Setting up and managing a quality improvement programme at the district level: district programme management guide

Si m pl e s tep s t o i nst ituti onalize quality improvement at district level Setting Up and Managing a Quality Improvement Programme at the District Level POCQI: Point of Care Quality Improvement District Programme Management Guide Version 02

Version 02 District programme management guide Setting Up and Managing a Quality Improvement Programme at the District Level Point-of-care quality improvement Setting up and managing a quality improvement programme at the district level. Point-of-care quality improvement. District programme management guide. ISBN: 978-92-9022-924-7 © World Health Organization 2022 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 specifi c organization, products or services. The use of the WHO logo is not permitted. 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Printed in India This district management guide, “Setting up and managing a quality improvement programme at the district level”, is an updated version of the previous edition prepared jointly by the WHO Regional Offi ce for South-East Asia (WHO-SEARO), the WHO collaborating centre for training and research in newborn care, All India Institute of Medical Sciences (AIIMS), New Delhi, and the United States Agency of International Development – Applying Science to Strengthen and Improve Systems Project (USAID ASSIST). Dr Rajesh Mehta (WHO-SEARO), Dr Sonali Vaid and Dr Ankur Sooden (Incluve Labs), Dr Nigel Livesley (independent consultant) and Dr Ashok Deorari (AIIMS, New Delhi) have mainly contributed to developing this guide. Inputs received from Dr Neena Raina and Dr Anoma Jayathilaka (WHO-SEARO), Dr Mahmuda Shayema Khorshed (Ministry of Health, Timor-Leste), Dr Pyae Pho Cho (UNICEF, Bangladesh), Dr Vikram Datta and Dr Anupa Vig (Nationwide Quality of Care Network India) and the health department functionaries in the Kurigram district of Bangladesh are sincerely acknowledged. This guide is an important component of the regional package for improving the quality of care for mothers, neonates and children in health facilities. The point-of-care quality improvement (POCQI) package consists of: 1. the training package, point-of-care quality improvement (POCQI Version 03), including a facilitator manual and a learner manual; 2. the guidance document on quality improvement (QI) coaching, Coaching for quality improvement; and 3. this document, Setting up and managing a quality improvement programme at the district level. All these documents can be accessed on the WHO-SEARO website – improving quality of care, (who.int). Collaboration from partner agencies UNICEF Regional Offi ce for South Asia (UNICEF ROSA), UNICEF East Asia and Pacifi c Regional Offi ce (UNICEF EAPRO), UNFPA Asia Pacifi c Regional Offi ce and USAID for promoting quality of care in the WHO SEA Region and for the development of the POCQI package is greatly appreciated. Acknowledgement

ENAP Every Newborn Action Plan EPMM Ending Preventable Maternal Mortality KMC kangaroo mother care MNCH maternal, newborn and child health MoH ministry of health MPDSR Maternal and Perinatal Death Surveillance and Response PDSA plan–do–study–act POCQI Point Of Care Quality Improvement QI quality improvement QoC quality of care RMNCAH reproductive, maternal, newborn, child and adolescent health SDG Sustainable Development Goal UHC universal health coverage WHO World Health Organization WHO-SEARO WHO Regional Offi ce for South-East Asia Abbreviations

Introduction 1 Regional framework for improving quality of care 3 National-level support 4 Facility-level support 5 Going beyond trainings – managing a QI programme 5 Purpose of the POCQI programme management guide 8 Managing a QI programme for RMNCAH in a district 9 Planning cycle for district QI programme 10 Key principles for a district QI programme 11 Prepare a plan for the district QI programme 13 Components of a district QI programme 14 Review current QOC activities and capacity in the district 15 Plan to start a QI programme in the district 16 Implement the district QI plan 19 District leadership support for the QI programme 20 Strengthen QI skills of healthcare teams 22 Arrange ongoing QI coaching support 23 Enable opportunities for peer-to-peer sharing and learning 25 Engage the community and stakeholders 27 Monitor and adapt the QI programme 29 Measurement of the QI programme 30 Learn and adapt the district QI programme 32 Conclusion 34 Annexes 35 Annex 1 – Planning template for developing the QI program for district level 36 Annex 2 – Summary of setting up and managing the district QI programme 38 Annex 3 – Challenges faced in managing district QI programmes 42 Annex 4 – Sample monitoring framework for QI programmes in the district 43 Annex 5 – Resources for further reading on managing QI programmes 47 Table of contents

DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 1 Introduction DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 2 Introduction For reducing maternal, newborn and child mortality, the focus has been on reaching higher coverage with key reproductive, maternal, newborn and child health (RMNCH) interventions.1 It has been observed that the evidence-based interventions are often delivered with insuffi cient quality.2 Several studies over the past few years have documented poor quality of care (QoC) provided to neonates and children.3,4,5 Similarly, defi ciencies in maternal health care, for both routine and emergency care, have also been described.6 Poor quality of care is harmful for the health of an individual and leads to adverse effects on future health-seeking behaviour by communities.7 Low utilization of healthcare services by the population can be partially attributed to the poor quality of the services. Issues of quality of care for maternal, newborn, child and adolescent health have been deliberated in several WHO-SEARO regional meetings. The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) and the Sustainable Development Goal (SDG) framework provide further impetus to ending preventable mortality among mothers, neonates and children. Universal health care (UHC) is a centrepiece for SDG3 wherein the quality of health care is a crucial element. Quality of care is embedded in global frameworks such as Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality (EPMM). It is, therefore, mandatory that interventions are delivered with good quality, meeting appropriate standards of care. WHO with partners has put forth a global vision for improving quality of maternal, newborn and child health (MNCH) care that emphasizes the provision of quality of care as well as improved experience of care during pregnancy, childbirth and postnatal period. WHO has worked with partners to fi nalize the standards for maternal and newborn health care8 for good-quality and respectful care, implementation guidelines and a measurement framework. Subsequently, global standards for small and sick newborn care and paediatric care have also been published.9 1Countdown to 2015. Accountability for maternal, newborn and child survival: the 2013 update. 2013. WHO and UNICEF. 2Souza JP, Gulmezoglu AM, Vogel J, Carroli G, Lumbiganon P, Qureshi Z et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet 2013 May 18;381(9879):1747–55. 3Sidik NA, Lazuardi L, Agung FH, Pritasari K, Roespandi H, Setiawan T et al. Assessment of the quality of hospital care for children in Indonesia. Trop Med Int Health 2013 April;18(4):407–15. 4Duke T, Keshishiyan E, Kuttumuratova A, Ostergren M, Ryumina I, Stasii E et al. Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: Systematic observational assessment. Lancet 2006 March 18;367(9514):919–25. 5Nolan T, Angos P, Cunha AJ, Muhe L, Qazi S, Simoes EA et al. Quality of hospital care for seriously ill children in developing countries. Lancet 2001;357((9250)):106–10. 6Ocviyanti D, Prasetyo S, Adisasmita A, Moegni E, Pambudi I, Lawintono L et al. Assessment of the quality of care for mothers and newborns in health facilities in Indonesia. In preparation 2013. 7Zaidi AK, Huskins WC, Thaver D, Bhutta ZA, Abbas Z, Goldmann DA. Hospital-acquired neonatal infections in developing countries. Lancet 2005 March 26;365(9465):1175–88. 8WHO: Standards for improving quality of maternal and newborn care in health facilities. Access: http://www.who.int/maternal_child_ adolescent/documents/improving-maternal-newborn-care-quality/en/. 9https://www.who.int/publications/i/item/9789240010765 DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 3 Regional framework for improving quality of care WHO-SEARO has published The regional framework for improving quality of care for reproductive, maternal, newborn, child and adolescent health (RMNCAH) and an assessment tool for measuring quality of hospital care for mothers, neonates and children.10 The framework describes the following steps for operationalization at the country level: 1. Getting started • Identify leadership and champions at national and subnational levels. • Defi ne roles to support quality-of-care work at various levels. 2. Setting standards of care • Develop service standards • Develop guidelines, based on standards. • Develop an assessment tool, based on standards and guidelines. 3. Assess current quality of care and identify gaps in quality with reference to the established standards, using assessment tools available. 4. Improvement • Train health providers (in technical content and QI methods) to carry out quality improvement. • Create improvement teams to identify problems in quality of care and try solutions. • Implement a collaborative approach to enable peer learning among teams regarding how to improve care. 5. Ensure continuous monitoring, support and measurement of progress towards the achievement of standards. 6. Ensure documentation and publication of QI efforts and recognition and celebration of achievements of the standards. 7. Scale up quality improvement efforts for all hospitals and health facilities and communities. 10WHO-SEARO: The regional framework on improving quality of care for reproductive, maternal, newborn, child and adolescent health. Access: http://www.searo.who.int/entity/maternal_reproductive_health/documents/qoc-framework/en/. • Identifi cation of leadership and champions • Defi ning roles at various levels (systematic process) Getting Started • Implement solutions: Implementation of improvement activities to address the identifi ed gaps with reference to the established standards • Technical and QI training • Collaborative problem solving meetings Improvement • Continuous monitoring of performance and provision of supportive supervision and (self-) re-assessments of quality of care to measure progress towards the achievement of standards. Monitoring and (self-) re-assessment • Documentation and publication of quality improvement efforts • Recognizing and celebrating the achievements of the standards Documentation and dissemination • Scaling up to all hospitals and health facilities and communities Scaling up • Defi nition of standards of care • Review of and agreement on standards for all of areas and levels of care • Development of guide- lines and on assessment tool based on standards Standards • Assessment of quality of care and identifi cation of gaps with reference to the established standards Assessment (external baseline) 1 2 3 4 Do Plan Assessment Assessment Im pr ov m en t Im provm ent Act 6 7 5 Check DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 4 Some common and specifi c actions are required at national, state/province or district levels and the facility level to implement the initiatives for improving quality of care in an ongoing manner as described in the regional framework. WHO and partners in the region have provided support for national and facility level actions to implement the regional framework of improving quality of care. National-level support For implementation of the regional framework for improving quality of care, WHO-SEARO has been working with ministries of health, partners and stakeholders in the Region to strengthen various components of a quality management system at national, district and health facility levels. Regarding Steps 1–3 of the regional QoC framework mentioned above, Member States in the Region have established mechanisms to govern quality of care for maternal, newborn and child health at national and subnational levels, as per the global RMNCAH policy survey 2019–2020. Countries have adopted global standards and guidelines for managing most common maternal, newborn and child health conditions. Several countries in the Region have also undertaken assessment of quality of care for MNCH using the WHO tools. Such assessments have identifi ed common gaps in quality of care. In the fi gure below are listed some of the quality gaps reported from assessments of maternal, newborn and paediatric care at multiple hospitals supported by WHO. These issues can be categorized into three types as reported by the assessors of quality of care. Some of these gaps can be corrected or addressed by interventions from higher administration, such as providing more rooms and more staff and ensuring the presence of line supervisors and mentoring experts. More Assessment of quality of care in hospitals Quality gaps identifi ed • Practice of standard protocols • Practice Emergency triage • Case records • Handwashing – infection control procedures • Workfl ow of patient care • Allocation of beds • Availability of essential equipment and drugs • Essential lab test availability 24*7 • Communication across the referral chain • Adequate HR deployed at all sites • Appropriate physical infrastructure • Supportive supervision and mentoring for QI Correctable at the level of health facility Correctable at the level of both facility and policy makers Correctable at the level of policy makers DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 5 importantly, the hospital teams considered that several quality gaps could be corrected at the health facility level with their own efforts. The examples include handwashing, proper upkeep of case records, compliance with standard treatment protocols for common diseases and rational use of antibiotics and medicines. Facility-level support Regarding the steps