From planning to implementation through Monitoring and Response

1. From planning to implementation through Monitoring and Response May 2018 DHP/DOPMonitoring and Evaluation Framework

2. Outline • Purpose • Recap important principles and where we are now in the process • Activity Matrix to guide and coordinate planned/ pro-active actions • Responsive Planning to augment pro-active planning • How can our current review and response processes be more effective

3. Purpose • To support operationalisation of the new DHP Framework through implementation of • DOP Proactive plans (safety net), augmented by • Responsive/(Reactive) plans (repairing holes in the net): • active, rapid cycle responses at facility and sub district levels in response to 24-hr mortality/adverse event surveillance or failure to meet targets • To provide guidance for how Proactive and Responsive plans can be tested, monitored and evaluated for their effect on outcomes • by using proven QI methodology • within formal “Monitoring and Response” Forums • ….with a focus on • the Learning districts identified by each province • coordination of support efforts and initiatives

4. Pro-active vs Responsive Planning Safety net

5. Burden of Disease: The Open Tap Analogy Thrive Incidence = flow out of tap Prevention- Turn off the Tap Prevalence Bucket = total Population Treatment As primary, secondary, and tertiary prevention Prevalence Mortality = Flow out of bucket Plug the hole in the bucket Survive

6. As we audit deaths… Actions needed at hospital (Plug the hole in the bucket) Actions needed at PHC to close the tap Actions needed at community/WBOT level to close the taps A Death is Everybody's Business!

7. Targets Measures What change do we need to make? (RCA/BNA) The Model for Improvement Proven QI methodology

8. Activity Matrix to guide and coordinate planned actions DHPF 5 steps to promote critical thinking using an outcomes base approach Responses: Inward Outward Upwards Responsive planning to augmented Proactive Planning 4. How can our current review processes be more effective

9. Proactive Planning

10. Top-down/bottom up approach to determining district planning Medium Term Strategic Framework (MTSF) National Outcomes and Sub-Outcomes Provincial DoH Strategic Plans and APPs Provincial Provincial Strategic Goals & objectives District Health Plans District Aspirations mapped to Provincial Goals Determine applicable aspirations • District Targets/Aspirations and Public Health Interventions • Target/Aspiration 1 • Public Health Intervention 1A • Public Health Intervention 1B • 2. Target/Aspiration 2 • Public Health Intervention 2A • Public Health Intervention 2B Critical thinking and planning process District, SD, Facility District Operational Plans

12. DHP NCD Plan SAM Plan DIP / HAST Plan District Operational Plan Newborn Care Plan MNCWH&N Plan SD / Cluster Operational Plan Facility Operational Plan DHP is a strategic document for 3 years

13. Start thinking in terms of the Action Matrix Value of seeing the bigger picture of how one component’s actions contribute to improving outcomes Coordinated response towards achieving common outcomes Clarifies roles and responsibilities at each level with need for Monitoring and Response

15. Responsive Planning

16. Compulsory 24 hr death reporting for Improved Outcomes at Sub-District and District level Death Event District (or sub-district) Action Plan System-wide Response to a death Institutional Response to a death Consolidated Death Report Accurate numbers and accurate causes of deaths Transfer deaths by referring and receiving facility Deaths related to Caesarean Deliveries Modifiable factors - Provider related - Administrative - Patient related -Recommended Responses at different levels Evidence Based Interventions MRU/MRF Accountability and Co-ordination Mechanism * Record Clinical Notes Registers Actions at Acute/EMS level* • Monitors Implementation of actions • Monitors performance in morbidity and mortality indicators ( Survive & Thrive) • Evaluates effectiveness of actions e.g. open-tap analogy Report -External (Home affairs/Stats SA) -Internal (Institution & DCST) Review -Primary Cause of death (CoD) -Complimentary CoD -Modifiable factors Actions at PHC level Actions at Community level Respond to Modifiable factors - Provider related - Administrative - Patient related Actions to reduce social determinants Draft CDR template is being revised and will be distributed

17. Activity Matrix to guide and coordinate planned actions DHPF 5 steps to promote critical thinking using an outcomes base approach Responses: Inward Outward Upwards Responsive planning to augmented Proactive Planning 4. How can our current review processes be more effective

18. Ideal Review and Response (Study and Act) • What did we / others complete and if not, why not? Know your targets or target limits Identify additional actions needed to improve performance Track original actions Track your indicators (performance) Implementation Enable implementation Adjust actions in light of results • If action completed, Has it yielded the expected results?

