HAS wishes you a warm welcome to Paris

1. HAS wishes you a warm welcome to Paris On the occasion of the International Forum on Quality and Safety in Healthcare Int'l Forum

2. Welcome to the International Forum on Quality and Safety in Healthcare HAS (Haute Autorité de Santé) Ensuring High-Quality Healthcare for All • Actions • Accreditation HCOs • Continuing Professional Development • Certification of information • Chronic diseases management • Guidelines • Good practice • Patient safety • Public health • HTA • Drugs • Devices • Procedures 2 Int'l Forum

3. Plenary 1: Introduced by: Laurent Degos, HASFiona Godlee, BMJSpeaker:Donald M Berwick, President and Chief Executive Officer, Institute for Health Care Improvement Int'l Forum

4. Troubles on a Hook:Global Health and Continual Improvement Donald M. Berwick, MD, MPP, FRCP President and CEO Institute for Healthcare Improvement Keynote Address International Forum on Quality and Safety in Health Care Paris, France: April 23, 2008

5. Millennium Development Goals • Eradicate extreme poverty and hunger. • Achieve universal primary education. • Promote gender equality. • Reduce child mortality. • Improve maternal health. • Combat HIV/AIDS, malaria, and other diseases. • Ensure environmental sustainability. • Develop a global partnership for development.

6. MDG Progress • Extreme poverty: 1/3 in 1990 to 1/5 in 2004. • Extreme poverty in Sub-Saharan Africa: 47% to 41%. • Children in primary education: 80% to 88%. • More women in parliaments. • Under-five mortality in developing countries: 10.6% in 1990 to 8.3% in 2005. • Measles deaths in children down by 60% between 1999 and 2005 (873,000 to 345,000). • Measles deaths in Africa down by 75% between 2000 and 2005 (506,000 to 126,000). • Tuberculosis per 100,000 down from 321 in 2000 to 255 in 2005.

7. Progress toward MDG #4

8. MDG Gap At current rates of progress, sub-Saharan Africa will not hit its 2015 MDG target for mortality reduction until 2115… ONE CENTURY LATE! 41 million more children will die between now and 2015.

9. Support Staff & Faculty United States Andrew Billi Stacey Downey Meredith Kimball Nicholas Leydon Barbara Tobin Joe McCannon Helen Smits

10. W. Edwards Deming “Trying harder is the worst plan.”

11. Paul Batalden “Every system is perfectly designed to achieve exactly the results it gets.”

12. “System” “A collection of elements interacting to achieve a common aim.” (Interdependency is inescapable.)

13. Four “Theories” of Improvement • Just Set the Goals. • Create Better Markets. • Add Resources to the Current System. • Redesign the System for Better Performance.

14. Mamphela Ramphele “It is the poorest people on earth who can least afford poor quality.”

15. Bwaila Hospital – Lilongwe, Malawi

16. IHI-Supported Sites in Malawi Kasungu Salima Lilongwe

17. Causes of Maternal Deaths Countdown to 2015 Core Group. Countdown to 2015 for maternal, newborn, and child survival: The 2008 report on tracking coverage of interventions. Lancet 2008;371:1247-58.

18. Reducing Maternal & Neonatal Mortality MALAWI Florence Bwanali Fannie Kachale Uma Kotagal Roger LeCompte Marco Linden Agnes Makonda-Ridley Charles Makwenda Violet Manjanja Gibson Masache Barbara Nagy Bejoy Nambiar Olive Sambani Eric Tsetekani Karen Zeribi

