫 生机构之间建立结对伙伴关系是一种创新方法，可用于改进卫生服务交付的方方面面。世卫组织结对促进伙 伴关系模式支持做出长期努力，在实现全民健康 覆盖大背景下提高卫生服务交付质量。该工作有 助于建设有韧性的卫生系统。方法的基础是推动 与国家卫生计划和战略保持一致，并努力实现可 持续发展目标。 结对促进伙伴关系是在世卫组织非洲患者安全 伙伴关系（APPS）经验基础上发展起来的。这些 丰富经验及之后受埃博拉影响国家恢复工作中 建立的结对伙伴关系为世卫组织结对促进伙伴 关系的设计提供了参考。世卫组织结对促进伙伴 关系的关键宗旨是支持卫生保健机构改进和加 强服务交付质量，同时确保符合本国在改进高质 量服务交付方面的整体战略方向。 机构间卫生伙伴关系可以在加强卫生系统方面 发挥关键作用。这一点已经在全世界得到越来越 多认同。许多全球性卫生集团1 强调，有必要“促 进利用机构间卫生伙伴关系加强卫生系统和交 付有效卫生服务”。过去十年间，各国也认识到伙 伴关系方法产生的协同作用，纷纷在国家政策文 件中强调机构间伙伴关系可以作为加强服务和 卫生系统工作的切入点。 除非洲患者安全伙伴关系规划外，结对促进伙伴 关系还以2014年西非埃博拉疫情后的结对支持 恢复工作的模式为基础。恢复领域结对促进伙伴 关系的关注点是建设有韧性的卫生系统和在受 疫情影响最大的国家重启安全的基本卫生服务。 恢复领域结对促进伙伴关系的目的是重建卫生 服务，以支持实施国家恢复计划。 实施结对伙伴关系涉及一系列服务交付和临床 护理领域，包括（但不仅限于）感染预防控制、患 者安全和具体临床服务。卫生人力队伍的能力建 设也是这一模式的应有之义。结对促进伙伴关系 有助于促进国家层面提高服务交付质量。这些伙 伴关系可以成为促进卫生改进战略的宝贵工具， 为一线服务交付带来真正的好处，并最终促进全 体人民的健康。结对伙伴关系开展协作，可以带 来单个组织或团队无法实现的有效卫生改进。此 1 如需有关全球性卫生集团的更多信息或阅读共识文件，请访 问世卫组织网站： http://www.who.int/patientsafety/implementa- tion/apps/global-catalyst-group.pdf?ua=1。 世卫组织结对 促改进伙伴关 系简介 · 结对促改进伙伴关系关 注机构间伙伴关系在催 化卫生服务改进方面的 价值。 · 非洲患者安全伙伴关系 发展起来的医院间伙伴 关系模式是发展结对促 改进伙伴关系的基础。 强调点是“边学边做”。 · 随着结对伙伴关系全球 网络的发展，有机会在 整个结对促改进伙伴关 系网络内学习和分享。 · 该方法促进协作、共同 发展并分享隐性和显性 知识，从而推动传播改 进服务的成功方法。 10 筹备伙伴关系措施 外，结对伙伴关系的工作也可以促进其 它国家和地区做出战略性努力，提高服务交付质 量。 筹备结对促进伙伴关系一 揽子措施的目的 本文件的目的是为有意通过结对伙伴关系提高 卫生服务交付质量的卫生机构提供实用的分步 骤方法。 本模式由六个步骤组成，起点是两家或多家伙伴 商定建立伙伴关系。结对促进伙伴关系通过系统 性流程指导各方伙伴，其中包括确定要改进的具 体领域，制定实施改进措施的行动计划以及评估 取得的进展和发生的变化。 机构间卫生伙伴关系既可以作为单个伙伴关系 发挥作用，也可以与其它伙伴关系协作支持全国 性类似伙伴关系网络。还可以通过联合解决问题 和分享经历积累供国家和省市主管部门参考的 证据和经验，从而支持这方面的全国性努力。这 也有助于进一步鼓励在卫生系统各级采取伙伴 关系模式。 目标受众 本文件的目标受众是致力于提高卫生保健和服 务交付质量的人，包括以下各方面： · 卫生机构 · 卫生设施 · 学术/研究机构 · 专业协会 · 捐助方组织 通过结对促进伙伴 关系，有机会支持 地方、省市和中央 各级改进服务交 付。它还可以催化 变化，从而在全民 健康覆盖背景下提 高质量。 谁会从结对促进 伙伴关系中获 益？ · 卫生工作者 · 医院 · 卫生设施 · 患者 · 社区 · 质量规划人员 · 国家决策者 什么是非洲患者安全伙伴关系？ 世卫组织非洲患者安全伙伴关系是以结果为导向的医院间服务改进方法。该伙伴 关系强调在互惠伙伴关系基础上联合开发解决方案。伙伴关系具有共同目标，其工 作的核心要素是感染预防和控制、安全手术、废物管理和卫生工作者安全。非洲患 者安全伙伴关系参加国产生大量实施经验，伙伴关系在激励员工、加强变革承诺、 强化能力建设和最终影响患者服务质量和安全性方面产生很大价值。非洲患者安 全伙伴关系方法示范地说明了伙伴关系如何加强卫生服务交付，从而使参加伙伴 关系的卫生设施乃至更广泛社区都从中获益。 11序言 · 卫生健康主管部门 · 政策制定者 · 政府。 《筹备结对促进伙伴关系的一揽子措施》还旨在 为中央一级负责规划、制订、实施和评估国家卫 生战略的决策者和主管部门（包括世卫组织国家 办事处和卫生部）提供参考。 谁会从结对促进 伙伴关系中获 益？ · 卫生工作者 · 医院 · 卫生设施 · 患者 · 社区 · 质量规划人员 · 国家决策者 什么是非洲患者安全伙伴关系？ 世卫组织非洲患者安全伙伴关系是以结果为导向的医院间服务改进方法。该伙伴 关系强调在互惠伙伴关系基础上联合开发解决方案。伙伴关系具有共同目标，其工 作的核心要素是感染预防和控制、安全手术、废物管理和卫生工作者安全。非洲患 者安全伙伴关系参加国产生大量实施经验，伙伴关系在激励员工、加强变革承诺、 强化能力建设和最终影响患者服务质量和安全性方面产生很大价值。非洲患者安 全伙伴关系方法示范地说明了伙伴关系如何加强卫生服务交付，从而使参加伙伴 关系的卫生设施乃至更广泛社区都从中获益。 何时使用一揽子措 施文件 本文件对任何现有 或新成立的结对卫 生机构有用，可以帮 助它们通过基于伙 伴关系的方法提高 卫生服务质量并将 相关努力纳入长期 服务改进的工作。 第1部分： 结对促进伙伴 关系的目标 目标概览 结对促进伙伴关系关注机构间伙伴关系在“边学 边做”2 模式下催化卫生服务改进的价值。结对促 进伙伴关系将各种实体均纳入考虑，包括卫生设 施、学术机构、私营单位等3。它有助于在地方、省 市和中央各级乃至跨洲实施各种类型的伙伴关 系。高收入国家的机构与低收入和中等收入国家 的机构之间也可以启动伙伴关系，为后者提供支 2 “边学边做”是指体验式学习理论，即从经验中学习，从而发展 技能或新的思考方法。（Lewis和Williams，1994年，第6页）。 3 各种各样的实体都可以参与伙伴关系，本文件采用“机构”一 词指代所有类型的实体。 持，从而使之获得独特机会，在实现全民健康覆 盖语境下促进提高卫生服务质量。 在结对促进伙伴关系模式下，每对伙伴关系应着 重实现三个目标。 · 第一个目标是发展伙伴关系。重点是促进卫 生机构间培育强大的双向伙伴关系。 · 第二个目标是根据服务交付一线确定的需求 实施有效干预措施，从而改进工作。 · 第三个目标是在地方和国家卫生系统内外推 广经验。 结对促进伙伴关系方法提供可测量的改进程序， 其中采用一整套经过验证的工具。通过参与结对 促进伙伴关系，各伙伴获得知识，提高文化意识， 并分享实现改进的创新方法。随着结对伙伴全球 网络的出现，有机会在更广泛的结对促进伙伴关 系范围内学习和分享经验，促进协作、共同发展 和分享，以及支持改进方法的推广和复制。 结对促改进伙伴关系 的终极好处在于双向 学习和改进，职工受 到鼓舞和激励，卫生 服务的交付得到加 强，患者和卫生工作 者得到更好结果。 ~ 恢复工具包 什么是共同开发？ 汇聚集体智慧促进协 作式 发展并开展联合决策 增进 信任的过程。 改进 伙伴关系 推广 结对促进伙伴关系 – 目标 14 筹备伙伴关系措施 目标1 – 伙伴关系 伙伴关系的形成是结对促进伙伴关系历程中的 第一步。两家或多家机构商定共同目标，并明确 伙伴关系的工作重点，以期实现本单位的可持续 发展。非洲患者安全伙伴关系对伙伴关系的定义 也包括关注人与人互动的社会学角度。在此定义 基础上，在结对促进伙伴关系模式下，要建设成 功的伙伴关系，以下价值观必不可少： 1. 协作 2. 信任 3. 平等 4. 双向 5. 责任共担 6. 透明。 在结对促进伙伴关系价值观和非洲患者安全伙 伴关系对伙伴关系的定义基础上，在落实伙伴关 系时可遵循以下原则4。 这些原则是形成和维护 有效、可持续伙伴关系的基础。 共同愿景和联合规划 · 协调并共同商定目标、时间框架和评价方法。 · 共同发展和制定伙伴关系计划和活动。 · 共同商定评估影响的关键绩效指标。 主人翁精神 · 确保本机构各分支（而不是个人）均支持以主 人翁精神参与伙伴关系。 4 这是之前伙伴关系中发展起来的一整套原则，但应根据每个 伙伴关系的具体情况调整。承认大量组织业已确定的类似伙 伴关系原则既重要也有用（例如：热带卫生教育信托基金；欧洲 Esther联盟）。 伙伴关系的定义 “伙伴关系可以定义 为两方或多方在信 任、平等和相互理解 基础上为实现共同商 定的目标而建立的协 作关系。伙伴关系既 有风险也有利益，因 而责任共担是关键。” ~非洲患者安全伙伴 关系，2009-2011年 15第1部分： 结对促进伙伴关系的目标 · 制定强调角色、职责和承诺的有效利益攸关 方策略，让利益攸关方都参与进来。 · 为卫生系统各级的参与制定战略和计划。 良好关系 · 在信任、不评判和承诺基础上建立和发展关 系。 · 利用个人的热情和力量。 · 尊重和理解当地规则、文化和习俗。 良好沟通 · 开展有效沟通，以促进决策和信息共享。 · 商定和确保决策渠道。 · 确定联系人5 并明确每个团队成员的职责。 工作方式 · 培养主动工作的个人，考虑具有幽默感的重 要性。 · 使伙伴关系具备透明、灵活和适应性强的特征 （同时关注不断变化的外部环境）。 · 进展顺利时表扬，不顺利时调整。 伙伴关系的力量 人们越来越认识到，协同运作的卫生伙伴关系可 以产生强大结果，联合努力通常比各干各的产生 的影响更大。 伙伴关系双方均可学到独特、意外的创新实践并 从中获益6。有时，还可以用更低费用实现同样或 更好结果。例如，乌干达教会基思兹医院与英国 切斯特医院国家医疗服务系统信托基金之间的 5 联系人是指被指定发挥项目、规划或具体活动相关信息协调 员职责的人。 6 有关每个伙伴的好处的更多信息见下文：https://www.ache.org/ pdf/nonsecure/White-Paper-International-Hospital-Partnerships.pdf。 “我们能够比单打独 斗时朝实现目标走得 更快。” ~加纳Komfe Anokye 教学医院Emanuel Addo-Yobo医生 非洲患者安全伙伴 关系伙伴关系优势 调查，2012年 16 筹备伙伴关系措施 伙伴关系充分利用本地资源，从本地获得酒精， 用于生产手部消毒剂。这种创新方法使伙伴关系 双方都以非传统方式进行思考并做出改进。 伙伴关系和全球目标 结对伙伴关系方法在本地机构变革、国家卫生系 统与全球舞台之间建立联系。可持续发展目标 承认伙伴关系有助于“动员和分析知识、专长、技 术和财政资源”，并认可伙伴关系的重要性（目标 17）。可持续发展目标进一步强调，“成功的可持 续发展议程要求在政府、私营部门和民间社会之 间建立伙伴关系。这些具有包容性的伙伴关系以 原则和价值观、共同愿景以及以人为本的共同目 标为基础，是全球、区域、国家和地方各级都需要 的。”与多个可持续发展目标的联系显而易见，特 别是有关全民健康覆盖的可持续发展目标3.8。 例如，伙伴关系方法可以提高孕产服务质量，从 而促进降低孕产妇死亡率（可持续发展目标具体 目标3.1）7。虽然结对促进伙伴关系强调在本地和 基层提高卫生服务质量，但全世界所有伙伴关系 合作的结果加起来，却会提高全球凝聚力并扩大 整体影响。重要的是，应当指出，结对伙伴关系产 生的好处将不仅会促进提高交付更优质卫生服 务的机构能力，而且如果设计和落实工作有效的 话，会对加强整个卫生系统都有帮助。 7 英国皇家助产士学会和乌干达助产士联合会。热带卫生教育 信托基金的案例研究： https://www.thet.org/case-studies/align- ing-partnership-plans-institutions-strategic-plan-2/。 可持续发展 目标17 重振可持续发展全球伙伴 关系 与结对促改进伙伴关系有 关的具体目标： · “加强在科学、技术 和创新领域的南北、南 南、三方区域合作和 国际合作，加强获取渠 道，加强按相互商定的 条件共享知识，包括加 强现有机制间的协调， 特别是在联合国层面 加强协调，以及通过一 个全球技术促进机制 加强协调。” · “加强国际社会对在 发展中国家开展高效 的、有针对性的能力建 设活动的支持力度，以 支持各国落实各项可 持续发展目标的国家 计划，包括通过开展南 北合作、南南合作和三 方合作。” 17第1部分： 结对促进伙伴关系的目标 可持续发展 目标17 重振可持续发展全球伙伴 关系 与结对促改进伙伴关系有 关的具体目标： · “加强在科学、技术 和创新领域的南北、南 南、三方区域合作和 国际合作，加强获取渠 道，加强按相互商定的 条件共享知识，包括加 强现有机制间的协调， 特别是在联合国层面 加强协调，以及通过一 个全球技术促进机制 加强协调。” · “加强国际社会对在 发展中国家开展高效 的、有针对性的能力建 设活动的支持力度，以 支持各国落实各项可 持续发展目标的国家 计划，包括通过开展南 北合作、南南合作和三 方合作。” 伙伴关系的发展和持续加强——日本 和利比里亚 日本长崎大学医院与利比里亚洛法州特莱沃恩纪念医院之间的伙伴关 系成立于2016年8月。当时，特莱沃恩纪念医院正处于2014年西非埃博 拉疫情之后的恢复阶段，需要依靠国际支持重启基本卫生服务，并根据 国家恢复计划推进本院恢复工作。 恢复过程中，特莱沃恩纪念医院迅速意识到，应对埃博拉的工作消耗了 大量资源，而要提高质量还需要开展大量工作。长崎大学医院看到特莱 沃恩纪念医院的广泛需求，同意与其结成伙伴关系。卫生部和洛法州主 管部门在正式结对促改进伙伴关系协议之初就大力支持。在承认双方伙 伴各自独特文化和背景的前提下，它们仔细考虑了伙伴关系的架构问 题。它们认识到，伙伴关系的成功将取决于一开始打下的基础，因而仔细 研究了伙伴关系的原则和定义。实践证明，这些做法对于伙伴关系的推 广至关重要。 之后，2016年10月，对特莱沃恩医院进行了形势评估和差距分析。然后 在2016年12月召开了正式的“行动计划会”，双方伙伴商定改进感染预 防和控制，其中特别关注手卫生和废物管理两项。人们指出，这两个领域 的改进将为提高医院整体质量奠定基础。 双方伙伴对利比里亚和日本进行了两次交流访问。在整个工作改进过程 中，伙伴关系的原则都得到加强，伙伴关系中相互学习的特征得到强调。 例如，特莱沃恩团队领导分享了应对埃博拉的经验，长崎大学医院表示 从中收获很大，因为他们了解到诊断和治疗埃博拉感染者的现实。 伙伴关系发展过程中，开展的活动一直符合也在不断演进的国家和洛法 州卫生健康计划。 18 筹备伙伴关系措施 目标2 – 改进 改进工作是伙伴关系的核心。一般而言，改进也 就是使一些事物变得更好的行动或过程。在医院 环境下，除改变态度和行为外，改进也常常意味 着组织和结构变化，从而使这一过程十分复杂， 因为它涉及人，且往往需要先改变文化。应先就 卫生保健设施内服务质量方面存在哪些不足达 成一致。在确定存在不足的基础上明确一个或多 个重点领域，将其作为伙伴关系合作的侧重点。 最终目的是通过采用有效改进方法成功落实干 预措施，进而提高服务质量和改善整体卫生健 康结果。伙伴关系的双方需要确定共同目标和重 点，以便发展起强大、有效和可持续的伙伴关系。 此外，在确定要改进的领域时，有必要让本地利 益攸关方以及卫生系统内部未来将接续相关努 力的团队和个人参与进来。 目标2包括以下必要工作： · 伙伴关系双方需要联合商定改进的切入点。 这种集体方法有助于形成支持开放心态、技 能使用和共同工作学习机会的安全空间，从 而促进主人翁意识及学习创新氛围。 · 实现伙伴间确定的共同目标，包括确定明确、 具体目标，商定最佳传播方法，制定清晰报告 机制以及对标准、方法和工作方式开展监督。 · 制定沟通计划，其中明确每个人应当担负的 责任，从而支持开展定期接触，协调改进活动 的实施。 · 试点实施若干调整措施，直到找到能实现预 期结果的良好流程。这个过程应有一定灵活 性，允许进行必要的改变和调整。 结对促进伙伴关系方法利用整套经过验证的工 具实现可测量的改进。通过参与结对促进伙伴关 系，各方伙伴获得知识，提高文化意识并分享在 改进 “包括卫生保健专业人员、患者及其家庭、研究人员、付 费者、计划制定者和教育者在内的每个人共同不懈努 力，做出调整，从而带来更好的患者结局（健康）、更好的 系统绩效（服务）和更好的专业发展（学习）。” Batalden, P. B., & Davidoff, F. (2007).什么是“质量改 进”？质量改进如何改变卫生保健？ 《卫生保健的质量与安全》，16(1), 2–3. http://doi.org/10.1136/qshc.2006.022046 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464920/ 19第1部分： 结对促进伙伴关系的目标 目标2 – 改进 改进工作是伙伴关系的核心。一般而言，改进也 就是使一些事物变得更好的行动或过程。在医院 环境下，除改变态度和行为外，改进也常常意味 着组织和结构变化，从而使这一过程十分复杂， 因为它涉及人，且往往需要先改变文化。应先就 卫生保健设施内服务质量方面存在哪些不足达 成一致。在确定存在不足的基础上明确一个或多 个重点领域，将其作为伙伴关系合作的侧重点。 最终目的是通过采用有效改进方法成功落实干 预措施，进而提高服务质量和改善整体卫生健 康结果。伙伴关系的双方需要确定共同目标和重 点，以便发展起强大、有效和可持续的伙伴关系。 此外，在确定要改进的领域时，有必要让本地利 益攸关方以及卫生系统内部未来将接续相关努 力的团队和个人参与进来。 目标2包括以下必要工作： · 伙伴关系双方需要联合商定改进的切入点。 这种集体方法有助于形成支持开放心态、技 能使用和共同工作学习机会的安全空间，从 而促进主人翁意识及学习创新氛围。 · 实现伙伴间确定的共同目标，包括确定明确、 具体目标，商定最佳传播方法，制定清晰报告 机制以及对标准、方法和工作方式开展监督。 · 制定沟通计划，其中明确每个人应当担负的 责任，从而支持开展定期接触，协调改进活动 的实施。 · 试点实施若干调整措施，直到找到能实现预 期结果的良好流程。这个过程应有一定灵活 性，允许进行必要的改变和调整。 结对促进伙伴关系方法利用整套经过验证的工 具实现可测量的改进。通过参与结对促进伙伴关 系，各方伙伴获得知识，提高文化意识并分享在 改进 “包括卫生保健专业人员、患者及其家庭、研究人员、付 费者、计划制定者和教育者在内的每个人共同不懈努 力，做出调整，从而带来更好的患者结局（健康）、更好的 系统绩效（服务）和更好的专业发展（学习）。” Batalden, P. B., & Davidoff, F. (2007).什么是“质量改 进”？质量改进如何改变卫生保健？ 《卫生保健的质量与安全》，16(1), 2–3. http://doi.org/10.1136/qshc.2006.022046 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464920/ 创新改进方法方面的学习收获。得到改进的领域 包括基线评估涉及的各种服务交付和临床护理 领域，例如感染预防和控制、患者安全和具体临 床服务。 这方面可以举出许多例子，不过其中最为一致的 概念是，服务交付的改进应对整个卫生系统的质 量产生直接和持久影响8。服务交付和卫生人力 之间的联系显而易见。伙伴关系的所有行动都会 凸显卫生系统各组成部分之间的内在联系。在以 下例子中，埃塞俄比亚的伙伴关系显示，设施层 面服务交付和临床护理的改进会对更广泛卫生 系统产生直接影响。最终，实现设施层面的平等 可以为整个卫生系统带来平衡和改进。 8 按世卫组织的传统说法，卫生系统由六个部分组成：领导和治 理；卫生信息系统；卫生筹资；基本医疗产品和技术；卫生人力 资源以及服务交付。 20 筹备伙伴关系措施 改进 – 埃塞俄比亚贡德尔医院和英 国莱斯特医院 埃塞俄比亚贡德尔大学医院与英国莱斯特大学医院国家医疗服务系 统信托基金之间建立伙伴关系的目的是在贡德尔医院实施世卫组织 《手术安全核对表》。通过开展定期检查、征求员工反馈意见和组织 跨学科学习，监测结果显示，《核对表》的实施很成功，得到工作人员 很好的遵守。此外，伙伴关系坚持开展联合学习和参与活动，促进了 研究能力建设。之后又开展了监测《核对表》在伙伴关系中实施情况 的多国研究项目。监测发现，《核对表》使用率从17%提高到53%，其 中在急救中的实施率达到100%。现在正对不同科室人员进行使用培 训。重要的是，研究还使我们有机会审视伙伴关系的工作，便于进一 步改进。值得注意的是，这一长期伙伴关系得到了热带卫生教育信托 基金和世卫组织的支持。 