on quality improvement (Steps 4–7) in the regional QoC framework mentioned above, WHO-SEARO has supported an ambitious initiative to improve the quality of care for pregnant women, neonates and children at health facilities in the countries of the South-East Asia Region (SE Asia Region) to immediately address the quality gaps that could be addressed at the local level, as discussed above. This is the point-of-care quality improvement (POCQI) model. The WHO-SEARO POCQI model is a simplifi ed approach to QI that has been prepared in collaboration with partner agencies. It emphasizes building the capacity of healthcare workers at health facilities to use QI science to solve local problems that are within their infl uence and can be solved without too many additional resources. WHO and partners have supported capacity-building in the POCQI model in Member countries for improving the quality of MNCH care at hospitals and health facilities. Although the initial QI efforts have focused on improving inpatient MNCH services, the same principles are also applicable to outpatient settings and community-based services. The simplifi ed QI process in the POCQI model starts with identifying specifi c QoC problems and forming teams of front-line workers at health facilities. The teams work together to analyse their current situation related to the clinical practices and make changes in their way of working so that patients get better care. QI also fi ts well and boosts the impact of other approaches used to improve the quality of services, e.g. clinical training, monitoring and supervision and various incentive schemes. In its vision for QoC for mothers, neonates and children, WHO identifi es standards for provision and experience of care and recommends that QI should address both demand- and supply-side issues. The development of QI skills among front-line health workers is critical since improvements in patient outcomes or experiences of care only occur if the change occurs at the level of the individual patient. Building QI skills among front-line workers is a good start and can lead to tangible improvements in health care at the health facilities in a short span of time. Going beyond trainings – managing a QI programme Efforts to improve quality at the point of care must be quickly scaled up and sustained across all health facilities in the district or region in the country, gradually covering the whole country in the long term. QI trainings of front-line healthcare teams at health facilities alone will have limited effects unless the local leadership at the health facility and the district health system supports them to continuously use QI skills locally as well as help fi x those problems that cannot be addressed on the front line. It is, therefore, important for the leadership at subnational and national levels to develop structures and systems in the districts to provide support to facilities carrying out improvement work and to develop a work culture that includes continuous QI. Quality improvement is a term that is used in several ways; it is often used to refer to any activity that could lead to better-quality care. WHO-SEARO has used a practical defi nition of QI: Quality improvement is a management approach that health workers can use to re-organize health services at their level to ensure that patients receive good-quality health care. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 6 QI primarily focuses on re-organizing healthcare services at the local level and uses existing resources, and, thus, is dependent on health system support and availability of minimum essential infrastructure at the health facilities and hospitals. Nevertheless, practice of QI also contributes to addressing related health system issues. For example, QI leads to more effi cient use of resources (human and material resources such as medicines) and can, thus, solve some issues of scarcity. It can also help identify the most relevant gaps in knowledge and skills among healthcare workers and helps prioritize clinical training and skill-building. QI interventions must be implemented within a broader programme of improving quality of care, covering quality planning and quality assurance at all levels of health care. Different actions for improving quality of care are taken at different levels of health system, covering multiple components, such as ensuring availability of essential resources at all health facilities to deliver good-quality, evidence-based services for MNCH: • adequate physical infrastructure, including basic amenities of clean water, sanitation and uninterrupted electricity; • adequate health workforce in terms of number and type of healthcare workers, who are appropriately trained, remunerated and motivated; • essential medicines, other supplies and equipment with maintenance services; • availability and practice of standard treatment guidelines for common conditions; and • engagement with patients, families and community. A district manager, responsible for improving quality of care, would be required to undertake activities towards quality assurance in terms of assessment to check if the health facility has all the inputs/resources, as per the national standards, and adopts the recommended process for effective, effi cient and timely health care that is patient-centric. This is usually carried out by periodic assessments and certifi cation (accreditation) to ensure uninterrupted availability of all essential resources. They also need to continue the clinical trainings of medical and nursing staff and other cadres to improve their clinical skills and knowledge that is critical to provide good-quality, evidence-based health care. In addition, the district management is expected to support work for quality improvement to be undertaken at the heath facilities by the healthcare teams. QI activities must be built upon existing activities, such as QA and clinical trainings mentioned above. What is the difference between quality improvement and quality assurance? [Source: POCQI Facilitator Guide: Improving the quality of care for reproductive, maternal, neonatal, child and adolescent health in South-East Asia: a regional framework (who.int)] Quality assurance (QA) ensures basic functions of a healthcare delivery system. QA determines whether the health care being delivered is in compliance with pre-defi ned standards. Many of the interventions, such as having policy, standards, guidelines, adequate human resource, equipment and infrastructure, are important quality assurance parameters. Quality improvement (QI) is about changing behaviours, approaches and systems to maximize the quality of care that patients receive. Quality improvement moves beyond quality assurance and seeks to transform the culture within which health care is delivered. Quality improvement requires the systematic use of models or tools of improvement, such as the plan–do–study–act (PDSA) cycle. (continued...) DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 7 Here are some more features or QA vs QI: Quality assurance Quality improvement It is driven by regulatory and accrediting mechanisms It is internally driven, empowers all personnel to make improvements Tends to focus on fi nding who is responsible for errors Focuses on improving the system and processes of care; seeks to prevent errors Relies on inspections to identify errors Relies on improving processes Periodically monitors quality Continuously strives to improve quality Management/leadership style is top down Management/leadership: Shared responsibility with involvement of people at the point of care Maintains a pre-defi ned level of quality Continuously improves quality Example: You want to make sure that everyone washes their hands on entry to a neonatal unit. Some illustrative standards to enable handwashing would be: • instituting a handwashing policy; • ensuring that there is a sink near the unit entrance; and • ensuring availability of soap and running water. Quality assurance assessment/accreditation will be periodically carried out by assessors to check if all of these standards are in place. Having a policy and availability of soap, water and sink are necessary, but it may not necessarily lead to the behaviour of consistent handwashing by the staff/ visitors. So, the staff at the unit would need to use QI methods to ensure that more and more people who enter the neonatal unit wash their hands. Staff would review if there are processes that make it diffi cult for people to wash their hands; make certain changes in the process; engage stakeholders in adopting those changes; and would measure the progress of handwashing rates to check if the aim has been fulfi lled. Thus, maintaining the healthcare delivery system up to the pre-defi ned standards is quality assurance. Understanding the processes of care (how the health care is delivered) and making such processes better continuously is quality improvement. Hence, QA and QI are interlinked, and both are important to ensure proper functioning of a healthcare system. (continued...) This programme management guide focuses on planning and managing implementation of quality improvement activities in the form of an ongoing programme. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 8 Purpose of the POCQI programme management guide This guide provides a practical approach to set up and manage a QI programme at the district level within an overall initiative for improving quality of care. It describes the key components of scalable and sustainable QI programmes. It highlights the need for a health systems approach to quality of care, with a common understanding among all stakeholders. The aim is to provide district programme managers with a practical approach to prepare an annual implementation plan for quality improvement, manage day-to- day QI activities during implementation and monitor its progress. The sustainability and effectiveness of quality improvement work require support from the hospital management and district and state/province levels of the healthcare system. It is understood that activities related to quality assurance are going on or will be undertaken ensuring the availability of essential infrastructure, staff and supplies in conformance to the national service standards. This POCQI programme management guide describes guiding principles that a district manager should keep in mind while planning and implementing the QoC programme, focusing on QI. It also describes some of the important steps to consider when implementing the QI programme, monitoring its progress and adapting the programme to take mid-course corrections on an ongoing basis. This guide focuses on improving quality of care for MNCH, although the same principles and methods apply to other areas of health care too like surgical wards and emergency rooms, etc. District managers are quite familiar with annual implementation planning for the MNCH programmes. In many districts, MNCH programme managers will be additionally responsible for running QI programmes for MNCH while in other districts, there may be existing QA/QOC units that are responsible for overall quality of health care and will get the additional responsibility for QI activities. Like MNCH programme managers, the nodal person responsible for quality of care at the district level must plan the QI programme activities, effectively manage implementation of these activities on an ongoing basis and periodically review the progress in the programme to undertake corrections and adapt, based on the learning. The point-of-care quality improvement resources include: 1. POCQI training package: For front-line workers to use QI methods, the package includes facilitator manual, participant manual, PowerPoint slide deck and a QI project template. 2. POCQI coaching guide: This is a training resource for developing QI coaching skills to be able to support front-line teams working to improve quality of care. This can be used to prepare a pool of QI coaches. 3. POCQI programme management guide: Setting up and managing a quality improvement programme at the district level helps district managers in planning and implementing quality- of-care programmes with a focus on the QI approach. This guide is a work in progress and will be updated as more experience is gained in the Region with regard to implementing district QI programmes. All these documents can be accessed on the WHO-SEARO website – improving quality of care, (who.int). DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 9 Managing a QI programme for RMNCAH in a district DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 10 Managing a QI programme for RMNCAH in a district Planning cycle for district QI programme A national QoC plan usually states the objectives for the MNCH QoC programme and the priority interventions to be implemented. The national plan provides direction for the district implementation (operational) plan. District- and state/province-level planning is necessary to manage the programme year by year. The district plan can be prepared based on the national plan or in absence of a national plan, a district plan can be made de novo by the district management itself. The district QI programme will be part of an overall plan to improve QoC for MNCH at the district level. The programme implementation cycle involves a set of common steps followed by all RMNCAH programmes as described in the WHO-SEARO guide on managing programmes on reproductive, maternal, newborn, child and adolescent health. The programme implementation cycle comprises three main steps: a. planning implementation b. managing implementation c. reviewing implementation A district may start planning at any point in the implementation cycle. To develop an implementation plan (planning implementation), programme managers should use the best available review fi ndings on what has been done so far and the results of the work. If the available data are limited, the implementation plan should include activities that generate data so that better data will be available for the next planning cycle. Then the cycle repeats, beginning with using the results of the review, to inform planning, moving forward. Planning implementation: Planning implementation (i.e. developing an implementation plan) of the