19. What is the problem we are trying to solve? • What did we / others complete and if not, why not? Know your targets or target limits Identify additional actions needed to improve performance Data quality is extremely poor Little or no interpretation or feedback from higher levels Data use limited Track planned actions Track your indicators (performance) Implementation Enable implementation • Actions and processes are rarely reviewed • Done or not done? • Disconnected from planned actions (planning for compliance) • Effectivity of actions not evaluated  disconnected from results • Inability to make decisions/act/ be responsive • Result: Current quarterly reviews are ineffective • lack of responsiveness •  minimal impact on outcomes Adjust actions in light of results • If action completed, Has it yielded the expected results?

20. Accountability and agency* What is the capacity or motivation of a person to exercise accountability • Skills and capacity to do the job • Clarity of performance expectations and targets • Involvement in or authority for decision making • What are the linkages between actors i.e. who is accountable to who, and who holds who accountable • What is the balance of risk for that individual (do nothing vs do something) Source: J O'Hagan; D Persaud: Creating a culture of accountability in health care. The health care manager. 2009 Brinkerhoff, D: Accountability and health systems: toward conceptual clarity and policy relevance. Health policy and planning. 2004 What systems exist to measure, support and promote improved service delivery through feedback and learning (e.g. CQI) • Rewards (or, sanctions) • Internal Feedback to be able to gauge own performance and build internal commitment • External Feedback (supervision/regulatory mechanisms) How good is the supporting infrastructure / enablers? • Information systems • Communication systems • Human resource management • Performance management • Inputs needed to do the job *”agency” = the capability of acting / of exercising power

21. Institutionalising Monitoring and Response Forums - what can we learn from the MRUs? Process of regular performance review • A team of local managers who are assisted and motivated to carry out their roles & responsibilities (not new people) • Led by a driver (person with authority to ensure implementation) • Structured agenda  structured review process • In-depth review and interpretation of data used to drive entire process • 24 hour death report (survive / plugging holes and mopping the floor) • Mortality Dashboards (progress towards achieving target limits – links targets, to actions, to outcomes) • Pro-active action plan • Reports from each level of health system (Hospital, PHC, +?Community), including • Reports on skills building activities • Reports on Implementation of Data QIP’s • Reports from partners (SASSA/Pepfar partners/Universities/Other) • Additional local responsive actions emanating from death / event reports) • Discussion and Recommended actions • Report / minutes and tasks sent out

22. Compulsory 24 hr death reporting for Improved Outcomes at Sub-District and District level Death Event District (or sub-district) Action Plan System-wide Response to a death Institutional Response to a death Consolidated Death Report Accurate numbers and accurate causes of deaths Transfer deaths by referring and receiving facility Deaths related to Caesarean Deliveries Modifiable factors - Provider related - Administrative - Patient related -Recommended Responses at different levels Evidence Based Interventions MRU/MRF Accountability and Co-ordination Mechanism * Record Clinical Notes Registers Actions at Acute/EMS level* • Monitors Implementation of actions • Monitors performance in morbidity and mortality indicators ( Survive & Thrive) • Evaluates effectiveness of actions e.g. open-tap analogy Report -External (Home affairs/Stats SA) -Internal (Institution & DCST) Review -Primary Cause of death (CoD) -Complimentary CoD -Modifiable factors Actions at PHC level Actions at Community level Respond to Modifiable factors - Provider related - Administrative - Patient related Actions to reduce social determinants Start with death review; however the same process to be used to cover near misses, adverse events, outbreaks, failure to reach targets

23. Review Forums • Composition: Drivers, Navigators, and Provider • Minimum Standard Agenda to give guidance structure to a review process, regardless of level at which review is taking place • Formal review forums at each level should promote responsiveness to critical issues affecting patient safety, and failure to meet targets, should coordinate actions at different levels, and hold stakeholders accountable for results