21第1部分： 结对促进伙伴关系的目标 目标3 – 推广 通过推广，可以在本地、国家卫生系统乃至更广 范围内分享和扩大利用改进工作的经验。通过分 享所采取的有效和无效措施信息，可以扩大伙伴 关系影响范围和影响力。在考虑推广时，应拟定 记录成功经验的策略，并及早就如下议题展开对 话： (1) 卫生服务已经得到哪些新的、有创意的改进？ 推广新出现的成功改进经验有助于大规模推广。 (2) 哪些方式有助于使这种改进持续下去？保持 改进的一个方法是让新做法有充足时间成为全 面落实的标准（例如将新做法纳入政策、程序、岗 位描述等）。 (3) 改进是怎么实现的？例如，展示新做法的好处 和优势有助于该做法得到保持和推广。 (4) 谁是推广的目标受众?在考虑目标受众时，重 要的是认识到推广工作应针对个人、设施还是整 个卫生系统。这些细节有助于有条理地确定传播 信息和成果经验的计划。 伙伴关系在工作中需要咨询考虑本国在质量问 题上的战略方向，特别是在推广方面。现在，许多 国家都在制定或修改国家质量政策和策略。结对 伙伴关系活动的经验可以供制定这些政策策略 参考。在已经存在此类国家策略的地方，结对伙 伴关系应认真地与国家总体指导保持一致。这 样，伙伴关系的工作就可以支持实施全国性的质 量改进努力，从而产生最大影响。可以通过初始 形势评估确定质量领域的全国性方向。在伙伴关 系发展的各个阶段，双方伙伴均应将该方向牢记 于心。 什么是推广？ “可以把推广理解为处于 相同或不同等级的机构和 个人之间传播实践方法的 过程。这是一个增加创新 卫生服务改进措施影响的 有意识过程，可以使更广 泛人群受益，并以可持续 方式促进政策变化和系统 发展。” ~非洲患者安全伙伴关系 推广工具包 22 筹备伙伴关系措施 可以考虑三种推广：横向、纵向和自然传播。从伙 伴关系成立伊始，就应进行以下思考： 1. 伙伴一开始为卫生设施改进做计划就 应讨论如何推广改进措施的问题。 2. 考虑通过不同渠道传播质量改进信息， 例如会议、专业期刊、媒体、口碑和第一 手记录。 3. 传播方式应尽可能有吸引力，使其他人 想要复制你们的改进。 4. 建设一个网络，以维持和推动这种传 播。 5. 最后，在一开始就要考虑如何将来自这 个项目的经验用于国家和全球层面的 学习系统。 横向推广指将改进措施在卫生保健系统内同一 级别的人群和组织之间推广。例如，把医疗机构 内一个部门的改进复制到其它部门。 纵向推广指将信息和改进在卫生系统内国家、次 国家和地方各级传播。纵向推广特别重要，因为 国家级可以推动地方上的变化，地方上也可以推 动国家层面的变化。重要的是，要收集改进的定 量数据和分析，因为这是循证实践的基础，也是 纵向推广的关键组成部分，会影响政策变化。 要推广经验，就要在质量改进证据与机构和国家 质量政策之间建立强有力的联系。该证据及其与 现行政策的明确联系有助于促进将结对促进伙 伴关系取得的进步纳入机构和国家质量政策。 自然推广是指没有预先计划但通过社交网络或 意见领袖等非正式渠道自然发生的传播，有时还 会跨越国境。例如，伙伴机构领导人与卫生系统 23第1部分： 结对促进伙伴关系的目标 内部具有重要影响力的人之间的交流。通常发生 在非正式会议和聚会场所的人与人之间互动和 交流能够促成变化，这一点已经越来越清楚了。 此外，有必要考虑观点、能力和技巧从低收入国 家向高收入国家伙伴传播的情况。这也涉及相互 的概念，而伙伴关系特别有助于相互学习。 社区的关键作用 让患者和社区参与进来，有助于促进推广，并加 强改进措施的实施和持续。与本地社区建立联 系，可以提高服务质量并使服务更加以人为本。 这对卫生保健需求特别高的资源缺乏环境尤为 重要。赋权患者和社区，为他们提供信息，让他们 有能力做出激发变革的决定，从而围绕他们的需 求与他们联合发展卫生服务。这样可以提升患者 体验，改善健康结局，提振其对卫生保健提供者 的信任和信心。理想情况下，患者、家庭及社区的 参与应成为所有国家卫生计划的组成部分。在没 有联系患者和社区的正式机制的情况下，卫生保 健工作者可以参加与他们联系的简单行动，例如 提供实用培训（例如手卫生、废物管理、药物使用 等），要求患者代表或社区领袖参加情况介绍会 并提供持续支持。 宣传伙伴关系及其取得的成就将促进其工作并 使社区对伙伴关系更感兴趣。可以庆祝和宣传相 关工作，以保持推动力和创造积极氛围。在发生 社区传播时，通过卫生保健机构内部改进程序产 生的知识就会成为正常做法和标准的一部分，从 而对整个人群的卫生健康产生积极影响，例如手 卫生方面的改进。 以下举例说明横向和纵向推广。 推广 – 布基纳法 索欧德拉奥格医 院和法国蒙彼利 埃医院 2013年，布基纳法索欧德拉奥格 教学医院与法国蒙彼利埃教学 医院建立伙伴关系，并开始实施 在神经外科病房中改善卫生的 试点项目。当时确定的目标是在 该科病房中达到医院卫生标准。 选出了四个重点领域：手卫生、 废物管理、医院感染和卫生工作 者能力建设。当时的想法是集中 精力在医院一个科室的病房中 开展活动，以便从中总结出可以 在其它病房和科室复制的经验。 此外，法国专业技术促进会确信 伙伴关系的做法很有好处，因而 争取到欧盟委员会的支持，将该 经验推广到该国其它卫生保健 机构。自2017年2月以来，已经成 立九个涉及全国性和地区性医 院的伙伴关系，对布基纳法索整 个卫生系统都产生了积极影响。 也就是说，同时发生了横向和纵 向传播 。 第2部分： 六步循环简介 伙 伴关系方法是分步骤的，可以促进伙伴关系的发展，系统地发现不足之处，制定行动计划并发展评估循环。 1. 伙伴关系的发展始于两家或更多卫生 机构正式成立全面运转、相互沟通的结 对伙伴关系。伙伴关系双方同意开展合 作，以提高卫生保健服务质量。 2. 需求评估使双方确认并了解卫生机构 的基线需求。这是差距分析的基础，并 将最终指导伙伴关系未来所有改进活 动。 3. 差距分析包括研究需求评估结果并确 定关键的重点行动领域。从差距分析开 始就以系统方式为行动规划奠定基础， 以便帮助各家伙伴机构开展更有针对 性的改进工作。 4. 制定行动计划，各家伙伴机构共同商定 书面行动计划。该行动计划以差距分析 为基础，为结对伙伴关系确定清晰的短 期和长期目标。在这个步骤中，重要的 是要考虑沟通、推广和预算。 5. 行动是开始实施行动计划中双方商定 的改进活动。到这个阶段，伙伴们已经 明确行动方法并制定了战略行动计划， 并已经为持续行动确定了沟通渠道。 6. 评价和审查使结对伙伴关系得以评估 其技术改进工作的影响以及结对关系 的长处和运转情况。对伙伴关系优势和 不足之处的反思有助于做出调整。 有多种工具和资源（附件2）可以支持每个步骤， 并可以在整个过程中指导参加伙伴关系的行动 实施者。 伙伴关系 的发展 结对促进 伙伴关系的 循环 制定行动 计划 需求评估 差距分析 评价和审查 行动 第3部分： 深入挖掘 – 实践六步循环 循 环中，各步骤均应有一项或更多可为之努力的有形产出或可交付成果。这些产出旨在帮助结对促进伙伴关系 行动起来。为协助参与伙伴，附件2提供一份支持 性工具和资源清单。 实施组织和结构变化的工作通常很复杂，因为在 许多情况下这都涉及到人，还需要发生文化变 化。因此，在为任何特定技术行动领域寻找适当 工具时，都要考虑这些工具如何支持为伙伴关系 活动、活动实施及重要跨领域主题（例如社区参 与、知识管理和沟通/宣传倡导）做计划。 另外，在为结对活动做计划时，还要考虑更广泛 的国家背景、政策、框架、战略重点和现有行动。 技术改进必须与国家政策和战略相一致。从短期 和长期看，这对实现可持续发展目标3并推广结 对伙伴关系改进经验特别重要。 第一步：伙伴关系发展 这是两家或多家机构间正式建立全面运转的沟 通性结对关系的开始。伙伴关系双方同意合作提 高卫生保健质量，合作重点是服务交付的不同方 面，包括临床护理。 要成功落实伙伴关系，一个条件是建立稳定的供 资结构。从一开始就要明确这一点，因为伙伴之 间将要开展的活动取决于能否获得人力和财力 资源。通过国际合作建立的伙伴关系9可以利用 来自伙伴关系一方的直接供资。在其它情况下， 各方伙伴可商定成本共担，或是努力争取外部资 金。这就要求伙伴机构合作确定潜在资金来源并 共同提出建议书。无论在开展活动时采取哪种供 资模式，伙伴之间商定明确的制度和程序都至关 重要。 主要活动 1. 确保结对伙伴关系双方的管理和领导层就采 取联合行动正式达成一致，例如通过机构之 间书面意见声明（如承诺函）。 2. 确定各伙伴机构的结对工作负责人和副手。 理想情况下，质量改进管理员应成为该工作 负责人。在本单位没有质量管理员的情况下， 可以指定主管质量和安全工作的人负责。 3. 确保多个学科的工作人员参与并致力于成 9 国际合作概念涉及代表不同国家的个人或群体之间为实现共 同目标或利益而进行的互动。 产出或可交付成 果 1. 酌情在机构管理层之间交换 信函（可以是承诺函或谅解备 忘录）。 2. 就结对伙伴关系定义达成一 致。 3. 伙伴关系双方选定各自团队 成员并交换联系方式。 4. 制定沟通计划。 5. 启动会纪要列明潜在工作领 域、下一步工作和进行需求评 估的暂定日期。 6. 正式指定双方团队负责人和 副手，这些人员应接受过相关 培训，能够利用本文件提供的 信息。 工具和资源链接 28 筹备伙伴关系措施 为“改进团队”的一员。例如，专门负责收集数 据和监督评估活动的人员。如果参与员工目 的明确，那么变化过程就会很有力，并且对抵 制变化的员工产生积极影响。 4. 考虑建议的伙伴关系定义；在结对伙伴之间 商议如何调整并就定义达成一致，以此作为 之后工作的基础。 5. 与管理人员谈判，确保改进团队有时间投入 确定的技术行动领域。 6. 建议召开启动会，让结对双方团队成员相互 熟悉。如无法召开面对面会议，也可以召开虚 拟会议。 7. 建立采用各种方法（电话、短信、电子邮件、网 络电话等）进行定期沟通（建议至少每月一 次）的制度。 8. 为规划的活动确定预算，包括管理费用。 第二步：需求评估 通过需求评估发现和了解相关卫生设施的基线 需求。这是差距分析的基础，并将最终指导伙伴 关系未来所有改进活动10。 主要活动 1. 对有关卫生服务质量的现有国家、省市和机 构文件进行书面材料审查。可能的文件包括： 国家卫生部门政策/计划、国家质量政策或战 略。 2. 确定有经验、有干劲的负责人协调评估工作， 并确定评估团队成员。团队构成取决于评估 范围、时限和可用资源。理想情况下，团队应 包括本地卫生管理部门代表、本单位管理层 人员和要评估的技术领域专家。 10 附件3举例说明为长崎大学医院和特莱沃恩纪念医院之间结 对促改进伙伴关系进行形势分析开发的“怎么做”工具。 