district QI programme can be aligned with the district RMNCAH planning cycle, which is usually executed annually. Prior to the planning exercise, the district management would need to form a planning team, involving stakeholders and deciding on the timelines and resources needed. The implementation plan helps programme managers to work out how interventions can be effectively delivered and what programme activities and resources will be required. Managing implementation: Managing implementation of the QI programme is the process of getting pre-decided activities and tasks done for improving quality of care, according to the district implementation plan. As the programme manager for QI (nodal person in the district), be prepared to undertake mid-course corrections in your plan as you learn more about how a district QI programme is performing. The programme manager needs to provide support for inputs that cannot be managed at the health facility level. Successful functioning of a large-scale QI programme requires some adaptation in the existing systems, roles and responsibilities of the staff members. Foster a positive environment for healthcare workers and ensure support systems for improving quality of care so that they remain motivated and desire to improve the services. Engage patients, families and community for considering their perspectives and preferences as well as promote demand for timely health care. Actively mobilize resources to address quality-of-care gaps, from government budgets, development partners, philanthropists DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 11 and communities. Facilitate QI coaching, peer-peer sharing and learning. Ensure collaboration across sectors towards meeting common goals. Reviewing implementation: Reviewing implementation of the QI programme is a systematic activity based on data and learning related to QI activities and outcomes. This is an impartial process that is transparent and without blame. It informs how effectively the activities of the QI implementation plan have been implemented. The review usually uses data and information from different sources to assess the strengths and weaknesses of the implementation. When a new district QI programme is to be initiated, a review of the situation at the beginning of the cycle serves as the baseline. While a mid-year review of the district QI plan is benefi cial for mid-course corrections, the end-year review serves as the baseline for the next annual plan. QI implementation plan/activities need to be reviewed more frequently, compared to the overall district RMNCAH programme, as described later in this document. Key principles for a district QI programme Here are some key principles for planning and managing a QI programme to improve MNCH services in a district. 1. Aim at improving healthcare outcomes for the people: All efforts to improve service delivery must be patient-centred and directed towards improving clinical outcomes and patients’ experience of care. You may use new plans, directives and training to support improved care, but they are only a means to an end. You should regularly review patient-level data to learn if services are improving. 2. Start fast: The only way to reduce mortality and improve experience of care is to change what is happening at the client level. Therefore, the district management should focus on supporting facility- level staff to start QI projects as soon as possible after the initial QI training. The motivation that you can generate from achieving early success in improving care on the front line is critical for spreading and sustaining a new QI programme. In addition, lessons from early efforts can be used to convince stakeholders and make your programme more acceptable. 3. Support health worker teams: Health workers often work in conditions that are diffi cult and under- resourced and that hinder performance and achieving excellence. Systemic conditions such as unclear goals and expectations, poor organization of healthcare delivery, policies that impinge on effi ciency and inadequate information fl ow prevent health workers from carrying out their tasks with ease and achieving success. District leadership should help health workers to identify quality gaps but not blame them for these gaps. Health workers should be encouraged to resolve problems by adopting solutions that are under their own control, such as changing the process of how care is delivered. For problems that are not within the capacity of health workers to solve, such as the need for additional infrastructure, staff, equipment, etc., district managers should fi x those problems at their end or refer to higher levels to fi x these. 4. Learn, adapt and share: New programmes (including those to improve quality of care) are unlikely to be perfect from day one. You will learn a lot during early implementation of the QI programme. Use this learning on what works and what doesn’t to make mid-course corrections and modify the plans in the district. Share these lessons with colleagues in other districts to help them learn and avoid re- inventing the wheel. 5. Integrate with existing structures and functions: Improving quality of care is a fundamental activity of the healthcare system and it is not an add-on task. The responsibility for providing good-quality services lies equally with the leadership, managers and front-line staff. You should avoid setting up parallel systems to improve quality, instead build on what you already have and utilize existing resources. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 12 Principle Action Improve care for people. Focus on patient-level care and not on activities like training to tell you if your programme is working. Start fast. Start QI projects at facilities as soon as possible after the healthcare teams have been oriented to QI. Support health worker teams. Create enabling environment for health workers to practice QI and provide good services. Learn, adapt and share. All plans can be improved upon. Learn what works and what doesn’t and adapt your programme accordingly. Integrate with the existing structures and functions. Assign responsibilities for QI to existing staff and management structure and utilize available resources. Subsequent sections describe in brief the steps of preparing a QI plan in the district, implement it and review it. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 13 Prepare a plan for the district QI programme DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 14 Prepare a plan for the district QI programme Components of a district QI programme These components are to be built upon or linked with the other quality of care activities being implemented in the district, like QA activities and clinical trainings of the staff. Key components of a district quality improvement program are summarized in the table below (Table 1). Table 1: Key components of a district quality improvement program 1 QI program management structure Departments / administrative bodies in the district who have or could take specifi c roles and responsibilities for QI program management. E.g. District health offi cer, district MCH offi cer, or district QoC offi cer 2 System functions (fi nance, human resources, data) aligned to support the QI program Successful functioning of a district QI program will require contribution and support from the existing district health system including: 1. Financial system (e.g. budget to provide training, support coaching visits and peer learning); 2. Human resource system (e.g. Training staff in QI and permitting them to undertake QI activities); 3. data systems (e.g. including QI indicators used by health facility teams and QI management). 3 Quality Improvement plan This is the overall program plan with identifi ed activities and timelines for QI. This is aligned with or included in the existing RMNCAH or QoC plans in the district. 4 Healthcare teams at health facilities/hospitals improving care at the frontline Quality improvement teams are formed in the health facilities. Healthcare workers need to be provided knowledge and skills in quality improvement that they can practice at their work place. 5 Healthcare teams receive ongoing quality improvement coaching support QI Coaches (who have prior experience in using QI methods) guide frontline healthcare teams to continue applying QI methods to deliver better care. 6 Peer-to-peer sharing and learning Opportunities for QI teams from the same or different facilities to learn from each other’s experiences and to motivate each other. 7 Support from leadership/ administration at health facility / hospitals and district-level Leadership support and active participation at health facility, district and state levels is critical to success. Leadership has to provide material support for QI, enable all of the above components and foster a culture of trust, transparency and improvement. Support for monitoring the improvement in quality of care at health facilities and the progress in implementation of district quality improvement programme. 8 Community engagement in health service delivery Patient groups, women groups and community leaders/representatives participate in running of health facilities and hospitals to deliver patient- centred healthcare. With QI training, post-training coaching, peer to peer learning, leadership support, structures and systems in place we can enable frontline teams in health facilities/hospitals to improve quality of healthcare leading to further gains in RMNCAH. It is also expected that this new way of working will lead to further DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 15 strengthening of the district health system that will make it easier to improve quality in other areas of healthcare (like surgery, internal medicine, trauma etc) in the future. Below, we provide brief guidance for what activities to consider in each of these components for a district QI programme and how to implement. A sample planning template for the development of such a programme is given in Annex 3. Review current QoC activities and capacity in the district Various QoC activities may be ongoing or planned in the district based on local needs and national priorities. One must take stock of structures and resources available, ongoing QoC activities, partners and stakeholders and their roles and responsibilities. Once we know what already exists, we can prepare a well- structured QI programme. Existing structures and staff currently responsible for QoC in the district: There may already be an existing district QoC team that is responsible for system-wide quality improvement in health care. If there is one, one should assess if the staff is adequate and if enough budget is available with the district team to undertake QI activities. If there is no existing team or structure for QI in the district, one should explore the possible options. It could be the district chief medical offi cer or a civil surgeon, or the RMNCAH programme manager who could be assigned the role of managing quality- of-care activities in the district. Ongoing QoC activities in the district: Please fi nd out if any of the following activities has been recently undertaken or is onging in the district and integrate new QI activities with these. • Health facility assessment: There may be activities related to health facility survey and assessment of quality of care or a quality assurance assessment system already in operation in the district. That could be used to build upon the QI programme. • Adoption of national standards: Please confi rm if national standards of MNCH care and treatment guidelines have been adopted in the district. • Clinical trainings: In many districts, in-service clinical trainings for doctors, nurses and other health workers are undertaken under the MNCH programmes. Assess how the existing supportive supervision mechanism and clinical mentoring are functioning and how that could be used for QI mentoring/coaching. • Death review system: Assess the status of implementation of death review system in the district like maternal and perinatal death surveillance and response (MDSR/MPDSR) and paediatric death reviews. QI activities can be easily linked with death review systems. • Training in QI methods (POCQI): Find out if training of doctors and nurses in QI has been undertaken, if QI projects have been conducted at hospitals and if QI/QoC review meetings are organized. What are the possible opportunities for sharing QI learning? • Engaging with community representatives: Find out if there is an existing mechanism for engaging with patient groups or community representatives in the district MCH programme. Opportunities for partnership for QI implementation: • Find out if there are partners who could support QI programmes and if resources from donors are available for the district. • Are there activities for engaging with stakeholders, patient groups and community? DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 16 Plan to start a QI programme in the district When starting a QI initiative, it is better to begin at a few health facilities in a defi ned clinical area and use this experience to learn how to scale it up. It is almost impossible for a district that is beginning its QI journey to immediately start a QI programme at all facilities and for all clinical areas. Trying to do too much at once risks failure. Your initial district QI plan should describe which facilities will start QI projects and how and when you will expand to new facilities. It should also include the initial clinical area the QI teams will work to improve. Finally, it describes what support you will provide to facilities and how you plan to manage the programme activities. A key part of the plan is to start QI activities quickly at facilities so that you can learn what works and what does not. This will help you adapt as you go. Select initial facilities and timeline for scale-up You want to support the staff at the initially selected facilities to improve care, but, almost as importantly, you want to learn about how the roles, mechanisms and systems need to be adapted to support QI work in your district. Because the focus is on learning, it is best to choose facilities that can contribute to it. Facilities will contribute more