24. Minimum Standard Agenda • Review per Targets / Aspirations • Aspirations / Each level reviews the actions for their level and the level below • Review of results/outcomes relative to Targets as a result of actions • Outcomes: Mortality dashboards (survive) & Consolidated Death report • Related PHC dashboard indicators (thrive) • Related Quality of Care measures (where available) • Related Systems Ideal clinic dashboards/NCS • Review of Actions: What did we plan to do vs what did we actually do • Pro-active actions (including data QIP’s and Skills development) • Re-active actions from the last review • Partners • What must be our response (new actions) • Inward • Outward • Upward (what must be elevated to the next level)

25. Inward, Outward, Upward for review of response • Look Inwards: • What do we as a facility/cluster SD/hospital need to do differently • Look Outwards: • What is needed from other levels/partners outside of our institution/level (what we cannot do on our own) e.g. EMS, SASSA • How do we assist externally e.g. outreach • What needs to be communicated outside of this institution/level e.g. from Hospital to PHC level, and what is the appropriate line of accountability through which communications must go • Look Upwards: • What responses are needed from the next level of management to unblock bottlenecks and facilitate implementation

26. Agency and local action - what are the real constraints? MRF Ideal situation? Implementation in reality Part of the MRF function is to move it to right i.e. enable implementation by removing obstacles through taking decisions, giving authority, prioritising budgets

27. PRO-ACTIVE PLANNING RESPONSIVE PLANNING • DHP Targets/Aspirations • DOP Activities outlined in Action Matrix Reactive actions Pro-active actions Community PHC Hospital Review by Outcome Target / Aspiration using Standard Agenda At different levels Targets Review Pro-active and Responsive Actions Outcomes: What were the results of our actions? How should we respond: new/ modified actions Outward Upward Inward

29. How can we use what we have more efficiently • Build on what we have (strengthen and coordinate better) • Start of Facility based Operational plans • Facility monitoring of data using dashboards (DHIS indicators) • PHC Cluster meetings • SD/District Reviews with referral hospital input • PPIP/ChPIP

30. James P Womack “There are no miracle cures for poorly designed processes, outmoded leadership styles, & unengaged employees There are only continuous experiments, conducted honestly by leaders with courage, an open mind, and a collaborative spirit, along the journey to lean health care systems” From the book ‘On the Mend’ by John Toussaint

31. Thank you!

32. Functions: District Planning Monitoring and Response Forum • Present and discuss National / Provincial / District Priorities of the forthcoming year as well as performance of the District. • Present results from the District Health Expenditure Review, and Budgets of the forthcoming year, and respond to all relevant procurement needs. • Present and agree on any programmatic needs for the next financial year • Present reports and agree on remedial interventions /actions for • latest self-assessment Ideal Clinic Dashboard at the District level • Inspection reports from Office of Health Standards Compliance • Data quality reports (data validation and completeness reports) • Review and discuss District performance for priority health programmes and other initiatives • Discuss challenges experienced by clinics, propose interventions, and obtain commitment from District managers to address challenges identified by “diagnosis”. • Discuss the report on death audits and determine or track corrective actions • Recommendations from DCSTs on clinical governance and quality, and improvement measures taken in past quarter (and consolidated death report)

33. Head of EMS, District Pharmacist, and HR Managers are requested to be added

34. SUB-District Planning Monitoring and Response Forum Meets at least monthly Includes district hospitals

35. Functions: Sub-District Planning Monitoring and Response Forum • Discuss and present budget (of the forthcoming month) and expenditure (for the past month) of the sub-District • Present and discuss run charts for PHC facilities and District hospital if relevant. • Discuss status of implementation of actions and whether implementation resulted in improvement, using a standardised report. • Present and discuss data quality reports (data validation and completeness reports), and develop remedial actions to improve data quality. • Present the outcome of the latest self-assessment Ideal Clinic Dashboard and formal OHSC inspections, and propose interventions. • Review and adjust actions

36. Sub-District Planning Monitoring and Response Unit