19. Likuni Hospital, Malawi

20. Likuni Hospital, Malawi

21. Nkhoma Hospital Infant Mortality

22. ≥95% all pregnant mothers presenting at PHC for 1st ANC visit are tested for HIV involvement of all PHC staff in VCT awareness; health education on programme and benefits delivered in waiting room 100% all pregnant mothers with CD4 counts <250 or WHO Stage 4 are referred to & arrive at ARV site for initiation on ARVs within 2 weeks of clinic getting test results/staging provide transportation; providing escorts; follow up with clinic early issuing of NVP >95% all HIV+ ANC clients take PMCTC drugs as indicated prior to or during labour (currently stat. dose Nevirapine (NVP) or HAART) reliable means of communicating mothers’ HIV status to other health care facilities without it being explicitly stated to ensure the primary health care-based component of the PMTCT programme (as defined by current local policy) is executed at ≥ 95% reliability by 1st Sept. 2008 fast-tracking of ANC patients at ARV site 100% all babies born to HIV+ mothers receive PMTCT drugs as indicated (currently stat. dose Nevirapine within 72 hrs of birth) educate mothers about need to bring in their babies to the clinic within 72 hours of giving birth at home; ensure reliable means of communicating mothers’ HIV status to other health care facilities ≥95% all HIV+ mothers make feeding choice that presents the lowest risk of serious illness/ death of their child and that they can consistently maintain use risk assessment tool as part of counsellors’ script and recording of feeding choice; support groups for HIV+ mothers (e.g. m-2-m) ≥95% all babies born to HIV+ mothers or those whose status is unknown receive a PCR test at 6 weeks dry blood spot tests introduced; health education to encourage mothers to have babies (and siblings) tested; linking PCRs to first immunisation visit encourage transfer of PMTCT mothers onto pre-ART registers; do routinely at one of immunisation sessions ≥95% all HIV+ mothers with CD4 >250 during pregnancy receive further test within 6 months

23. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Act Plan Study Do Model for Improvement(Ref: Associates in Process Improvement)

25. Life Expectancy and AIDS

26. Increasing Access to HIV/AIDS Treatment & Care SOUTH AFRICA Pierre Barker Brandon Bennett Cathy Green Wendy Mphatswe Kimesh Naidoo Patty Webster

28. Before and after Initiation of Antiretroviral Therapy

29. Before and after Initiation of Antiretroviral Therapy

30. Clinic Design Data Systems Long queue / waiting time No formal way to track Poor record keeping/ history taking No supplies available Lack of available staff PROBLEM: HIV+ Patients not getting CD4 counts Denial/attitude Protocol not understood No time to stay Staff lack knowledge and skills Feel fine now / misconceptions Prompts and Care Paths Patient and Family Input Fishbone Diagram

31. Potential “botlenecks” or failures Sample Process Map: PMTCT CD4 <200 Start ART HIV test Mother attends ANC- 1st visit HIV test pos CD4 test Nevirapine to mother and infant CD4 >200 31

32. Mhlontlo Subdistrict Progressive Engagement of Primary Care Clinics in Comprehensive HIV/AIDS Care

33. Mhlontlo Subdistrict Cumulative ART Initiations in Mhlontlo Sub-District Total No. of Patients Started on ARVs

34. Mhlontlo – Resources Matter

35. South Africa

36. Umkhanyakude DistrictKwaZulu-Natal

37. Inner City Johannesburg Project

38. Inner City Johannesburg

39. Western Cape –Helderberg and Eertse River

40. Ghana

41. Ghana

42. Causes of Deaths under Five Years Countdown to 2015 Core Group. Countdown to 2015 for maternal, newborn, and child survival: The 2008 report on tracking coverage of interventions. Lancet 2008;371:1247-58.

43. Saving Lives Under Five Ghana George Dabuo Cleytus Dakura Gilbert Buckle Nii Coleman Enoch Osafo Lloyd Provost Nana Twum-Danso

44. Reducing Under-Five Mortality Countdown to 2015 Core Group. Countdown to 2015 for maternal, newborn, and child survival: The 2008 report on tracking coverage of interventions. Lancet 2008;371:1247-58.

45. Wave 1: 0 – 12 months Wave 2: 12 – 30 months Wave 3: 30 – 42 months Wave 4: 42 – 60 months Sequential Scale up of Improvement in Ghana

46. Challenges for Improvement in Developing Nations • Logistics – Travel, Communications, Infrastructure • Information Systems • Data Quality • Habits of Hierarchy • Misaligned Policies • Thin Staffing and No Slack • Workforce Training in Improvement Skills • Despair

47. My Hopes • Hit the goal of 0.7% of GDP for development assistance. • Link new resources to new designs. • Involve the workforce in redesign. • Incorporate improvement skills into all workforce development. • Foster formats, systems, and sponsors to share freely new models and lessons learned.

48. A Dream… A “Learning World” for Global Health and Development