to learning how to improve care if they: • Are interested in joining in. You can work with sceptics later, but, initially, enthusiastic facilities will generate more learning. Choose facilities that are willing to use QI methods. • Are not the best performers (if they are the best performers, then they don’t have much room to improve) and not the worst performers (they may have deeper problems, which will take time to address). It is recommended that the initial facilities selected are the ones whose performances are in the middle. • Do not have unmanageable workload. If the facility has very little workload, it will take too long to show improvements. If a facility is very busy the healthcare staff may not have time to learn and practice QI. As a practical approach, it is advisable to initially select facilities that have at least 30 deliveries per month each. • Are easy to visit for the management team and coaches. If you cannot visit a site regularly, you cannot provide proper support. You will eventually want to work with all the facilities, but, at the beginning, choose facilities that are easy to visit. It is also preferred that the initial sites are those where the QI team members have some digital connectivity so that online support can be provided if in-person visits are interrupted for any reason. Case scenario – selecting initial facilities and timeline for scale-up Current situation Proposed plan District X has a population of about 500 000. It has approximately 50 health facilities, including a district hospital and four subdistrict hospitals. Each subdistrict hospital is a referral centre for about 4 primary health centres and 8 sub-centres. The district decides to start the QI programme at the district hospital and two subdistrict hospitals in the fi rst year. They plan to spread to all subdistrict hospitals and to include all primary health centres after 12 months and later they will involve the sub-centres in the district. Select clinical areas to initially focus on It is diffi cult to work on improving every part of health care at once. Asking people to do so can be overwhelming and demoralizing. Asking people to focus and work on specifi c healthcare areas that are important to them and their clients and are fi xable is a good way to get people motivated to improve care. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 17 Case scenario – selecting clinical areas to focus on Current situation Proposed plan The current national healthcare priority is to reduce maternal and neonatal mortality. The district management decides that the district QI programme’s initial focus will be to improve care around childbirth. After the fi rst year, they plan to broaden their focus to apply QI methods in antenatal care and sick newborn care (e.g. in newborn care units) and later expand to improving pediatric care. Set up systems to support facility QI teams When setting up systems to support facility QI teams, it is helpful to think about key components that are important in supporting teams and managing the district QI programme.11 For a district QI programme to be successful, we need two main components: a) Front-line staff with the knowledge, skills and motivation to improve QoC: This includes both clinical skills and skills in improving QoC. For this, we need to provide: • Clinical skills and QI skills training » to support health workers in strengthening their clinical skills and provide post-training support; and » to ensure that front-line health workers know QI basics. • Clinical mentoring and QI coaching support: This is to guide and support staff to practise clinical and QI skills, as they work on QI projects. • Peer-to-peer sharing and learning support: This is to support staff at different facilities to learn from each other about their experiences of improving services. b) District managers providing adequate governance and support to improve QoC: For this to happen, the decision-makers will need to focus on the following: • Management processes: These are to ensure that the QI programme is functioning, that there are adequate human and fi nancial resources for managing QI and that problems not fi xable at the facility level get addressed at their level. • Community and stakeholder engagement: This is to ensure systematic and meaningful engagement of the community in efforts to enhance quality as per their needs, priorities and preferences. • Measurement: Collect and analyse data and information about how the planned QI programme activities are progressing and how patient-level processes and care outcomes are changing at health facilities. Details on how to strengthen the system and operationalize each of the above components to support the district QI programme are described later in the document. 11Quality health services: A planning guide. Geneva: World Health Organization; 2020. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 18 Components of a QI programme Building the knowledge, skills and motivation of front-line workers to improve care Adapting management practices and improving governance of the QoC programme Ensuring a supportive environment that encourages learning QI by doing Provide adequate resources, time and permissions for undertaking QI. The district QI plan should include ideas on how to build these components. As you learn more by supporting QI at a few facilities, you will be able to adapt the programme and make it better. Management processes Resources and permissions for QI Identify and address quality gaps Stakeholder engagement Community (patient groups, etc.) Stakeholders (WASH/civic adminis- tration) Measurement Quality of care QoC programme management Facility teams improving care QI skills Clinical skills Ongoing QI coaching support QI and coaching skills QI coaching plan Peer-peer sharing and learning Skills to document and share QI experience Sharing opportunities Summary – key points for starting a QI programme in the district • Selecting initial sites (health facilities) in the district for starting implementation: » Select facilities with reasonable resources. No point in starting QI if there are very few health workers and no water/sanitation. » Select facilities that you can support every month and that can generate learning to help you make your programme stronger. • Selecting initial QI Projects: » Select priority area for QI (as per the national priority), for example, MNCH. » Select aims for QI in the priority area that are important to health workers and communities and are fi xable at the facility level. • Setting up systems to support facility-level QI teams: » Provide POCQI training to healthcare teams from the selected health facilities - classroom, onsite or virtual. » Ensure that QI coaches can visit each month. » Ensure that peer-to-peer learning can happen periodically. » Ensure measurement system and identify data for improvement and ensure that data for management gets to those who need it. » Ensure that the stakeholders and communities are involved in determining how to improve services. » Ensure that the programme is managed within the existing healthcare system. Please see Annex 1 for a sample of planning template for developing QI programme for district level. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 19 Implement the district QI plan DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 20 Implement the district QI plan Effective implementation of planned activities identifi ed in the district QI plan is critical for achieving the aims, objectives and targets of the programme for the year. The district managers must manage human resources and logistics to complete the planned QI activities that mainly include: primary POCQI trainings of the new healthcare teams; ongoing QI coaching for the trained healthcare teams; and peer-to- peer learning in QI as well as community engagement. This section provides guidance on these important programme activities to support QI for MNCH. District leadership support for the QI programme To ensure that the QI programme does not become a series of standalone activities that are unconnected to the overall health system and MNCH services, it is important that a district programme manager integrates the QI programme with the existing management structures, such as the ones for MNCH or QOC programmes in the district. Improving quality of care may be the responsibility of an MCH programme manager or a quality of care programme manager in the district. One of the two (MNCH and QoC) management structures would assume the responsibilities to support the QI activities, including QI training of staff, post- training coaching visits, peer-to-peer learning, community engagement and using QI data for monitoring progress of the QI programme. This means that these structures must have adequate staff and budget for planning, implementing and managing the QI programme. QI programmes are not necessarily expensive, but some funds need to be allocated for QI trainings, QI coaching, peer-to-peer learning and management meetings. If there is a need to have additional, dedicated QI staff in the district to support the programme, this is another cost to consider. The district management must ensure that the QI programme has the material and non-material support required to solve problems that are not solvable at the health facility level. Alongside the QI activities at the point of care (by healthcare teams at health facilities), the district QI management will also need to strengthen the health system building blocks (human resources and their clinical training, fi nancing, supplies, information systems) to support delivery of high-quality MNCH services. Managing an effective, district-level QI programme requires clarifying roles, providing resources and setting up oversight to ensure that: 1. There is an identifi ed unit, team and/or a person within the district management responsible for improving quality of health care, including the quality of MNCH services. 2. Staff in district management and health facilities receive training in basic QI skills. 3. QI coaches are trained and resourced to visit health facilities. 4. Meetings are organised for reviewing the activities, progress, and peer-to-peer sharing and learning are facilitated between health facilities. 5. Quality gaps that are not fi xable at the health facility level are addressed by the management at district or state/province levels. 6. Communities and stakeholders are included as partners so that health services meet the needs and priorities of citizens. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 21 Identify and fi ll quality gaps Delivering good-quality care is not the sole responsibility of the facility-level staff. They can improve the local process of health care and improve the quality of care, addressing certain quality gaps, some of which, however, are beyond their control. They need support from the programme management at district and higher levels for getting additional essential resources for MNCH services. Therefore, the district management should use data and information from QI coaches and facility staff to actively identify and fi x any problems that the facility is unable to solve. If the district management identifi es a need that they cannot address, they should bring it to the attention of the higher authorities at the state or national level. The district QI management should think of both short- and long-term solutions for these types of problems. Illustrative examples of the type of support that the facility staff may need: Challenge faced by facility Immediate support from the district Long-term solutions from the district Supplies – a facility does not have enough iron folate tables for women coming for antenatal care. The district level provides a temporary supply from another facility that has extra. Help the facility improve inventory forecasting and management so that it does not run out of stocks. Clinical skills – staff have asked for clinical skills training in managing pre-eclampsia. The district sends some staff from the facility to the regional medical college for clinical skills training in management of eclampsia in the pregnant women. In partnership with the nearest medical college, develop a simulation-based clinical skills training programme for all staff in the district. Plan to conduct this twice a year. Foster positive environment for QI work Health workers are often hesitant to try to improve care. They can sometimes get in trouble for raising issues or trying new things. It is important for the district management to recognize these fears and create a positive environment so that health workers feel safe and supported in their efforts to deliver better care. Some of the practical things that a district QI manager can do to support a positive environment for QI work: 1. Encourage sharing of problems, data and experiences with the district management without fear of punitive actions. 2. Demonstrate that you consider fi nding and identifying problems is a good thing! Many health systems implicitly encourage people to hide problems by taking punitive approaches. You should demonstrate that you want people to identify and solve problems. 3. Encourage staff to participate in QI activities. Be very clear that staff are allowed and expected to join QI activities. Simple solutions include changing job descriptions to include QI activities and providing offi cial letters clarifying that individuals are expected to carry out QI coaching or training activities, including fi eld visits. 4. Help solve problems. Show that you are involved and supportive by solving problems that front-line teams are not able to solve on their own (e.g. problems that require new resources or a change in existing policies). DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 22 5. Appreciate and motivate people, who are improving services. Ask the health facility staff what problems they face or what they think could make their jobs easier. Recognize people for participating in QI activities. In addition to giving permission for participating in QI activities, it is also important to publicly recognize people for their work on improving services. 