The Quality Improvement Collaborative Methodology

1. The Quality Improvement Collaborative Methodology To accelerate the pace of improvement and scale up best practices James Heiby GH/HIDN/HS MAQ Mini-University, May 10, 2004

2. Agenda • How collaboratives are different from traditional QI methods • Summarize the methodology • Development in the US • Fundamental elements • Experience in low and middle income countries • Discussion

3. The Basic Principles of the Improvement Movement • The delivery of modern health services is complex and dynamic • It is feasible to study the process of health care and find ways to improve it • Our hypotheses about how to improve health care should be tested before we accept them

4. Basic Principles, continued • Improvement work consumes health resources, and should be accountable • Benefits should exceed the costs • Current investments are • Extremely small • Primarily the time of health staff • The benefits of successful improvement work grow as it is: • Extended into the future • Spreads geographically

5. In practice, quality improvement activities in LDCs are: • Carried out by regular health workers, usually in teams • Use tools to study the process of health care, e.g., flow charts • Test potential improvements • Teams select the problem to work on • What other models for improvement do we use?

6. How important are issues of quality and efficiency in health care? Can resource-poor, highly stressed health systems afford to pay attention to such things?

7. Following standardized clinical protocol: Mortality 9% Oral fluids only 60% Antibiotics used 18% Following usual practice at ICDDR,B Hospital: Mortality 17% Oral fluids only 29% Antibiotics used 40% Impact of an EBG for Diarrhea in malnourished children in Dhaka(Ahmed, et al, Lancet, 1999)

8. Sick child care in 5 studies in Nigeria, 1991-3 (analyzed by S. Etian)

9. Implications of these examples: • Deficiencies in quality and efficiency are widespread and serious • The impact of training and supervision strategies appears limited • AIDS will make things much worse • What does traditional CQI have to offer?

10. Standards for Neonatal Resuscitation will be Applied at Each Delivery

11. Issues with traditional CQI in Developing Countries • Successes (and failures) not widely shared • Limited motivation for extra work • Poor documentation of QI process • Weaknesses in measurement • Often not focused on important problems, esp. clinical care • Spreading slowly

12. How Collaboratives are Different from Traditional QI • Organized around a specific topic • Participants are motivated • Volunteers • Leadership support • A community of practice • 10-30 teams • Every team knows the work of the others

13. How Collaboratives are Different, continued • Chief source of improvement is mutual learning by peers • Provides a mandate to test changes in the organization of care • Teams share data on selected indicators • Meetings • Monthly reporting • Visits

14. How the collaborative addresses issues with traditional CQI: Organize multiple teams to work on a single problem area: • More rapid progress • Each team learns from work of the others: don’t re-invent the wheel • Peer group provides motivation for QI work • facilitates spread of improvements--more efficient

15. Multiple Teams Value Added continued • Pressure to keep better records • Can be focused on priority health care issues • Basis for scaling up a successful package of changes

16. History of the Collaborative Methodology • Developed chiefly by IHI in 1990s • Extensive applications in US, Europe • >50 collaboratives, dozens of topics • 12-160 teams, over 2000 total Modified version in Russia: • pilot results in 3 clinical problems • sustained at oblast level • phase 3 expansion to 31 oblasts

17. Percent of Neonates Arriving to the Neonatal Center with Hypothermia Intervention Started, Nov-99

18. Basic questions behind the design • Who knows about clinical content issues, eg, case management of TB? • Who knows about the organization of health care, eg TB case finding? • Are current levels of quality and efficiency known? • Are improvement methodologies known? • How can facility teams communicate?

19. Collaborative Steps Participants Select Topic Prework P P Identify Change Concepts A D A D S S Planning Group LS 1 LS 2 LS 3 Supports E-mail Visits Phone Assessments Senior Leader Reports * © 2002 Institute for Healthcare Improvement

20. Overview of the Methodology • Adapt for developing country setting • Traditional QI teams and methods • Starts with a specific topic • Leaders and experts develop a “change package”: • systematically outlines all components of the service • describes feasible improvements • indicators to measure progress *

21. Malaria Collaborative Overview • Geographical Scope • 4 districts(Gisenyi, Kibungo, Muhima, Ruhengeri) • 61 teams and sites • 3 hospitals • 58 health centres • Progress • baseline study in 2 districts completed Nov 2002 • quality improvement (QI) changes and indicators proposed by level of care • 70% of sites used flowcharts to analyse their problems • QI changes currently being implemented