工具和资源链接 29第3部分： 3. 开始评估前，应向所有评估团队成员介绍情 况，使之全面了解工作的预期结果，包括数据 收集程序。 4. 与本单位其它员工沟通，因为收集用于需求 评估的数据时需要其它团队合作；确保一开 始就得到其它员工理解；讨论保密问题。 5. 利用适当评估工具对选定技术领域进行具体 需求评估。可评估主题示例如下： a. 感染预防和控制 b. 患者安全和卫生工作者安全 c. 基本外科手术服务 d. 废物管理 e. 水、环境卫生和个人卫生（WASH） f. 孕产妇和新生儿保健 g. 卫生人力。 6. 考虑采用标准化工具完成需求评估。附件3举 例说明为特莱沃恩纪念医院需求评估开发并 使用的工具。 考虑此前6至12个月对任何相关领域进行的评 估，收集评估结果和相关专业知识，作为宝贵学 习来源。 第三步：差距分析 差距分析就是审查需求评估结果，发现需要采取 改进行动的关键重点领域。系统的差距分析是行 动规划的基础，可以帮助伙伴机构实施更有针对 性的改进工作。虽然分析可能揭示若干差距，但 可能不是所有差距都适合在伙伴关系框架下处 理。建议选择两到三个重点干预领域，以确保能 产出或可交付 成果 完成针对相关技术领域的基 线分析和形势分析报告。 30 筹备伙伴关系措施 够做到预期改进11。 主要活动 1. 伙伴双方改进团队召开面对面会议或虚拟会 议，讨论第二步形势分析的结果。 2. 分析和解读收集的数据和信息。 3. 利用基线分析和形势分析结果确定存在哪些 需要改进的不足之处，并争取厘清存在这些 差距的原因。 4. 根据急迫程度及可用人力和财力资源情况， 从上述差距清单中明确重点领域。 5. 确定改进计划中要包括哪些指标。 6. 关注小规模的简单行动。 7. 列出可以缩短差距的具体措施。 8. 向高级领导层汇报工作，争取其认可和支持 差距分析结论和确定的重点领域。 第四步：制定行动计划 通过制定行动计划，各方伙伴共同商定书面行动 计划。该行动计划以差距分析为基础，为结对伙 伴关系确定明晰的短期和长期目标。在这一步骤 中，也要考虑与宣传、推广和预算有关的事项.12 主要活动 1. 在伙伴机构举行团队会 · 明确伙伴机构的重要团队成员： · 支持伙伴关系工作的机构领导或 11 在根据第二步完成差距分析时，特莱沃恩纪念医院和长崎大 学医院之间的结对促改进伙伴关系召开了一次规划研讨会， 以审查存在的差距并确定下一步工作重点。完整报告见附件 2第三步。 12 例如，有关制定行动计划的模板见附件4-7。 工具和资源链接 产出或可交 付成果 1. 一份差距分析报告， 其中包括当前形势和 需要做出的改进。该 报告应列出存在哪些 不足之处以及造成差 距的因素。 2. 根据伙伴关系双方的 能力确定的重点和指 标清单，以处理发现 的差距。 31第3部分： 结对促改进伙伴关系的核心是质 量改进 《筹备结对促改进伙伴关系的一揽子措施》文件列出所有六个步 骤，支持和指导有关各方启动伙伴关系并确定需要改进的服务交付 或诊疗领域。除本文件外，阅读以下有关第四步和第五步简介时，也 可同时阅读更为详细的实用实地指导手册《采取行动：结对促改进 伙伴关系发展的第四步和第五步》。《采取行动》深入探讨各种质量 改进模式和方法，并支持伙伴关系内部的计划制定、行动、实施和质 量改进工作。该手册综述有关伙伴关系中采取务实行动的各种理 论，任何已经明确质量挑战、具体需求和当前服务差距或是已准备 好制定卫生保健环境下有针对性干预和改进行动计划的质量改进 团队均可利用。 《采取行动》文件还包括一份清单，其中列出通过世卫组织促进高 质量全民健康覆盖全球学习实验室收集的提高质量的常见障碍和 关键成功因素。印度、马拉维、墨西哥、尼日利亚、英国、委内瑞拉和 津巴布韦七国就常见障碍和关键成功因素提供了反馈意见。这些反 馈意见带来一线人员对于医疗机构质量改进面临的挑战和机遇的 重要看法。如需有关常见障碍和关键因素的更多信息，请查阅《采取 行动：结对促改进伙伴关系发展的第四步和第五步》。 如需有关世卫组织全球学习实验室的更多信息，请访问: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/ 32 筹备伙伴关系措施 经理 · 专门负责该项目的质量改进团队 负责人 · 技术/临床/主题事项专家 · 测量和评价工作负责人 · 社区/患者代表 · 提供技术和行政支持的质量改进团 队工作人员 · 确保就重要定义达成共识 · 简要列出筹备活动 · 回顾迄今为止开展的六步循环中第 一步至第三步活动 · 确保整个团队都熟悉已经确定的 重点领域 · 评估基层的兴趣和能力 · 估算预计费用，包括人力、时间和 金钱。 2. 商定干预措施 · 审查可能干预措施的证据，其中关 注得到改善的结果 · 寻找该主题领域所有相关文献 的相关资源 · 咨询本单位和伙伴机构的专家 · 咨询其他卫生工作者。 · 选择能产生最大好处、使用障碍最 低和持续潜力最大的干预措施 · 仔细考虑如何利用技术交流支 持相关干预措施 · 注意伙伴关系结束后干预措施 的可持续性 工具和资源链接 33第3部分： · 将干预措施分解为必要的行为、结 构和程序变化。 3. 概述实施活动 · 概述实施计划 · 总结落实干预措施各方面工作 的职责和责任 · 确定本地在实施和设计方面存在 哪些障碍 · 联系利益攸关方，确定可能存 在的关切 · 根据本地情况确定需求 · 确定与实施有关的潜在效益和 损失，包括哪些人将受益哪些 人将受损 · 评估当前沟通方法并酌情调整。 4. 概述职责和确保能力 · 估算预计支出 · 估算团队成员费用/时间 · 估算物资/设备费用/时间 · 估算投入数量和现有能力 · 确定每个团队成员的作用和责任 及其为改进目标做贡献的方式 · 确保工作人员投入时间和得到支 持 · 获得本单位领导的必要批准， 以确保关键员工能够投入时间 · 指定行政支持或其它援助人员 · 确保明确伙伴机构团队成员的职 责，并使整个伙伴关系都了解相关 34 筹备伙伴关系措施 情况。 5. 概述监督和评价活动 · 概述监督活动 · 检查医院采取的流行病学和其 它现有措施 · 确定重要的实施成功指标 · 确定收集评价证据的重要方法 · 概述评价活动 · 确定重要成果指标 · 确定收集评价证据的重要方法 · 评价和监督方法应尽可能简便 · 考虑与处于类似环境下的其它医 院对标。 6. 完成书面行动计划 · 分享初步计划，确保参与伙伴关系 各医疗机构的团队意见一致 · 确定一系列伙伴关系互访日期，并 明确访问目标，包括结对伙伴、其 它伙伴及国家/世卫组织牵头（如适 用） · 商定伙伴进展报告安排（见附件 4-7）。 第五步：行动 行动是实施行动计划所列明双方商定改进活动 的开始。到这个阶段，各方伙伴已明确行动方法 及其重点，并已确定采取持续伙伴行动的沟通渠 道。应每半年审查一次进展情况，以便在必要时 采取整改措施。改进工作团队应利用之前确定的 指标按计划进行定期监督审查。在这个行动阶 产出或可交付 成果 1. 完成书面的两年伙伴关系 计划 2. 完成书面的半年期初始短 期行动计划 35第3部分： 段，建议采用适当办法跟踪预算。 主要活动 1. 与伙伴一道落实伙伴关系计划 · 确保在伙伴之间持续保持行动一 致 · 确保相关活动一直与国家和省市 有关加强卫生服务质量的努力相一 致 · 确保在同一家机构内工作的伙伴 一直了解改进活动 · 确保现有改进活动与机构层面 已经开展的工作保持一致 · 伙伴双方均标记采取初始行动的 时刻 · 选择一个日期。 2. 管理活动的实施 · 确定质量改进团队定期分享项目 进展最新情况的日程安排 · 确保采取措施使工作人员能够定 期看到数据 · 确保整个机构的参与，包括未直接 参加具体改进工作的员工 · 确保整个伙伴关系内就实施活动 定期开展沟通。 3. 指导团队实施质量改进活动 · 为质量改进团队领导提供促进和 质量改进方法培训 · 利用所有（本地的和基于伙伴关系 的）可用资产提供辅导、指导和一般 工具和资源链接 36 筹备伙伴关系措施 性现场支持 · 在团队会议期间专门安排时间让 团队领导向团队成员转移质量改进 知识，以便培养一批能够催化和辅 导质量改进的卫生工作者。 4. 实施质量改进行动，对变化进行测试 · 实施干预措施 · 采用PDSA循环（计划-执行-学习- 行动循环）或其它商定方法通过小 范围测试变化测量绩效 · 对照计划的活动和预算跟踪进展 情况 · 根据获得的信息（例如小范围变化 测试的结果和反馈）对干预措施做 出调整 · 在日志中记录出现的问题及处理 情况 · 建立快速反应机制，与伙伴一道解 决问题。 5. 评估和调整干预措施 · 每半年审查一次 · 拟定报告 · 据此调整团队工作 · 根据人员流动、能力建设需求 以及人员重新培训和培训更多 工作人员的需求情况调整变化 · 向伙伴关系报告出现的问题13 · 双方都庆祝取得的或小或大 13 例如面对失败的伙伴关系，见附件1。 37第3部分： 成就。 6. 分享经验和推广变化 · 持续调整改进措施，直到做好在更 大范围内实施的准备 · 实施推广计划，其中仔细考虑省市 和国家情况 · 利用试点项目的成功实施经验，并 在整个组织内复制发生的变化，从 而推广改进措施 · 发现利用伙伴关系活动在其它 机构内带来变化的机会，鼓励 在全国范围内推广。 7. 记录并传播观察到的改进情况 · 提炼有关变化的故事 · 提炼实施经验，开发知识产品14， 例如知识简报和行动简报（见附件 8-9） · 综合来自伙伴关系一方并使对方 受益的经验，突出学习的双向性 · 利用国家、区域和地方层面适当机 构传播进展报告，以保持对话和与 整体国家计划的联系。 14 如需有关知识简报的更多信息，请访问世卫组织全球学习实 验室 产出或可交付成果 1. 拟定一系列报告，其中概述伙伴关 系计划中的行动及其进展 2. 对实施活动进行中期审查 38 筹备伙伴关系措施 第六步：评价 评价和审查使结对伙伴关系得以评估其（在基线 基础上开展的）技术改进工作的影响及结对关系 的优势和运转情况。通过反思伙伴关系的优势和 不足，可以调整改进。 监督和评价是成功伙伴关系的重要组成部分，必 须从伙伴关系循环的一开始就予以落实。这一 步骤标志着循环的闭合，使伙伴双方可以审查评 估伙伴关系实现目标的情况及其真实影响。评价 是最后阶段，但整个循环过程中均需监督，监督 结果可供整体评价参考。除本地审查会和伙伴关 系讨论外，每个结对伙伴关系也应编写定期监督 报告（半年报告；一年期重复基线评估；两年期审 查）。 有人认为，由专家进行外部评价可以确保客观 性；也有人认为，由项目团队本身评估更有助于 总结经验。