The State Of The Art In The Field Of Quality Improvement

1. The State Of The Art InThe Field Of Quality Improvement Jim Heiby, MD, MPH, Medical Officer, USAID Washington, CTO QA/WD Krishnapada Chakraborty, CTO, USAID/Dhaka, Bangladesh Kerry Pelzman, MPH, Chief of Health Division, USAID/Russia Rashad Massoud, MD, MPH, Associate Director, QA/WD, URC-CHS, Bethesda, MD Elena Gurvich, MD, PhD, DSc, CTO QA/WD, USAID/Russia

2. Creating A Norm of Access and Quality Leadership/Management Problem Solving & Tools Client Engagement Community Engagement Evaluation/Certification Provider Rewards/Engagement Supportive Supervision Standards/Guidelines Supplies/Logistics/Environment Organization of Work Job Aids Training SYNERGY OF INTERVENTIONS

3. Why should I care about “Quality Improvement”? • A well-developed, distinct field • addresses both quality and waste in health care • carried out by regular staff • adapted to different settings • short term results • long term cumulative impact • dynamic

4. Why care about QI, continued • An important strategic option • acceptance of evidence-based guidelines • health care becoming more demanding • complements technical training and T/A • can focus on priority services • low cost • USAID comparative advantage

5. Improving Health Care Quality in the Russian Federation Kerry Pelzman, MPH Chief of Health Division, USAID Moscow

6. Three Phases of the QAP/Russia • 1998-1999: Demonstration Improvements in Facilities • 2000-2001: Oblast-wide implementation • 2002: National Scale-Up

7. Phase I: QA DemonstrationProjects Maternal and Child Health (Tver Oblast) • Improving care for women suffering from Pregnancy-Induced Hypertension (PIH) • Improving care for neonates suffering from Respiratory Distress Syndrome (NRDS) Primary Care (Tula Oblast) • Improving care for patients suffering from Arterial Hypertension (AH)

8. Key Changes Made in the Care for Women with PIH in Tver • Classification ICD - 10 • Early and induced delivery • Fewer number of women hospitalized • Poly-therapy mono-therapy MgSO4 • Promotion of the role of the midwife

9. Key Results in the Care for Women with PIH in Tver (3 hospitals 1998-2001) • No cases of maternal deaths since intervention • No cases of progression to eclampsia • 77% reduction in hospitalizations due to PIH • Economic Effect: 87% reduction in the cost of care for women with PIH

10. Key Changes Made to the System of Care for Neonates with RDS in Tver • Evidence-Based Clinical Guidelines Developed & Implemented • Central Referral NICU Created • Neonatal Transport System Set Up • Neonatal Resuscitation Instituted • New Directives “Prikaz” Issued • Resources Re-allocated

11. Re(Designing) the System of Care for Newborns Suffering from Respiratory Disease Syndrome Neonatal I.C.U. Neonatal Transportation Neonatal Resuscitation Neonatal Resuscitation Neonatal Resuscitation

12. Key Results of (Re)Designing the System of Neonatal Care in Tver (5 hospitals 1999-2001) • 95% 7-day survival rate after initial resuscitation • 99% increase in neonates transported to NICU with normal body temperature • 64% reduction in neonatal mortality due to RDS

13. Key Changes Made to the System of Care for Patients with AH in Tula • Evidence-Based Clinical Guidelines Developed & Implemented • Screening Program Instituted • Health Promotion Program Instituted • Hypertension Chart Developed & Instituted • New Directives “Prikaz” Issued

14. Key Results in Improving the System of Hypertension Care in Tula (5 clinics 1998-2001) • Number of patients managed at the primary care level increased by 7.6 times • BP stabilization achieved in 69.4% of patients • Hypertension related hospitalizations decreased by 85% • Hypertensive crises decreased by 60% • Economic analysis: • Cost of hospital care reduced by 41% • Cost of care at the primary care level increased by 39% • Overall reduction in the cost of care of 23%

15. Phase II: Oblast-wide Implementation 2000-2001 • PIH from 3 to 42 maternity hospitals • RDS from 5 to 42 maternity hospitals • AH from 6 – 500 clinics

16. Results Large-Scale Implementation NRDS (42 hospitals 2000-2001) • 87% 7-day survival rate after initial resuscitation • 99% increase in neonates transported to NICU with normal body temperature • 62% reduction in neonatal mortality due to RDS • 49.6% reduction in early neonatal mortality (from 10.8/1,000 in 1998 to 5.3/1,000 in 2001)

17. Phase III: National Scale-Up • Begin with 19 new Oblasts to Spread the QA Methodology • Implement Improvements Accomplished • Develop New Improvements • Implement Oblast-Wide Improvements • QA in Medical School Curricula • Federal Center for QA • MOH Appointed QA Official • MOH Working Group for QA • MOH Directive on QA Staff in each Oblast

18. Improving the Quality of Health Care:- Principles and Frameworks M. Rashad Massoud, MD, MPH Associate Director, QA/WD, Bethesda, MD

19. What Do We Mean By Quality Health Care? …”Quality health care is what happens at all the points of service along the continuum of care. High quality care is a function of the system’s ability to produce care that will address the client’s health issues in an effective, responsive, and respectful manner”… …David Nicholas

20. How Does Quality Improve? • Scientific Discovery • Mastery • Trial & Error • Coincidence • Improvement Methodology

21. The Fundamental Concept of Improvement “Every System is Perfectly Designed to Achieve Exactly the Results it Achieves” … Don Berwick

22. Principles of Improvement 1- Understanding health care delivery in terms of systems and processes

23. Screening Clinical Content Organization of care Health Promotion Policy/ Regulation Resource Allocation The System of Care for Patients Suffering from Hypertension in Tula Oblast

24. Principles of Improvement 2- Working in Teams

25. Principles of Improvement • 3- Customer Focus • 4- Scientific Method

26. InterventionStarted

27. The Quality Improvement Methodology

28. The Framework for Clinical Quality Improvement Content of Care Process of Care • Evidence-based: • Standards • Protocols • Guidelines Quality Improvement Methodology + Continuous Quality Improvement Traditional Quality Improvement Adapted from: Paul Balalden, Patricia StoltzA Framework for Continual Improvement in HealthcareThe Joint Commission Journal on Quality ImprovementOctober 1997

29. The Cost of Poor Quality illness THE TIP OF THE ICEBERG drugs/antibiotics treatment patients Death THE REST OF materials time patients ICEBERG infectiousness services Frustrated community workers productivity managers

30. Concluding Remarks on Quality Improvement • Tackling health care priorities • Evidence-based practices • Re-organizing health care delivery • Developing the Interventions • Motivation/ Teamwork/ Leadership • Significant Improvements • Health Systems Strengthening • Rationalizing Health Care • Cultural Transformation

31. QAP – Russian Perspectives Elena Gurvich, MD, PhD, DSc, CTO QA/WD, USAID Moscow

32. QAP – Russian Perspectives • Powerful Methodology for Health Reform • Two Key Success Factors: • Motivated Health workers • Committed Health leadership • Bottom Up Health Care Reform • National Demand for Dissemination