22. Exampless of Findings from Initial Assessment • no children were (case) managed according to norms • only 29% of children treated according to norms • mothers wait an average of 3 days before going to health centre • 31% of health centres have had stock-outs during the 30 days before assessment

23. Key Changes • For malaria in children 0-4 years • Decision to seek care within 24 hours • Diagnosis and treatment at health centers and hospital according to national standards • No stockouts of drugs or supplies at district • Appropriate and successful referral of serious cases

24. Measures • Numbers of children treated in health centers • Numbers of severe cases treated in district hospital • Number of deaths due to malaria in hospital • Hospital case fatality rate for child malaria cases • Percent of children treated according to national norms in HC and hospital • Error rate of lab tests on quality control exercises • Stockouts of drugs or supplies at HC/hosp

25. Recruiting the Teams • Rule of thumb: 10-30 teams • provides a critical mass for innovation • but is manageable • Voluntary participation • Can work with multiple organizations, e.g., NGOs • Multinational collaboratives *

26. TRAC CDC Family Health International (FHI)/Impact Pangaea Institute Caritas Central Hospital of Kigali (CHK) Butare University Hospital King Faisal Hospital Kanombe Military Hospital UNICEF Medecins sans Frontieres (MSF) INTRAH/Prime WHO Cooperation Francaise Elizabeth Glazer Foundation LUX Development (Luxemburg) – Main partner with CHK Hospital Cooperation Belge- helps many districts in Rwanda Rwanda Collaborative Partners

27. Implementing Structure • Planning/Organizing Committee • Experts Group • National Coordinating Committee • Provincial or District • Site Teams

28. How Collaboratives Usually Work • Local ownership from day 1 • prominent leadership • do the work • Facilitators remain in background • Teams start by studying existing system • use the change package • creates a baseline

29. Next steps • Team representatives meet 3 or more times to: • learn about QI methods • learn about the change package • discuss team experiences, share learning • share results • Teams communicate ~monthly • indicators and QI activities • various means of communication--from visits to the web

30. Next steps, continued: • Leaders and facilitators support teams • emphasis on communications system • also use the meetings • low level of external T/A overall • Teams use rapid QI cycles • focus on immediate, small scale changes • evaluate, measure • expand scale or move on, based on results

31. Continuous Quality Improvement teams at work • WHAT ARE WE TRYING TO ACCOMPLISH ? • HOW WILL WE KNOW A CHANGE MADE AN IMPROVEMENT ? • WHAT SPECIFIC, CONCRETE CHANGES CAN WE MAKE TO THE PROCESS ? Plan • IMPLEMENT • AND TEST THE • INTERVENTION Act Do Check

32. Monitoring Results, Muhima District, 2003% of children 0-5 years old with malaria who were treated according to national norms in selected health centers LS2

33. Results collected from field visits December 2003% of children 0-5 years old with malaria who consulted within 24 hours of the first symptoms LS2 LS2 LS2

34. Team Monitoring of Partograph Use-EOC

35. Kinds of AIDS care implementation problems solvable at local level • Demand creation • Testing logistics • Roles for staff and volunteers • Strategies to ensure adherence • Re-supply of patient medication • Patient follow-up • Patient self care strategies • Counseling and support

36. Evolution of the Collaborative • Expected duration of 9-18 months • Leaders schedule final meeting based on results: teams using a package of improvements • Expansion (or Spread) Collaborative: • high performers can each lead a new effort • change package requires minor adaptation • Rogers’ Diffusion of Innovations

37. Early Majority Late Majority Early Adopters Laggards Factors Influencing Rate of Adoption: Adopter Categorization # Adopters Innovators Time to Adopt

38. Organization of Tula Intentional Spread

39. Key Elements in the Design of the Oblast Level Scale-Up - I • Gaining leadership support • Clarity on purpose & methods • Health authority leadership/management • Champions from phase I teams • TOT for champions from phase I teams • Training of all team members in QI and clinical content • Team approach for re-invention & clinical guideline adaptation

40. Scale up Plan

41. Current Collaboratives in LDCs • Topics • Under way: EOC, pediatric hospital care, PMTCT, malaria, PIH, RDS, adult AH • Planned: TB, ART, RH-PMTCT, infection control • Countries: Russia, Ecuador, Honduras, Nicaragua, Eritrea, Niger, Rwanda, Tanzania, Cambodia