结合这两种方法可以产生更好的结 果，并提升伙伴满意度。不论最终决定怎么做，各 方伙伴均应参与到该工作中来；专家应负责评价 的特定方面，应在伙伴关系一开始就对评价和监 督过程做出计划。 成功的评价工作应在结构上考虑三个目标，即伙 伴关系的长处、改进的重点领域以及改进的推广 情况。 主要活动 应在伙伴关系六步循环的较早阶段就开始对评 价工作做出计划。定计划时应包括考虑以下内 容： · 确定改进工作有效性的重要指标 · 评估伙伴关系的长处 · 伙伴关系以外的推广 工具和资源链接 39第3部分： · 对参与伙伴关系的人进行评价方法培训 · 定期报告。 在整个六步循环中均需开展评价活动。第六步关 注综合各种发现的活动，并进行任何必要评估。 1. 双方伙伴一道审阅监督报告，并确定如何 综合评价（收集统计数据、访谈、讨论组、调 查等）。 2. 综合显示所开展活动有效性的重要指标的 结果以及伙伴关系的长期影响。 3. 根据伙伴关系计划所列各项行动（并采用 适当评价工具）准备评价报告。 4. 对评价培训的成果进行反思。 5. 重复进行一次基线评估/形势分析，以观察 进展情况。 6. 对协作的长处进行评估。 7. 对推广活动进行评估。 8. 合成所有结论，并商定存在哪些重要经验 教训（可考虑仅限最重要的十条）。 9. 准备评价报告，以便显示影响并争取财政 支持。报告应重点涉及项目产出和结果实 现情况。 10. 在内部和外部传播得到的结论。 产出或可交付成果 1. 对一个两年期项目而言，应产生三 份监督报告，在伙伴关系内共享并 提交医院领导者。报告概述实现伙 伴关系计划的行动和进展情况（半 年报，一年报和两年报）。 2. 重复进行基线评估/形势分析。 3. 评价报告。 保持学习势头 参 与采用伙伴关系方法改进质量的医院和卫生系统已取得显著成功，包括伙伴关系得到延续，共同开发了产品 和规划并实现推广。很显然，在许多情况下，来自 高收入环境的技术专家和低收入机构的本地服 务提供者都没有影响改进的足够知识和技巧。因 此，需要有强大且相互信任的机构间伙伴关系来 共同寻找能够成功和推广的解决方案。与强化质 量的全国性工作相协调是将相关经验成功传播 从而对卫生健康结局产生最大影响的关键。 通过伙伴关系实现改进的六步循环法及筹备工 作一揽子措施提供了行动的务实蓝图。但是，应 当指出，每对伙伴关系都有其独特之处，因而具 体实施中肯定需要调整。经验肯定会涌现，而本 文件也可以在未来得到改进。 质量改进仍是一门正在发展的科学，结对促进伙 伴关系的各方伙伴均应保持谦卑。事实上，成功 的伙伴关系会对所有参与者都有好处。发展中国 家可以学习如何应用质量改进原则和实践加强 卫生服务交付并建设有韧性的卫生系统，而发达 国家的伙伴也可以学到很多东西。利比里亚特莱 沃恩纪念医院和日本长崎大学医院之间的伙伴 关系为设计之后更大规模结对促进伙伴关系倡 议提供了宝贵信息。各种伙伴关系的经验将为有 关质量改进的更广泛努力提供参考，并参考后者 的成功经验。而这在继续推进全球实现全民健康 覆盖努力的大背景下越来越突出。 资源有限。要继续有关质量改进的全球学习，就 要分享知识、经验和想法。世卫组织促进高质量全民健 康覆盖全球学习实验室等实体可以促进这种分享。全 球学习实验室也是可以庆祝成功并分享知识、经 验和想法的空间。有时会失败，但需要有韧性，以 便找到通往成功的路径：在这些最初的失败中有 大量经验教训。本杰明富兰克林曾经说过，“告诉 我，我会忘记；教给我，我可能会记得；让我参与 进去，我会学习”。他的话仍然很有道理。这就是 人际间互动的力量，而这正是伙伴关系的核心。 参考文献 1. African Partnerships for Patient Safety. Improving Patient Safety Partnership Preparation Package. A resource for all health partnerships committed to strengthening patient safety. Geneva: World Health Organization;2012. (http://www.who.int/ patientsafety/implementation/apps/resources/ preparation_package_EN.pdf?ua=1, accessed 24 June 2018). 2. Twinning Partnerships for Improvement. Recovery Partnership Preparation Package. Building ca- pacity to reactivate safe essential health services and sustain health service resilience. Geneva: World Health Organization;2016. (http://apps. who.int/iris/bitstream/handle/10665/206542/ WHO_HIS_SDS_2016.3_eng.pdf;jsessionid=0D0AE- C895C8BD6F8D8D192A3236F89BF?sequence=1, accessed 24 June 2018). 3. Lewis L, Williams C, Jackson L, Caffarella R, ed- itors. Experiential Learning: A New Approach. San Francisco: Jossey- Bass;1994:5-16. 4. Successful partnerships a guide. OECD LEED Forum on partnerships and local gover- nance. 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(http:// apps.who.int/iris/bitstream/ handle/10665/78043/WHO_ IER_PSP_2012.7_eng.pdf?se- quence=1, accessed 24 June 2018). 9. Greenhalgh T, Robert G, Bate P, Kyriakidou O, Macfarlane F, Pea- cock R. How to Spread Good Ideas. A systematic review of the literature on diffusion, dis- semination and sustainability of innovations in health service delivery and organisation. Re- port for the National Co-ordi- nating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). 2004. (http://www. netscc.ac.uk/hsdr/files/proj- ect/SDO_FR_08-1201-038_V01. pdf, accessed 20 June 2011). 10. WHO Community engage- ment Framework for Quality, People-Centres and Resilient Health Services. Geneva: World Health Organization;2017. (http://apps.who.int/iris/bit- stream/handle/10665/259280/ WHO-HIS-SDS-2017.15-eng. pdf?sequence=1, accessed 20 June 2018). 11. Partenariats Africains pour la Sécurité des patients. Rapport d’évaluation des partenariats hospitaliers pour la sécurité des patients entre la France et l’Afrique. Genève: Organisation Mondiale de la Santé;2017 (http://www.who.int/pa- tientsafety/implementation/ apps/evaluation-report/fr/, ac- cessed 20 June 2018). 12. Taking action: steps 4 and 5 in twinning partnerships for improvement for health care facility managers, quality im- provement teams and insti- tutional health partnerships. Geneva: World Health Organi- zation;2018. (http://www.who. int/servicedeliverysafety/twin- ning-partnerships/steps4-5/ en/, accessed 19 July 2018). 13. EQUAL Partnership Develop- ment toolkit. European Com- mission. Directorate-General for Employment, Social Affairs and Equal Opportunities ; 2005 (http://ec.europa.eu/employ- ment_social/equal_consoli- dated/data/document/pdtool- kit_en.pdf, accessed 13 April 2018). 附件 附件1.案例研究 – 工作无 效时调整行动 在马拉维发展学习文化15 伙伴关系一道努力确定哪些措施有效、哪些无效 以及有哪些经验教训。 马拉维松巴精神卫生服务与英国约克大学卫生 服务系结成伙伴关系，共同开展了一个旨在加强 马拉维松巴县社区精神卫生服务系统的项目。该 项目的思路是提供培训和支持，发展当地乡村卫 15 该伙伴关系得到热带卫生与教育信托基金的支持。 