6. Facilitate learning and adaptation. Health workers will be more likely to pay attention to the QI work and adapt what they are doing to get better results if they see their peers and leaders carrying out exemplary work. Strengthen QI skills of healthcare teams Once you have initiated a QI programme in the district and selected the fi rst set of health facilities, it is important to start work with the facility in-charge / manager and the healthcare teams at these facilities. Make sure that: a) Quality improvement teams are formed in the health facilities, b) facility staff know and have the skills regarding how to use QI approaches and c) they hear from the hospital administration and the district manager that they have the permission and support to apply these skills to deliver better care. The focus of the initial training should be on ensuring basic knowledge of the quality improvement method and practical skills that people can understand easily and use immediately in their day to day work. There is no need to delve deeply into theory or complicated QI methods as this can overwhelm the people who are new to QI. The POCQI training approach has been successfully used to train hundreds of QI teams in the SE Asia Region. It uses a simplifi ed, four-step method that the new teams fi nd easy to relate to. The standard POCQI training is undertaken with a group of 20–30 healthcare workers in teams by 4–6 facilitators. It is a classroom training using short presentations, examples, audio-visual clips, interactions and small-group work and games. On the second day, the participants are assisted to prepare their own QI projects that they would carry out after returning to their place of work. The training package has been converted into a digital format and e-training is available for synchronous learning for participants on internet platforms under the guidance of POCQI facilitators (e-POCQI). POCQI training can also be conducted within the hospital if there are enough healthcare workers/teams to be trained. We need experienced POCQI facilitators to impart QI training. One useful approach is to fi rst train facilitators (trainers) at the national/subnational level. Such a pool of trainers is usually composed of staff from higher-level facilities, such as medical colleges, who have been trained previously and practised QI skills themselves. This ensures that the QI trainers gain both theoretical and practical expertise before training others in QI. These national/state-level trainers can train district-level trainers, who can then train front-line workers at health facilities. Using such trainers to train front-line workers also helps build relationships between QI practitioners at different levels of the health system and that can be important in building a critical mass of QI practitioners along a referral chain of health facilities in the district. Existing line supervisors of health workers in the district could be trained as POCQI trainers over time so that they are available to train new staff members that get posted in the district and provide ongoing QI coaching as well, after the training. QI training should be carried out for teams of multiple cadres of health workers – for example, nurses, doctors, midwives, paramedics, cleaners and support staff from the same facility who take care of mothers and neonates around the time of delivery. It is recommended that the hospital manager/in-charge joins the fi rst training to understand improvement science and POCQI methodology. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 23 Case scenario: Plan for building QI skills of front-line teams Current situation Proposed plan This district already has clinicians at the district hospital who have been practising QI. They were earlier trained by the faculty from the medical college in POCQI. The district organizes a training for a multi-cadre team from each of the initial set of health facilities. The trainers are the district hospital staff, who know QI, and at least one trainer is from the national level to ensure the quality of training. QI teams are formed in the health facilities. Common challenges faced in providing QI knowledge and skills Challenges Options to address QI trainers are not available in the district. • Request for QI trainers from other districts or request for QI trainers from the state or national level. Also, get the district-level people trained as trainers. • There may be QI trainers available with the partner agencies in the district. People, who were initially trained in QI, have now left the district (transferred/retired). • Organize QI training for new staff. Arrange ongoing QI coaching support Initial QI training in classrooms is useful to teach people QI knowledge and skills and get them started. But many people will require hands-on support to apply those skills in the real world at their place of work to address the local quality problems at their facilities and to learn more advanced QI skills. Most QI programmes provide this post-training support to QI teams through QI coaches from outside the facilities. The district and state QI trainers are the ones who could assume the role of QI coaches. QI coaches are not inspectors or supervisors, their role is to help facility-level staff learn how to apply QI methods and work together to fi x problems. Coaches need to be enabled to take time out of their routine work and be given travel support to visit the health facilities they are supporting. Some follow-up and discussions could also take place over telephone or internet audio-video calls. For more information on QI coaching, see the POCQI guide on coaching support for quality improvement (web link: https://www.pocqi.org/wp-content/uploads/2018/07/Coaching-guide.pdf ). In general, a QI coach should visit each facility at least once a month and one coach can usually support 5–10 facilities, depending on his/her other responsibilities and the ease of transportation to these facilities. In addition to in-person visits or when such visits are not possible, provision should be made for coaches and their teams to connect online for discussing the progress and problem-solving. While managing the district QI programme and implementing the plan, the district manager must set up a QI coaching system to sustain this activity of providing on-the-job support to QI teams. a) Initially, when the plan is to initiate and demonstrate a small QI programme in a limited number of facilities, it may be best to identify people from the state/national level, who are already experienced in using QI methods, and assign them as coaches for the new teams. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 24 b) Later, in the scale-up phase of the QI programme, coaching capacity needs to be created within each district health system. This can be done either by creating dedicated positions for quality-of-care work or assigning some of the existing staff to assume the responsibility of QI training and coaching for the healthcare teams at the health facilities. Existing line supervisors of health workers in the district who have been trained in QI could be trained as QI coaches over time so that they are available within the district. Case scenario – providing coaching support to front-line teams Current situation Proposed plan There is currently no QI coaching being conducted in the district. Some staff at the district hospital have been trained in POCQI and have carried out a few QI projects that have led to improvements in care, but further QI activities are not being sustained. The district management discusses two options: a) assigning the district hospital staff, who have QI experience, to coach other facilities or b) preparing QI coaches among district-level staff by building their skills in QI coaching. The advantage of using the hospital staff is that they are clinicians and are experienced in QI and can quickly begin to support other facilities. However, this approach may be diffi cult to sustain. The district hospital staff is, usually, very busy and will fi nd it diffi cult to coach all facilities in the district. Given this reality, the district management decides to build skills of other district staff in coaching. But they are unsure about which cadre will be most suitable for this task. They decide to opt for nurse supervisors as QI coaches to start with and see how this works. They also think the line supervisors will work well because there are enough of them to support all facilities and they are already routinely making supervisory visits to various facilities in the district. The trained district hospital staff is asked to train line supervisors for nurses and doctors in POCQI and coaching and accompany them during the initial QI coaching visits to strengthen their performance as QI coaches. There are often challenges to the logistics of carrying out coaching visits and the quality of coaching. These are common problems that come up early in the programme. Challenges Options to address Transportation for coaching visits is not provided to QI coaches. • Inform transportation in-charge to provide vehicle for transport. • Provide the coach with funding for travel. • If it is not possible to arrange any transportation and strong internet connectivity is available, some form of coaching can be carried out online. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 25 Challenges Options to address Coaches’ skills in supporting teams to use QI approaches are weak. • Arrange joint coaching visits with more experienced coaches. • Arrange peer-to-peer learning for coaches to learn from each other about how to effectively coach. • Ask them to keep practising. • Ensure that the QI teams at health facilities do not select complex QI projects initially, so that the new QI coaches are able to manage and learn faster. Coaches’ facilitation skills and rapport with QI teams are weak. • Emphasize the importance of building connection and strong rapport with the team and of not being seen as an inspector. • The district leadership should model the desired behaviour with the coaches. • Arrange joint coaching visits with more experienced QI coaches. • Consider trying to recruit other coaches from a different cadre. Supervisors of coaches do not let them travel to visit sites. • The district management should send clear directives and permission letters as well as allocate adequate budget. • Change the job description to include QI coaching and spend time on this work. Enable opportunities for peer-to-peer sharing and learning In addition to QI training and coaching, people from different facilities can improve their QI skills by meeting their peers and learning from how they used these skills. Peer-to-peer learning can help teams to solve logistical challenges (e.g. by learning how other teams organize QI team meetings) and improve their QI skills (e.g. by learning how other teams have use fl owcharts to identify what needs to be improved). Peer-to-peer learning can be highly motivating. Teams that are struggling get a chance to see that the people at similar facilities are fi xing problems and everyone gets a chance to share their commendable work and be recognized. You can try multiple opportunities and methods to give health workers the chance to share and learn from each other, such as: • In-person learning sessions: » During in-person learning sessions, QI teams from different facilities meet to share their work. These are not training or lecture sessions, instead there are group discussions so that team members from different facilities get a chance to talk to each other about what they are doing and what they have learned, what has worked and what has not. » The district QI manager can organize these learning sessions at the time of the routine district or subdistrict meetings. Or he/she can organize standalone meetings, specifi cally for QI work. In general, you should give people a chance to learn from their peers every three months. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 26 • Virtual learning sessions: » In areas with good internet connectivity, you can organize virtual learning sessions over a web- based platform to allow teams to meet each other more frequently, in addition to physical meeting. • Exchange visits: » You can also organize exchange visits between different facilities. These visits are particularly useful when staff from less experienced QI teams get a chance to visit more experienced QI teams and see them in action at the work place. QI teams can document their work in different formats for sharing. Teams can use case studies, journal publications, PowerPoints presentations, posters, narrative videos, etc., depending on the skills and time availability of the QI team members. You may need to provide some external support from QI coaches to build the team members’ skills in documenting the key learnings from their experiences. Case scenario: Providing opportunities for peer-to-peer sharing and learning Current situation Proposed plan Currently, monthly review meetings are held at the district headquarters. All facilities from the district share their updates at these meetings. These meetings have a “report-out” format and there is limited discussion between teams. The district QI manager gets these meetings extended by one hour. During this extra time, QI teams from different health facilities are invited to share their work. The QI coaches facilitate discussions. Discussions on topics suggested by the QI teams are also included in these meetings. In addition, the district allocates funds for a one- day meeting every six months for the QI teams to display and share their improvement work and to discuss progress. Offi cials from the government and community leaders are invited to these meetings. The district management is responsible for creating opportunities for sharing learning within the district and with other districts. Most health systems are not used to supporting information-sharing between facilities. Learning to describe how you improved care is a new skill for most health workers. It will usually take practice to build these skills. Some challenges that can be faced in ensuring peer-to-peer sharing and learning and possible options for addressing them are listed below. Challenges Options to address QI teams are not able to describe specifi cs about how they actually improved care. Thus, other facilities are unable to benefi t from their experience. • Coaches can help identify what information would be useful for another facility. • Organize an exchange visit with a facility that is struggling with the same aim. Staff from the site that is struggling may ask practical questions that prompt robust information or inputs from the team that has done well. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 27 Challenges Options to address Teams are reluctant to share their work in district meetings or other forums. • Leaders must encourage sharing by focusing on how to fi x poor care rather than responding negatively to problems described by the facility staff. • Coaches should help build confi dence by guiding teams on how to present their work and holding a practice session with them. • Coaches should demonstrate how to moderate QI-sharing forums to enable learning among teams. • Time for sharing between teams needs to either be set aside during existing meetings or by setting separate meetings. Engage the community and stakeholders One of the objectives of the districts QI programmes will be to learn which ways of ensuring stakeholder and community engagement can help improve quality of care. Patients are not passive participants in health care; they are important stakeholders, decision-makers and knowledgeable about their own lives and experiences. The district should make intentional and systematic efforts to invite stakeholders and community representatives (including women and marginalized communities) to initiatives to improve the quality of care of health services. Community feedback can help identify gaps, monitor performance and zero in on resources to address the problems identifi ed. Stakeholders and community members can also often help solve problems and contribute to improving care and ensuring accountability. Stakeholder and community engagement will vary in scope and involvement, depending on the local context and culture. Challenges may be encountered in involving communities. Case scenario: Engaging the community and stakeholders Current situation Proposed plan Facility staff has worked on improving the processes of care, but utilization of services remains low. • Try to understand the reasons for not seeking services from community members and stakeholders. • Community health volunteers can be involved as members of the QI team for this. Similarly, health facilities also encounter challenges in engaging communities actively in QI. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 28 Challenges Options to address Relationships between the community and the district health offi ce are not always good. Neither side feels that the other understands their concerns. One of the biggest problems in the district concerns women coming to facilities late in labour and not seeking antenatal care. The district realizes that both these problems will be hard to fi x without community participation. They hold a meeting with local leaders to introduce the programme to the community and ask for volunteers to join the monthly meetings and be involved in providing oversight. Stakeholders are not participating at the district level. Community strengths are not being used. There is a community-run bike ambulance service, which is not being utilized fully. • Invite community stakeholder representatives to planning meetings for MNCH quality of care. • Identify available resources in the community and use them strategically to contribute to improving MNCH quality of care. Please see the Annex 2 for a summary of setting up and managing the district QI programme. The Annex 3 refers to some common challenges faced in managing district QI programmes. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 29 Monitor and adapt the QI programme DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 30 Monitor and adapt the QI programme Monitoring the district QI programme and reviewing the progress and challenges in implementation are important for mid-course correction and adapting new ideas to improve performance of the programme. For this, a measurement plan is necessary. Measurement of the QI programme Ongoing measurement of QI activities is needed for answering two important questions in QI programmes. 1) Is the quality of care improving? 2) Is the district providing the right support to front-line QI teams? Is quality of care improving (data for assessing improvement in care)? Facility QI teams use data on processes and output of care and review it daily or weekly, based on the QI aim that they are working on. Existing health information systems do not, usually, collect this type of data or collect it this frequently. Teams may sometimes need to use temporary systems to collect frequent data on the aim they are working on and use locally to check the impact of the changes they have brought about in their work process (PDSA cycles). As the district manager you may not need all this data to be reported to the district level but will need enough information to know how different facilities are progressing. QI teams at health facilities should submit the QI project data in MS Excel or even on paper. You should review these data at least every month. If you see facilities that are getting impressive results, you can put some effort into helping those facilities share the lessons they have learned through peer-to-peer sharing opportunities. If you see facilities that are not performing well, you can provide them with extra support, as needed. With accumulated experience across the health facilities in the district, selected QI indicators could be included in the routine health information system. Is the QI programme working (data for programme management)? The district management will need programme data to determine whether the structures and systems and the planned activities to support the QI teams are working. Programme management data should include information such as below that can be reviewed 3–6 monthly: • How many facilities and staff members have been trained in POCQI? • How many facilities have started specifi c QI projects? • How many facilities had a QI coaching visit? • What is the number of peer-to-peer learning sessions organized in the district in the previous quarter? • Are QI data being adequately collected and shared between the facility and the district levels? • Are problems that cannot be fi xed at the facility level being addressed by the district or higher levels? Based on this information, the district management should respond to solve any issues identifi ed. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 31 Case scenario: Measuring the QI programme Current situation Proposed plan Currently, the data system includes only input and some outcome indicators – such as the number of patients admitted and discharged or expired. There is no information on indicators on processes of care – such as how many patients received the correct treatment interventions, as per the standards of care. A few selected indicators related to key processes of care that are in the current priority areas of the QI programme are included in the routine health information system. E.g. proportion of babies whose temperature was recorded one hour after birth; and proportion of babies in whom cord-cutting was delayed to three minutes after birth Staff is currently used to collecting data for reporting and are not keen on collecting additional data for their QI project. This is leading to incorrect and missing data. Staff is reassured during the POCQI trainings and during QI coaching that the data from their improvement work will not be merely for reporting to higher levels but that they will fi nd this data useful to solve their own problems and improve quality of care. Staff are also assured of “No blame, no name and no shame” culture and encouraged to transparently share the local data, showing how they improved the situation. The district level should review data related to specifi c aims the facilities are working on and data on the functioning of the QI programme itself. There can be challenges to collecting these data and to making sure that it gets to the people, who need it. Some illustrative challenges related to collection, reporting and use of data for QI and QI programme management are described below, along with some options for addressing them. Challenges Options to address Facility-level teams fi nd it diffi cult to collect data on QI process and outcome measures • Do not focus on too many measures at the start. Facilities should begin with collecting only the data that is relevant to their quality improvement aim. • Check whether facility staff is burdened with other unnecessary data collection activities and reduce these, if possible. • Provide relevant data collection formats/tools (registers) and train staff in how to use them. Data is being collected at the facility level but not reported to the district level. • Consider setting up a temporary, parallel system to report these data, using Excel formats or paper charts. Often, learning districts start with this option. • In due course, when the QI activities are expanded, incorporate selected indicators applicable to all health facilities into the existing reporting system. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 32 Challenges Options to address Programme performance measures are not collected. • Clearly identify and communicate which QI programme activities are to be monitored in the district and with which indicators. • Clearly identify data sources and who should be responsible for collecting and reporting the data, e.g. district QoC manager or supervisor. Data are not reviewed at the district level. • Clarify which management structure should review these data and when and how the feedback will be provided to the reporting units. Facilities/districts become channels for data transfer to the next level and data are not used for decision-making. • Ensure that QI teams at the facility level are empowered to use their data and make changes to improve care. • Emphasize use of data for carrying out improvement, and not just reporting of data. Data are not valid or reliable. • Ensure that a positive environment is fostered during QI discussions in the district. There is no blame and punishment for poor data or sharing of problems and challenges. • Ensure that facilities are engaged in using their own data for improving care. • Ensure that unnecessary data are not being collected. A sample measurement plan for a district QI programme is given in Annex 4. The specifi c indicators being monitored may need to be adapted, based on the local programme priorities and context. Learn and adapt the district QI programme District QI managers will learn over time by identifying and solving the challenges faced and then actions will be taken to overcome the initial teething problems of setting up new QI programmes. We have discussed above the importance of QI training and ongoing QI coaching, peer-to-peer learning and measurement of quality of care. These are new activities for MNCH programmes and the initial plans may not work out as envisioned. This is fi ne as one must learn from the initial plans and adapt the way forward based on the experience. The district QI manager should respond to solve any issues regarding the functioning of the coaches and the teams. For example, if the people appointed as coaches are not given time to carry out coaching support or are not given transportation for onsite visits, then the system will not work. Try various options to address these challenges. In the process, you will learn how to adapt the existing systems to support QI teams. Sometimes, a few weeks of actual implementation can teach you more than months of planning. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 33 You need to build as you go and adapt the programme as you see what works and what does not. You need to keep in touch with the state/national level and get their support for fi xing problems not fi xable at the district level. Maintain engagement with staff at the state/national level to share data on progress, identify specifi c problems that you need help with and share any key learnings about how best to organize such an effort. Case scenario – assigning responsibility to manage the QI programme Current situation Proposed plan The district has a functional District MNCH Committee with one district offi cial and one administrative assistant. This committee is responsible for an active programme on clinical skills training in maternal, newborn and child health. The district asks this district offi cial to support QI coaching and peer-to-peer learning. The district asks the data offi cer to ensure that QI team data and data on coaching visits and peer-to-peer sessions get to the District MNCH Committee on time for its monthly meeting. Discussion on the QI programme is also added as an agenda item to the monthly meeting. Case scenario: Aligning the fi nancial systems to support the QI programme Current situation Proposed plan The district currently does not have any assigned budget for a QI programme. There are, however, budget line items for training, supervision visits and district meetings. For the fi rst year of the QI programme, the district earmarks some funding for QI trainings, coaching, peer-to-peer learning sessions and management meetings from the existing line items. For the following year, they develop a dedicated budget line for the QI programme with a request for specifi c funding from the state. Review fi ndings at the end of the year will form the basis for preparing the district QI plan for the next year. Once the programme has been introduced to the facilities and they have started their own QI projects, the district has fi ve key responsibilities: • Create and maintain a positive environment so that the health workers want to improve services. • Help them solve problems that are not fi xable at the facility level. • Make sure that the coaching and peer-to-peer support work. • Ensure that the data gets to the people who need it. • Involve the communities throughout the programme activities. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 34 Conclusion A district QI programme builds upon the ongoing efforts of the healthcare system by offering effective approach to solve problems related to quality of care towards delivering more effective healthcare and improved experience of care for the patients. This guide is an important component in the POCQI package that has been used for improving quality of care for RMNCAH. This approach and principles of QI can however be used in other healthcare areas as well. Supporting health workers to learn QI skills is an important fi rst step that could also be combined with the existing clinical trainings that are regularly offered to healthcare workers. However, building a sustainable QI programme that can be scaled up to multiple health facilities in a district requires more than just one-time QI training. It requires ongoing support for QI teams in health facilities and hospitals through on-the-job coaching, providing them opportunities for peer-learning in quality improvement, recognition for healthcare teams who excel in QI work, engaging community for QI, as well as periodic monitoring of the district QI programme. The district QI programme also requires management processes within the district health system to align existing manpower and procedures to help the QI programme that supports the trained people to practise QI skills at the point of care. The district leadership is required to integrate QI activities with other ongoing or planned activities for improving quality of care, like quality assurance (certifi cation / accreditation) that ensures the availability of essential infrastructure, staff and supplies as per the national service standards, as well as the ongoing clinical training of the staff in the district. Under the POCQI model, QI in MNCH in the Region has initially focused on improving the quality of care at health facilities. However, these same principles are applicable across the health system – from community-based services to outpatient care. The success of QI movement for MNCH care would encourage application of the POCQI approach to other healthcare areas, which may be equally important and relevant for people in the district. A QI programme could usher in a change in culture to one that moves away from blaming individuals to supporting teams to identify and fi x problems on an ongoing basis for continuous quality improvement. This guide provides a way forward for district managers for MNCH and quality of care to build QI programmes within the ongoing MNCH and quality of care programmes in the district or provinces in the country. Please refer to Annex 5 for additional resources on managing QI programmes. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 35 Annexes DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 36 Annex 1 – Planning template for developing the QI program for district level 1. QI Program Plan for the district Activity Person responsible Timelines Program management structure Form management structures at the district-level - Identify QI management / leadership structure in the district and program planning team and role description Develop action plans for each management structure and unit for the next 12 months As far as possible, integrate QI approaches and coaching support into the existing district management system System alignment (Finances, HR, Data) Prepare additional budgetary requirements for the QI program Prepare plan for how will the HR system support QI (trainers, coaches, supervisors, training workshops) Identifying the indicators needed for the program and easiest ways of collecting data and ensuring data reliability Program Plan Identify initial set of health facilities and hospitals in the districts where QI will be introduced Identify the focus clinical care areas for QI (E.g. MNCH) Building skills for QI at the frontline Plan for POCQI training for healthcare teams in the identifi ed health facilities and hospitals in the district – standalone or integrate with already planned clinical trainings Identify POCQI trainers and plan to prepare a resource pool within the district Form QI teams and initiate QI projects in the health facilities Ongoing QI coaching support Identify QI coaches (could be the POCQI trainers who have received additional orientation in coaching) and plan to prepare a resource pool within the district Arrange for fi eld visits for QI coaches and virtual contacts DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 37 Activity Person responsible Timelines Integrate QI coaching into district management system, like supportive supervision system Enable peer-peer learning and support Plan for periodic meetings among the QI teams (physical and virtual) - Use existing opportunities of review meetings for QI teams to share learning Prepare meeting reports, support preparation of case studies Recognize and ward the QI teams that excel Community engagement in QI programme Identify patient groups, hospital welfare committees that could contribute to QI activities Invite to QI related meetings Prepare and a patient feedback system and use the feedback to improve services 2. Monitor the QI program on an ongoing basis and use the results to improve Activity Person responsible Timelines Assess QI trainings: Are they happening as planned? Any bottlenecks to be addressed? Assess ongoing coaching support: Is it happening as planned and any challenges to be resolved? Assess peer-to-peer learning: Are monthly meetings happening? Is there an environment of learning and improving instead of punishing and reprimanding? Assess community engagement activities Assess functioning of the management structures: Is the data system working? Are problems at the frontline being solved? Assess the impact of the program at the end of the year: How much improvement has happened and what are the learnings? DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 38 Annex 2 – Summary of setting up and managing the district QI programme Key component of the district QI programme Description Actions Tips Management and leadership for quality of care Leadership support and active engagement ensured at health facility, district and state levels. Leadership provides material support for QI, enables all the above components and fosters a culture of trust, transparency and improvement. Management also adapts the overall district QI programme based on experience. Review and progressively strengthen leadership commitment and participation. Determine management roles and responsibilities for specifi c aspects of the QI programme in the district. Adapt systems – fi nance, human resources, data systems, etc. – to accommodate the needs of the QI programme. It is better if the QI programme is housed within existing district management. Roles and responsibilities of members in the district management should be modifi ed to include QI programme in their functions. Prepare a plan for QI in the district This is the overall district QI programme. Most districts prepare an annual plan for MNCH. This QI plan would be part of the MNCH programme cycle and integrated with existing QoC activities in the district. Review current district QoC plans and capacity. Select initial set of health facilities, select clinical care area of focus for improvement. Prepare a plan to set up systems to support the QI teams at these facilities as described below. Select sites that have reasonable infrastructure and resources such as staff, supplies, WASH, etc. Select the ones that have some prior experience in quality improvement. Start small and don’t try to do everything at once or aim at mortality reduction in the fi rst few years. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 39 Key component of the district QI programme Description Actions Tips Build upon existing QoC work QI activities will be built upon what already exists. E.g. some districts may have QA system and undertaken assessment for accreditation. Some districts may have undertaken QoC assessment at health facilities. Most districts have undertaken clinical trainings for doctors, nurses and other staff in MNCH. Take stock of these activities during the baseline situation analysis mentioned above. Complete the accreditation work and continue periodic assessments using QA checklists so that infrastructure is sustained, as per the standards. Consider clinical trainings of newly posted staff and offer refresher trainings, as required. Add activities for continuous QI on top of these QA and clinical training activities. The same staff at health facilities needs clinical and POCQI trainings. Such trainings can be clubbed or arranged in a sequence. Existing clinical trainers in the district or the district QoC/QA team members can be provided with additional training in POCQI and in QI coaching, so that the same experts assume the role of clinical and QI mentoring for healthcare teams. Strengthen QI skills Health-care teams at a facility need knowledge and skills regarding how to use QI approaches to improve quality of care. A district QI plan includes training activities for building QI skills of the front-line healthcare teams along with the budget. Follow the plan for building QI skills of the front-line healthcare teams at the selected facilities. Ensure the support of facility leadership (managers) so that front- line staff are supported by them to apply QI skills to improve care. Build a pool of resource persons (POCQI trainers) to support these trainings in the initial years. Existing clinical trainers and district QoC/QA team members can be trained as POCQI trainers and QI coaches. If there are no QI trainers within the district, one can arrange experts from outside the district, such as trained medical college faculty, in the initial phase. They can train the people within the district for these new roles in QI. Facility managers should also be oriented in POCQI and provided an administrative guidance/ directive to support and supervise healthcare teams to learn and practise POCQI approach. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 40 Key component of the district QI programme Description Actions Tips Ongoing QI coaching support QI coaches have prior experience in using QI methods and guide front-line workers on applying these methods to practise QI at their workplace and help in problem- solving. District QI plan includes a plan for ongoing, on-the-job QI coaching following the initial POCQI training, including budget for travel for onsite visits to the facilities in the district. Follow the QI coaching plan approved in the district plan – who will coach which site and how often and ensure that coaches have support to carry out their tasks throughout the year. Build capacity for ongoing QI coaching of the trained healthcare teams by upgrading QI coaching capacity in the district in the initial years. Use the existing POCQI trainers to build them as coaches and recruit others, if required. As mentioned above, the clinical trainers can become POCQI trainers and QI coaches. District QOC/QA teams can also be trained as POCQI trainers and QI coaches. So, the same experts could take up clinical mentoring and QI coaching for healthcare teams. Peer-to-peer sharing and learning Opportunities for staff from different facilities to learn from each other’s experiences improve their performance and keep them motivated. The district QI plan includes a schedule of such meetings along with the budget. The QI team in the district health department follows the schedule of learning meetings, as mentioned in the district QI plan. Create opportunities and sustain system for peer-to-peer learning and sharing. Use existing opportunities such as district monthly meetings for experience- sharing among QI teams. Create new opportunities for sharing learning, if current ones are inadequate. In subsequent years, such learning meetings should be arranged across the districts too. Stakeholder and community engagement Systematic efforts made to invite stakeholders and community representatives (including women and marginalized communities) for improving quality of care right from the stage of preparing district QI plan and its implementation. Engage community members and stakeholders to better understand their situation and preferences and for their ideas and support in improving quality of care. Use available district resources strategically to improve MNCH quality of care. Invite community groups in meetings with healthcare teams at the health facilities and in the district management. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 41 Key component of the district QI programme Description Actions Tips Measurement Data is used to track progress in implementation of programme activities included in the district QI plan (data for programme management). Data is also used to check improvements in quality of care at the health facilities (data for improvement). uses programme data to ensure that QI teams are getting the support they need (POCQI training, QI coaching support, peer-to-peer learning, etc.). QI teams at health facilities collect and use data related to their improvement aims and send selected data to the district management, as per the monitoring plan. Do not include too many indicators initially. Clarify data collection and use processes. Check if staff is overburdened with data collection. Reassure the healthcare teams that the data will be used for quality improvement only and not for any punitive purpose so that transparency is practised and encouraged. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 42 Annex 3 – Challenges faced in managing district QI programmes Challenge What are the possible causes? What to do? The QI programme turns into yet another data reporting system without any improvements taking place. Data is not being used on the front line for improvement. Front-line staff do not have the skills for quality improvement. But they are already used to reporting data, so they do that much only. Front-line staff knows quality improvement but is not getting adequate coaching support and is pressured by supervisors to just report data. Management focuses more on data collection and reporting and not on problem-solving. The district management should be aware of this major risk to any QI programme. They should explain to the facility managers and healthcare teams that the purpose is to improve quality of care. More emphasis should be put by the leadership and coaches on other elements of improvement, such as analysing and understanding processes of care and problem-solving. Data shows some improvements but there is no information on how these improvements happened. This is not an unusual situation. Possible causes include: New teams may not know how to interpret the data that the process and outcome of care have improved. Often new teams cannot articulate well how they have improved. Often teams will consider their new ideas too simple or straightforward and do not mention these ideas till they are asked specifi cally. Teams often do not document what they have implemented. The coach should show the team how the data is displaying that they have improved care and congratulate the team on the improvement. A QI coach must be skillful and thorough in asking questions about what the team did to improve care. QI coach and the district management should provide extra support to teams that are showing improvements to document their work and keep them motivated to undertake more QI projects. Care is not improving despite good training, adequate coaching support, having commendable skills in quality improvement and robust leadership support. Some quality of care problems can be challenging and the front-line teams may not be able to solve them even with support from a coach. Some of these problems may be beyond a team’s control and need problem-solving at higher levels. E.g. the number of staff is inadequate or supplies are not regular, water and sanitation facilities are insuffi cient. The programme leadership should identify other teams, which have been able to improve in this specifi c area of care, and organize a site visit for the struggling team to learn from the successful site. A larger learning session can also be organized for all sites to learn from each other. If the problem needs to be solved at higher levels, then the leadership should be solving these issues. DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 43 Annex 4 – Sample monitoring framework for QI programmes in the district This framework lists some objectively measurable indicators that may be used to monitor implementation of POCQI initiatives in a group of health facilities 1. Suggested program management indicators – to be tracked at a district level Leadership % of sites where a facility-level meeting was held to review ongoing POCQI work % of facility leaders (superintendents/heads of departments) who received training in POCQI programme management % coaching visits funded via dedicated coaching budget from regular district funding mechanism Action % of sites that actively completed an improvement project last quarter % sites submitting data related to their QI project to the district level last month % of sites that received coaching support (onsite/web-based) in a month Learning % sites that presented their completed project in a review/learning-sharing meeting % sites that have documented their completed project as a case study % new POCQI workshops where examples from similar context were shared by in-country local champions Accountability % facility QI teams with community or client representatives % problems that sites could not fi x themselves, that were fi xed by the district level in the past quarter % problems that sites or district could not fi x themselves, that were fi xed by the higher level in the past quarter Capacity-building in POCQI: % of healthcare providers who received training in POCQI (account for transfers and new staff; count relevant departments only) % facilities where all staff (from relevant departments) are trained in POCQI DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 44 2. Facility-level indicators – decided on the basis of local priorities These consist of measurement for clinical processes and related outcomes of care that the QI programme aims to improve. • It is out of the scope of this document to include all possible indicators for MNCH QI. • This provides a sample list of selected indicators. • Care must be taken to limit the number of indicators so that QI teams don't feel overwhelmed. • Focus should be on selected processes and outcomes that the district and QI teams have identifi ed for improving at present. • The list of indicators will change as other areas of care will be considered. • Try to ensure that the indicators are common across participating sites in the district. • Table 1 below includes a few selected process and outcome indicators that individual QI teams will collect for specifi c QI projects at the facilities and review on weekly basis. Table 1 Indicators No. of neonates who were wiped and dried thoroughly Total number of live births Proportion of neonates who were wiped and dried thoroughly (N/D*100) No. of neonates in whom cord clamping was delayed by 1–3 min. Total number of live births Proportion of neonates in whom cord clamping was delayed by 1–3 min. (N/D*100) No. of neonates, who were given skin-to-skin care for at least 1 hour after birth Total number of live births Proportion of neonates, who were given skin-to-skin care, for at least 1 hour after birth (N/D*100) No. of neonates in whom breastfeeding was initiated within 1 hour after the birth Total number of live births Proportion of neonates in whom breastfeeding was initiated within 1 hour after the birth (N/D*100) No. of neonates with temperature recorded at one hour after birth Total number of live births Proportion of neonates with temperature recorded at one hour No. of neonates with temperature <36.5 °C at one hour after birth Total number of neonates with temperature recorded at one hour after birth Proportion of neonates who suffered from hypothermia within one hour of birth (N/D*100) No. of women given uterotonic within one minute of delivery No. of women delivering DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 45 Indicators Proportion of women given uterotonic within one minute of delivery (N/D*100) No. of women with postpartum haemorrhage (PPH) No. of women delivering Proportion of women with PPH (N/D*100) No. of neonates who receive all age-appropriate vaccines No. of neonates discharged alive from the facility Proportion of neonates who receive all age-appropriate vaccines Table 2 Patient disposition numbers: Monthly No. of stillbirths No. of newborn deaths No. of neonates referred to other facilities for care No. of neonates leaving against medical advice No. of women coming to the facility for childbirth (including women who come for other reasons but are identifi ed as requiring assistance for childbirth) No. of women referred to other facilities before delivery No. of women delivering at the facility No. of women referred after delivery No. of women die before discharge No. of women leaving against medical advice Table 3 Patient disposition ratios: Monthly % stillbirths (stillbirth/all births) % newborn deaths (newborn deaths/live births) % newborn referrals (newborn referrals/live births) % neonates leaving against medical advice (newborns leaving ama/live births) % women referred before delivery (women referred before delivery/women coming to the facility for childbirth) % women referred after delivery (women referred after delivery/women delivering) % women dying after delivery (women dying before discharge/women delivering) % women leaving against medical advice (women leaving AMA/women coming to the facility for childbirth) (Table 1 continued) DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 46 Fa ci lit y- le ve l q ua lit y im pr ov em en t pr oj ec t tr ac ke r T hi s is a li st o f a ll P O C Q I pr oj ec ts a cr os s he al th fa ci lit ie s: H ea lth fa ci lit y / H os pi ta l R es po ns ib le de pa rt m en t / un it C on ta ct de ta ils o f ke y Q I pr oj ec t fa ci lit y st af f m em be r D om ai n ar ea – se le ct o ne Q I pr oj ec t a im Q I pr oj ec t in di ca to rs D id th e te am d o sm al l- sc al e te st s fo r ch an ge id ea s? St ar t d at e of Q I pr oj ec t H as th e Q I te am re ce iv ed Q I co ac hi ng – w he n an d by w ho m ? Q I co ac h fo r th e pr oj ec t (e xt er na l, in te rn al ) H as th e te am pa rt ic ip at ed in an y sh ar in g an d le ar ni ng a ct iv it y? C ur re nt st at us N am e an d lo ca ti on of h ea lth fa ci lit y E .g . o bs te tr ic s or p ae di at ri cs de pt t/ la bo ur ro om /w ar d Pe rs on a nd em ai l, ph nu m be r C ar e ar ou nd bi rt h; si ck a nd sm al l ne w bo rn ca re ; pa ed ia tr ic ca re ; IP C & W A SH ; ot he r E .g . t o re du ce hy po th er m ia at a dm is si on am on g ne on at es re fe rr ed fr om O T to S N C U fr om 8 0% to 20 % in 1 2 w ee ks ( 1 Fe b. to 26 A pr . 2 01 9) E .g . % n eo na te s im m ed ia te ly dr ie d af te r bi rt h % n eo na te w it h te m p <3 6. 5 °C at a dm is si on E .g . t ri ed a ch an ge id ea fo r a fe w pa ti en ts , th en ad ap te d th e ch an ge id ea an d tr ie d ag ai n. E .g . 1 5 M ar ch 20 20 20 M ar ch 20 20 , o ns it e co ac hi ng vi si t, ph on e su pp or t b y co ac h C oa ch n am e E .g . t ea m ha s st ar te d do cu m en ti ng th is Q I pr oj ec t as a p os te r. Te am al so p ar ti ci pa te d in o nl in e sh ar in g w eb in ar o n 25 M ar ch 2 02 0. Pr og re ss of th e Q I pr oj ec t a nd pl an s fo r ne xt Q I pr oj ec t DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 47 Annex 5 – Resources for further reading on managing QI programmes 1. The Network for Improving Quality of Care for Maternal, Newborn and Child Health (Quality of Care Network) The Network for Improving Quality of Care for Maternal, Newborn and Child Health (Quality of Care Network) is a broad partnership of committed governments, implementation partners and funding agencies working to ensure that every pregnant woman, newborn and the child receives good quality care with equity and dignity. The goals of the Network are to halve maternal and newborn deaths and stillbirths in health facilities by 2022 and to improve patients’ experience of care in participating in health facilities in Network countries. The network’s website provides webinars, practical resources, peer engagement opportunities, country progress updates and more information on improving quality of care in MNCH. https://www.qualityofcarenetwork.org/ 2. WHO quality health services The World Health Organization’s Department of Integrated Health Services supports countries in moving their health systems towards universal health coverage, through equitable access to quality health services that are integrated, safe and people-centred. The department’s quality health services webpage lists technical information, events, initiatives, factsheets, publications, and multimedia related to quality of health care services. https://www.who.int/teams/integrated-health-services/quality-health-services 3. Point-of-care Continuous Quality Improvement – POCQI regional learning platforms POCQI- Point of Care Continuous Quality Improvement is a movement towards ending preventable mortality among mothers, newborns and children and will contribute to making progress towards achieving new goals of the Global Strategy for women’s, children’s and adolescents’ health and Sustainable Development Goals (SDG-3). A dedicated website maintained by WHO Collaborating Center at AIIMS, New Delhi with the support of WHO-SEARO serves as a collaborative learning platform for progressively building capacity of healthcare teams and other stakeholders, and as a repository of knowledge in quality improvement as well as the acquired experience from the Region and beyond. https://www.pocqi.org/ WHO-SEARO has supported Nationalwide Quality of Care Network (NQOCN), India to establish a virtual community of practice for POCQI (POCQI-COP) that hosts a variety of virtual sessions for disseminating knowledge and experience sharing. The website is also a repository of technical resources related to quality of care. https://www.nqocncop.org/ DISTRICT PROGRAMME MANAGEMENT GUIDE (VERSION 02) Setting up and managing a quality improvement programme at the district level 48 4. USAID ASSIST project – 25 essential resources for health care quality improvement From 2012-2020, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project worked in over 40 countries, building the capacity of service delivery organizations and implementing partners to improve the effectiveness, effi ciency, client-centeredness, safety, accessibility, and equity of the health and social services provided. As URC’s parting contribution, they offer this curated collection of 25 quality improvement (QI) resources from ASSIST that capture key learning from their work that they hope will inform yours. https://www.urc-chs.com/assist-25/ 5. British Medical Journal (BMJ) and the Health Foundation quality improvement series The BMJ in partnership with and funded by The Health Foundation launched a joint series of papers exploring how to improve the quality of healthcare delivery. The series discusses the evidence for systematic quality improvement, provide knowledge and support to clinicians and ultimately to help improve care for patients. https://www.bmj.com/quality-improvement 6. Institute of Healthcare Improvement resources The Institute for Healthcare Improvement (IHI), an independent not-for-profi t organization based in Boston, Massachusetts, is a leading innovator in health and health care improvement worldwide. Their website provides a wide selection of quality improvement resources. IHI offers free tools, change ideas, measures to guide improvement, IHI White Papers, audio and video, improvement stories, and more. http://www.ihi.org/resources/Pages/default.aspx 7. BMJ Open Quality journal BMJ Open Quality is a peer reviewed, Open Access journal covering all content in healthcare improvement work. The journal publishes a wide variety of quality improvement work, including quality improvement reports. Their website also provides resources such as templates to help you run and write up quality improvement projects. https://bmjopenquality.bmj.com/ BMJ Open Quality’s new South Asia Edition, in partnership with NQOCN, highlights research related to South Asia. All content is free to read and features original research, quality improvement reports and editorials. https://bmjopenquality.bmj.com/content/10/Suppl_1