生工作者（称为健康监测助理） 首次提供精神卫生干预措施的 职能。松巴县精神卫生服务机 构专家、县卫生部门官员参与 了项目规划和交付，还与健康 监测助理进行了讨论。 为收集数据，松巴的项目经理 每月都会拜访村里的健康监测 助理，并与后者讨论相关数据。 这个过程使健康监测助理也 参与到整个项目中来。项目经 理说：“这使人们充满热情和动 力，使项目势头得以保持。如果 没有这种面对面的访问，这种 情况就不会发生。” 由于存在一些实际困难，未能 高效地收集到监测和评价所需 数据。松巴的项目经理曾计划 在一次月度探访中就把所有数 据都收集到自己的手提电脑 上，但这项工作太耗时间了。团 队意识到数据收集系统没有发 挥预期作用，就商定每次探访 后把记录数据的纸质文件带 走，并允许用更长时间收集数 据。这就影响到伙伴关系改进 的进展，参与工作的同事们也 商定根据临时情况调整行动计 划。 松巴的项目经理认为，伙伴之 间相互尊重对方的观点和想法 并作出集体决策的做法促进学 习。“英国伙伴非常支持我们有 关工作实施的新想法。这使伙 伴关系能够更好地促进共同目 标，并取得成功结果。在这个过 程中，马拉维伙伴学到了知识 和技能，包括与良好项目和财 务管理以及数据分析、解读和 报告有关的知识和技能。” 承认问题使伙伴们能够寻找解 决方案并将挑战转化为经验。 46 筹备伙伴关系措施 附件2. 工具和资源 下列工具和资源旨在支持编制和执行你单位自己的行动计划。资源多样且跨度较 大，涵盖宣传、业务/财务、指导/政策/标准、模板、工具包和学术出版物等。各种资源 均经仔细审查世卫组织资料后纳入。采纳标准是实用性和可获得性。将某材料纳入 下表并不意味着世卫组织支持与该资源有关的任何具体组织。 可以通过世卫组织21世纪医院网站访问适用于医院的诸多工具和资源： http://www. who.int/hospitals/en/ 资源类型 网址 热带卫生与教育信托基金 伙伴关系手册 https://www.thet.org/wp-content/uploads/2017/09/How-to-start-a-Health-Partnership. pdf 开启一段卫生伙伴关系 （热带卫生与教育信托 基金） http://www.thet.org/health-partnership-scheme/resources/tools-guidance/ how-to-start-a-health-partnership 承诺函示例 http://www.who.int/patientsafety/implementation/apps/APPS_registration/en/ 谅解备忘录示例 https://www.thet.org/wp-content/uploads/2017/09/Memorandum-of-Understanding- Template.pdf 国际医院合作良好实践指 南（法国医院联合会） https://www.fhf.fr/Europe-International/La-cooperation-internationale/ Guide-cooperation-internationale-hospitaliere 医院合作促发展指南 https://www.cultura.com/guide-de-la-cooperation-hospitaliere-pour-l-aide-au- developpement-9782859526849.html 经济合作与发展组织成功 伙伴关系指南 https://www.oecd.org/cfe/leed/36279186.pdf 促进机构间卫生伙伴关系 全球促进组立场声明 http://www.who.int/patientsafety/implementation/apps/global-catalyst-group.pdf 用于第一步“伙伴关系发展”的核心资源 47附件 用于第二步“需求评估”的核心资源 下列需求评估工具并非全部。这些是特莱沃恩纪念医院和长崎大学医院之间伙伴 关系原型所开展合作进程中发现的工具。 资源类型 网址 发表时间 感染预防和 控制以及患 者安全 患者安全形势分析。针对12个行动领域评估 一家卫生保健机构当前患者安全水平的工 具。 http://www.who.int/servicedelivery- safety/twinning-partnerships/tools/ en/ 2009 年， 2015 年修订 世卫组织手卫生自查表。卫生机构改善手卫 生的关键第一步就是完成这项评估。 http://www.who.int/gpsc/country_ work/hhsa_framework_October_2010. pdf 2010 年 结对促进伙伴关系形势评估报告：特莱沃恩 纪念医院和洛法州卫生系统的质量和患者安 全。 http://apps.who.int/iris/bitstream/10 665/253523/1/9789241511872-eng. pdf?ua=1 2017 年 通过有效的基线评估评价支持全国实施的感 染预防和控制工具。 http://www.who.int/infection-preven- tion/tools/core-components/ICPAT2. pdf 2017 年 人力 公立和私营医疗机构人力资源管理快速评估 工具 http://www.lmgforhealth.org/sites/ default/files/HRM_Rapid_Assessment_ Tool_0.pdf 2005 年 卫生专业人员激励措施指南。该文件强调，经 济和其它激励措施对于全世界确保有效招募 和留用卫生工作者并提高其绩效至关重要。 http://www.who.int/workforcealliance/ documents/Incentives_Guidelines%20 EN.pdf 2008 年 饮用水、卫生 设施和个人 卫生 关于饮用水、卫生设施和个人卫生的FIT战略。 通过卫生保健机构内实施饮用水、卫生设施 和个人卫生措施提高服务质量的实用指南。 http://www.who.int/water_san- itation_health/publications/ water-and-sanitation-for-health-fa- cility-improvement-tool/ en/ 2017 年 卫生服务交 付管理 服务有无及就绪情况评估（SARA）。用于评估 和监测服务交付的工具，考察点是卫生部门 是否提供相关服务及服务就绪情况。该工具 可以产生数据支持卫生系统的规划和管理。 http://apps.who.int/iris/bit- stream/10665/104075/1/WHO_HIS_ HSI_RME_2013_1_eng.pdf 2015 年 坦桑尼亚卫生保健质量改进工作形势分析。 该分析涵盖质量改进工作当前形势、标准及 其评估、质量改进指标、采用的方式方法、已 取得的进展以及态势分析。 http://www.tzdpg.or.tz/fileadmin/ documents/dpg_internal/dpg_work- ing_groups_clusters/cluster_2/ health/Sub_Sector_Group/Quality_ Assurance/11.a_Situation_Analysis_ of_Quality_Improvement_in_Health_ Care_Tanzania_-_Final.pdf 2012 年 基本外科 护理 用于评估急诊和基本外科护理的形势分析 工具 http://www.who.int/surgery/publica- tions/s15986e.pdf?ua=1 2012 年 48 筹备伙伴关系措施 用于第三步“差距分析”的核心资源 资源类型 网址 发表时间 差距分析 运用差距分析框架，改进对患者的诊疗服务 质量。美国国际开发署案例研究，其中分步骤 展示了一份差距分析。 https://www.usaidassist.org/sites/assist/ files/hci.ghc_gap_framework_workbook. 14jun10_1.pdf 2010 年 差距分析 AHRQ质量指标工具包：差距分析说明 https://archive.ahrq.gov/professionals/sys- tems/hospital/qitoolkit/d5-gapanalysis.pdf 2012 年 实用资源 结对促进伙伴关系。日本和利比里亚伙伴计 划会报告。 http://www.who.int/servicedeliverysafety/ twinning-partnerships/partnership-plan- ning-report.pdf 2016 年 用于第四步“制定行动计划”的核心资源 世卫组织恢复工作工具包 (由此访问） 集中提供大量指导文件资源，可以快速、简便 地访问，以指导行动。恢复工作工具包的一个重要目的是支持各国重启可能经历大 规模突发事件的卫生服务。这些服务包括持续进行的各类规划，例如免疫接种、孕 产妇和儿童卫生服务以及非传染性疾病防治。此外，由于工具包包含实现国家卫生 系统正常运转所需的核心信息，它也可用于支持各国在突发公共卫生事件后的恢 复阶段实施国家卫生计划。 资源类型 网址 发表时间 知识转化 将证据转化为实践：大规模知识转化模 式 http://www.bmj.com/content/337/bmj. a1714 2008 年 规划和实施 世卫组织地区卫生服务的规划和实施 http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 年 世卫组织实施战略和工具。对实施世卫 组织多种方式改进手卫生策略的指导。 http://apps.who.int/iris/bit- stream/10665/70030/1/WHO_IER_ PSP_2009.02_eng.pdf?ua=1 2009 年 支持机构和国家层面实施《世卫组织感 染预防和控制规划核心部分指南》的实 施工具和资源。 http://www.who.int/infection-prevention/ tools/core-components/en/ 2018 年 国家和急诊设施一级感染预防和控制规 划核心部分指南。支持各国拟定和执行 本国抗微生物药物耐药性性计划的循 证指南。 http://apps.who.int/iris/bitstream/10665/ 251730/1/9789241549929-eng.pdf?ua=1 2017 年 地区卫生服务的规划和实施。计划、基本 卫生服务、卫生系统研究和灾害防范的 十个步骤。 http://www.who.int/management/ district/planning_budgeting/ PlanningImplementationDHSAFROMd4. pdf?ua=1 2004 年 地区卫生服务运行状况评估工具。一整 套帮助地区卫生管理团队产生信息用于 改进卫生服务运行的工具。 http://www.who.int/management/dis- trict/assessment/assessment_tool.pdf 2003 年 49附件 世卫组织卫生保健活动废物的安全管 理。就正常形势下和突发事件中处理和 处置卫生保健废物的安全、高效和对环 境无害的方法提供全面指导。 http://www.searo.who.int/srilanka/doc- uments/safe_management_of_wastes_ from_healthcare_activities.pdf?ua=1 2014 年 卫生设施安全规划（实施工具）。废水、中 水和粪便安全使用和处置手册。 http://apps.who.int/iris/bitstre am/10665/171753/1/9789241549240_ eng.pdf?ua=1 2015 年 世卫组织人员配备需求的工作量指标 （WISN）用户手册 http://www.who.int/hrh/resources/WISN_ Eng_UsersManual.pdf?ua=1 2010 年 感染控制和流行病学专业人员协会 （APIC）医院获得性感染成本计算器 http://www.apic.org/Resources/ Cost-calculators 用于第六步“评价和审查”的核心资源 资源类型 网址 发表时间 监督和评价 用于实施和审查监督和评价计划的规划工具 https://www.thet.org/resources/ hps-monitoring-evaluation-plan/ 2014 年 评价常见问题 解答 以常见问题解答的方式为卫生伙伴关系有效 评价其项目和伙伴关系提供分步骤指导 https://www.thet.org/resources/ health-partnerships-evaluation-faq/ 2014 年 非洲患者安全伙 伴关系评价手册 评价伙伴关系五个方面（形势分析、伙伴关系 优势、患者安全改进、患者安全措施推广及年 度评价报告） http://www.who.int/patientsafe- ty/implementation/apps/ Evaluation-Handbook_EN.pdf?ua=1 2012 年 监督、评价和 学习 网络研讨会：分享经验，提供有关监督和评 价的反思 https://www.youtube.com/ watch?v=v_oHEvgE_aA 2016 年 监督和评价 有关监督、评价和学习的卫生伙伴关系研讨 会。收集文件以认识监督和评价的价值的建 议，其中包括例子和练习。 https://www.thet.org/wp-content/ uploads/2017/09/Monitoring-and- Evaluation.pdf 2017 年 监督和评价 促进有效实现变化落地扎根的EFFECt工具。 该工具的关注点是评估实施方面的最佳实 践，利用伙伴关系方法使个人和机构真正落 实变化及其带来的好处。 https://esther.eu/index.php/ effect-tool/ 2017 年 用于改进的核心资源 资源类型 网址 发表时间 PDSA循环（计划-执行- 学习-行动 获得有价值经验和知识以便持续 改进的系统性过程 https://deming.org/explore/p-d-s-a 2018 年 改进模式 用于加快改进的一个简单却强 大的工具 http://www.ihi.org/resources/Pages/ HowtoImprove/default.aspx 2018 年 处理卫生机构人员配 备和流失问题 理解在资源有限环境下建立卫生 保健机构质量改进程序面临的障 碍：马拉维利隆圭市卡穆祖中心 医院医务科的形势分析 https://bmchealthservres.biomedcentral. com/articles/10.1186/1472-6963-14-1 2014 年 世卫组织多模式改进 策略 一页纸信息，描述由五个部分组 成的支持卫生保健机构改进感染 预防控制工作的多模式策略 http://www.who.int/infection-prevention/ publications/ipc-cc-mis.pdf?ua=1 2017 年 50 筹备伙伴关系措施 附件3. 结对促进伙伴关系形势评估“怎么做” 工具示例 第二步：结对促改进伙伴关系形势评估“怎么做”工具 以下“怎么做”工具务实地分步骤解释如何计划和执行深度形势评估以便为感兴趣 的伙伴机构双方就结对伙伴关系倡议提供参考信息。该评估旨在为双方机构联合 发展有效、可持续的结对伙伴关系奠定基础。“怎么做”工具为开展促改进伙伴关系 六步循环中的第二步工作流程提供参考。“怎么做”文件可与《筹备结对促改进伙伴 关系的一揽子措施》及相关资源一并使用。 评 估 后 ：建 设 （ 评 估 后 四 周 ） 目标： 与重要利益攸关方分享相关结论，启动行动规划进程 · 与 各 主 题 牵 头 人 合 作 编 写 评 估 报 告 ，必 要 时 寻 求 上 级 审 批 · 记 录 来 自 评 估 的 小 故 事 ，突 出 实 现 质 量 改 进 和 安 全 的 机 会 ，并 与 世 卫 组 织 高 质 量 全 民 健 康 覆 盖 全 球 学 习 实 验 室 分 享 · 参 与 结 对 伙 伴 关 系 的 行 动 计 划 会 ，摘 要 介 绍 访 问 结 论 和 建 议 · 围 绕 伙 伴 机 构 确 定 的 焦 点 行 动 领 域 共 同 制 定 伙 伴 关 系 计 划 · 以 评 估 结 果 为 基 础 拟 定 伙 伴 关 系 计 划 · 就 评 估 计 划 核 对 表 向 世 卫 组 织 结 对 进 步 伙 伴 关 系 团 队 提 供 反 馈 意 见 · 讨 论 存 在 哪 些 机 会 利 用 伙 伴 倡 议 确 定 地 区 和 国 家 层 面 存 在 的 瓶 颈 · 在 六 步 循 环 的 第 四 步 至 第 六 步 ，查 阅 一 揽 子 措 施 文 件 中 提 供 的 质 量 改 进 资 源 的 行 动 步 骤 和 评 价 /审 查 相 关 内 容 · 在 促 改 进 伙 伴 关 系 循 环 的 第 六 步 工 作 过 程 中 开 展 评 价 /评 估 · (酌 情 ）每 年 开 展 一 次 形 势 评 估 · 在 本 国 诊 疗 服 务 质 量 测 量 行 动 中 协 调 和 建 设 针 对 伙 伴 关 系 的 监 测 和 评 价 体 系 · 查 阅 结 对 促 改 进 伙 伴 关 系 中 有 关 医 院 伙 伴 关 系 质 量 改 进 的 资 源 ，供 发 展 伙 伴 关 系 的 监 测 和 评 价 体 系 参 考 评 估 ：学 习 （ 国 内 10 天 ） 目标： 建立关系，了解一线人员的角度 · 与 卫 生 机 构 员 工 和 地 区 卫 生 团 队 开 展 团 队 工 作 ，以 便 ： · 熟 悉 伙 伴 机 构 · 了 解 本 地 环 境 下 的 质 量 与 安 全 状 况 · 查 阅《 筹 备 结 对 促 改 进 伙 伴 关 系 的 一 揽 子 措 施 》， 了 解 第 二 步 所 用 核 心 技 术 工 具 和 资 源 · 确 定 重 要 信 息 提 供 者 ，这 些 人 应 在 同 行 中 深 受 尊 重 · 审 阅 针 对 重 要 信 息 提 供 者 个 人 或 团 体 的 访 谈 指 南 ，并 集 体 根 据 本 地 情 况 调 整 该 工 具 · 安 排 重 要 信 息 提 供 者 与 卫 生 工 作 者 的 访 谈 时 间 。如 果 要 访 谈 人 数 超 过 五 位 ，建 议 对 同 类 卫 生 工 作 者 采 用 小 组 访 谈 法 。小 组 访 谈 法 有 助 于 促 进 开 放 讨 论 和 保 密 · 开 展 手 卫 生 和 患 者 安 排 评 估 的 那 天 不 要 进 行 任 何 小 组 访 谈 ，这 样 可 以 使 卫 生 工 作 者 有 限 参 与 到 评 估 中 · 每 天 都 收 集 、分 析 和 交 叉 联 结 所 有 五 个 主 题 领 域 的 数 据 · 总 结 并 向 以 下 人 员 和 单 位 介 绍 评 估 发 现 · 医 院 工 作 人 员 和 地 区 相 关 人 员 · 世 卫 组 织 国 家 办 事 处 /卫 生 部 · 相 关 伙 伴 ，例 如 供 资 机 构 · 根 据 不 同 利 益 攸 关 方 需 要 采 取 哪 些 行 动 确 定 初 步 建 议 · 结 对 促 改 进 伙 伴 关 系 · 卫 生 机 构 · 地 区 卫 生 团 队 · 卫 生 部 · 每 日 举 行 评 估 团 队 例 会 ，总 结 当 天 活 动 ，处 理 出 现 的 重 要 问 题 ，为 第 二 天 工 作 做 准 备 评 估 前 ：解 构 （ 至 少 评 估 工 作 开 始 前 四 周 ） 目标： 审查国内相关文件，确定质量改进机会及国内伙伴 · 确 定 有 经 验 、有 积 极 性 的 牵 头 人 协 调 评 估 工 作 · 向 世 卫 组 织 国 家 办 事 处 和 区 域 办 事 处 通 报 即 将 到 来 的 形 势 评 估 · 对 有 关 质 量 和 安 全 的 国 家 、省 市 和 机 构 文 件 进 行 审 阅 。可 能 的 文 件 包 括 ： · 国 家 卫 生 部 门 政 策 /计 划 · 国 家 质 量 卫 生 战 略 · 地 区 /县 市 级 业 务 或 工 作 计 划 · 卫 生 机 构 年 度 计 划 或 工 作 计 划 · 伙 伴 协 调 机 制 · 国 内 诊 疗 质 量 测 量 文 件 或 项 目 · 确 定 评 估 中 想 要 评 价 的 领 域 。理 想 情 况 下 ，应 考 虑 全 部 五 个 评 估 主 题 领 域 ： · 质 量 改 进 · 患 者 安 全 · 手 卫 生 · 地 区 卫 生 系 统 · 患 者 和 社 区 角 度 · 审 阅 访 谈 问 题 长 表 指 南 ，处 理 尚 未 解 答 的 疑 问 · 确 定 形 势 评 估 工 作 排 期 ，并 与 世 卫 组 织 国 家 办 事 处 分 享 · 世 卫 组 织 国 家 办 事 处 安 排 会 议 ，协 助 促 进 对 机 构 /地 区 进 行 现 场 访 问 · 确 定 访 问 团 组 成 并 指 定 五 个 主 题 领 域 的 牵 头 人 · 理 想 情 况 下 ，访 问 团 应 包 括 卫 生 部 、组 织 各 级 和 伙 伴 机 构 代 表 · 确 保 访 问 团 具 备 各 相 关 主 题 领 域 所 需 技 能 · 确 定 要 咨 询 哪 些 发 展 伙 伴 和 利 益 攸 关 方 · 启 动 一 系 列 与 访 问 团 的 电 话 和 电 子 邮 件 交 流 协 调 ，讨 论 访 问 的 技 术 范 围 和 后 勤 安 排 · 如 资 金 允 许 ，启 动 任 务 宣 传 工 作 ，吸 引 卫 生 部 和 利 益 攸 关 方 注 意（ 如 资 金 不 允 许 ，该 工 作 可 渗 透 在 评 估 过 程 中 ） 卫生工作者队列 示例 设 施 级 地 区 /县 市 级 • 临 床 工 作 人 员 ：医 生 、医 生 助 理 、护 士 、助 产 士 、药 师 、实 验 室 技 术 员 、助 理 等 • 非 临 床 工 作 人 员 ：维 修 人 员 、清 洁 工 • 医 院 管 理 层 • 患 者 和 社 区 代 表 • 设 施 内 部 的 伙 伴 • 卫 生 委 员 会 • 管 理 团 队 • 卫 生 部 门 主 管 • 地 区 /县 市 主 管 、地 区 专 员 、传 统 负 责 人 • 伙 伴
53附件 附件4. 结对促进伙伴关系规划模板 摘要信息 结对机构甲名称 牵头人姓名 结对机构乙名称 牵头人姓名 所用形势分析/基线评 估名称和日期 完成计划的人员姓名 关注的技术行动领域 伙伴各方根据形势分析 结果考虑开展工作的具 体领域 （根据经验，有必要关 注最多2-3个领域） 举例 项目1：感染预防和控制 项目2：有关质量改进的知识和技能 每个行动领域均需填写以下模板表格。根据需要关注的行动领域填写所需数量的表格。 项目编号和行动领域 · 例如：项目1：感染预防和控制 简要描述项目 · 一两句话概述项目 项目目标 · 一两句话概述项目将促成哪些变化。 · 酌情描述项目与国家和/或地方政策和计划（包括在质量问题上的国家指导方向）之间 的联系。 · 试着强调项目目标如何响应基线评估中确定的需求。 项目结果 · 描述你希望项目带来哪些改进。 · 通常，结果是指实践或卫生健康结局方面发生的变化。 · 结果应有助于实现目标 项目产出 · 项目的直接结果。例如，20人接受感染控制培训。产出应带来结果的实现。 主要活动 · 列出所有计划的活动，简要概述每个活动是要做什么、在哪里开展及结对伙伴各方都有 哪些人参加、活动将需要多长时间、要采用什么方法以及相关费用。 · 列出技术交流日程，例如每两周进行一次视频联系，每月双方牵头人联系、每六个月访 问一次等。 · 是否为项目计划了一次访问？（如回答是肯定的，列出可能的人力和财政成本）。 · 应详细考虑第一年的结对伙伴访问计划。第二年的计划可以更泛泛一点。包括建议的时 间。 · 计划采用哪些机制接收有关即时问题的意见？ · 如何与世卫组织支持质量改进的努力建立联系？ 受益人 · 将（直接间接）从项目中受益的人员信息，例如实验室技术员、医院管理者、护士及各类 患者和社区成员。 · 描述这些人员将如何受益并务实估算每个群体中会有多少人受益。 · 是否结对伙伴关系双方都会从中受益？ 利益攸关方 · 确定重要利益相关方及其在项目中的利益（例如其它科室、地区和国家卫生主管部门）， 即（伙伴关系双方）任何可能对项目活动和结果产生影响的个人或团体。 · 考虑本地社区和重要利益攸关方，包括可能为计划的工作作出贡献或创造价值的患者 和家庭。 · 概述结对伙伴关系需要向哪些利益攸关方报告工作及报告频率。 54 筹备伙伴关系措施 监测和评价 · 明确用于监测项目结果是否实现的重要指标。 · 总体介绍监测和评价计划，并概述所用方法、参与人员以及过程管理和伙伴各方共同学 习的方式。 可持续性和推广 · 描述活动将持续多长时间及有无长期供资计划。 · 最初两年项目结束后哪些效益将持续存在及如何持续？ · 列出在项目成就基础上继续努力的计划。 · 描述你将如何积极传播新消息及考虑采取哪些活动支持纵向、横向和自发性的推广。 风险 · 确定与计划有关的潜在风险，例如重要人员岗位或工作变化、单位重点调整、结对伙伴 之间发生矛盾等，描述将如何管理这些风险。 · 列出外部风险，并说明将如何管理风险（例如信息通信技术故障、签证出问题、政治不确 定性）。 项目管理和支持 · 概述项目责任，包括结对伙伴关系之间的责任分工。 · 提供伙伴关系双方参与的重要人员的详细信息。 · 考虑重要管理问题：采用哪些系统管理两地财务？谁对预算负主要责任？如何确保沟通 有效及所有伙伴均了解情况？ 审批人 审批日期 55附件 附件5. 结对促进伙伴关系访问建议书模板 在商定访问后应立即填写访问建议书模板，以确保访问有明确目标且有助于促进 整体伙伴关系规划工作。 结对伙伴关系（列出参与伙伴关系的双方机构） 机构甲: 机构乙: 填写访问建议书表格的人员姓名 访问目的：描述访问涉及哪个（些）伙伴关系项目 建议的访问日期 起始日期: 结束日期: 访问是否与现有国内活动相协调，没有重复培训或政策制定工作？ 是 否 不适用 访问是否明显满足结对伙伴机构的需求？ 是 否 不适用 简要描述拟议访问的预期结果（结果应明确、务实且符合逻辑） 简要描述拟议访问的产出（产出应明确、务实且符合逻辑） 简要描述你认为可能与访问有关的风险 列出估计的访问费用 简要描述拟议访问将如何促进相关伙伴关系计划的监测和评价 列出拟议访问将涉及多少人及其在实现访问目标方面分别发挥什 么作用 访问是否已经伙伴关系双方共同计划商定？ 是 否 访问是否将为结对伙伴都带来好处（如回答是，请简要描述） 是 否 不适用 简要描述访问将如何促进有效基本卫生服务交付工作的可持续性 和推广 56 筹备伙伴关系措施 附件6. 结对促进伙伴关系行动报告模板 行动报告模板记录伙伴关系发展各阶段的重要产出、经验教训和相应行动。这是发 展强大、有效的行动型伙伴关系的必要步骤，且有助于促进伙伴关系治理。 结对伙伴关系（列出参与伙伴关系的双方机构） 填写本报告表格的人员姓名及填写日期 本进展报告涵盖的时间阶段 采取的重要行动 所采取行动产生的重要成果 面临的重要挑战 下一份进展报告的预计日期 57附件 附件7. 定义 问责：报告或说明自身行动的义务，例如通过详细审查、合同、 管理或规制等方式向理事当局报告或说明或者向选民报告或说 明。 非洲患者安全伙伴关系规划：世卫组织非洲患者安全伙伴关系规 划是一种专注于医院间协作、以结果为导向、由结成伙伴的医院共 同发展的方法。该规划的核心要素是感染预防控制、安全手术、废 物管理和卫生工作者安全问题，确定了共同的相关目标，使每个人 都能围绕目标致力于改进。其结果是，整个非洲区域在这些领域获 得大量实施经验。非洲患者安全伙伴关系方法显示，通过伙伴关系 开展工作可以使职工更加充满工作热情，更致力于变革，能力建设 得到加强，目的更明确，更希望找到可以立刻对患者保健质量和安 全产生影响的适当解决方案。而这又可以用于加强向全球社区交 付卫生服务。 临床有效性：应用来自研究、临床经验和患者偏好的最佳知识以便 使患者获得最优保健过程和结果。 社区伙伴：代表某个通常按基本政治社会责任所在且涉及所有大 多数当地人生活活动的日常社交发生地地理区域定义的人群的质 量改进团队成员。 持续改进：使事物变得更好或得到改善的过程。 58 筹备伙伴关系措施 以人为本的综合卫生服务框架：以人为本的综合卫生服务框架要 求针对相应挑战从根本上改变卫生服务供资、管理和交付的方式。 它的愿景是“所有人都能平等获得优质卫生服务，其联合生产方式 应满足生命过程中的需求、在持续护理全过程得到协调并且全面、 安全、有效、及时、高效和可接受；所有护理人员都充满工作热情、 技能熟练且在支持性环境下工作。”世卫组织推荐实施五个相互交 织的策略，以实现以人为本的综合卫生服务。应用该方法可以建设 强大且有韧性的卫生服务，并且是实现全民健康覆盖和可持续发 展目标的关键。 伙伴关系：两方或多方在信任、平等和相互理解基础上为实现共同 商定的具体目标而建立的协作关系。伙伴关系既有风险也有利益， 因而责任共担是关键。 以患者为核心：提供尊重并响应患者个人偏好、需求和价值观的护 理，并确保患者价值观指导所有临床决定。 患者安全：将与卫生保健有关的风险和不必要危害减少到可接受 的最低水平。 绩效：与预期结果相比一个人、团队、项目、规划、组织或政策实施 的情况。 质量：全世界对质量的定义和理解存在多种方式。其中两种主要定 义如下： · 为个人和人群提供的卫生服务在多大程度上提高达到预期健 康结局的可能性并且符合当前专业知识。 · 决定一个实体能否满足明示和隐含需求的所有特征的总和。 59附件 质量审核：旨在确定质量活动和相关结果是否与规划安排一致及 这些安排是否得到有效实施和适合实现目标的系统性独立审核。 质量保证：在质量系统内实施并根据需求展示以便使人相信一个 实体能够满足质量要求的所有有计划的系统性活动。 质量控制：评估实际绩效、将实际绩效与质量目标对比并针对其中 差距采取行动的过程。 质量改进：创造有效益变化和实现前所未有绩效的过程。 质量规划：为开发满足客户需求的产品和服务确定质量目标的过 程。 利益攸关方：对组织和交付卫生服务感兴趣的个人、团体或组织。 参考书目 Chisholm G. 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Geneva: World Health Organization; 2018 (http://apps.who.int/iris/bitstream/handl e/10665/272357/9789241565561-eng. pdf?ua=1, accessed 22 June 2018 ). WORLD HEALTH ORGANIZATION 20 Avenue Appia CH-1211 Geneva 27 Switzerland PLEASE VISIT US AT: http://www.who.int/servicedeliverysafety/ twinning-partnerships/en/