Standards Based Management and Recognition Approach To Quality Improvement

1. Standards Based Management and Recognition Approach To Quality Improvement By Prof. Emmanuel Oladipo Otolorin, FMCOG, FWACS, FICS, FRCOG Country Director, ACCESS/JHPIEGO

2. Learning Objectives • Define Quality of Care • List a variety of quality improvement approaches • Describe the Standards Based Management and Recognition (SBM-R) model • Describe lessons learnt so far in Nigeria

3. What does “Quality of Care” mean? • Illustrative definitions: • “Doing the right things right” • “Meeting minimal standards for adequate care” • “Offering the greatest health benefits, with the least health risks, to the greatest number of people, given the available resources”

4. World Health Organization’s Definition Of “Quality Of Care” • “The proper performance, according to standards, of interventions that are known to be safe, that are affordable to the society in question, and that have the ability to produce an impact on mortality, morbidity, disability and malnutrition”

5. Social-cultural Client Q Civil Society State/ USAID Provider Context Different Perceptions of Quality

6. Criteria of good quality maternal health services • Accessible and available • Acceptable to potential users/responsive to local cultural and social norms (e.g. privacy, confidentiality, quick, care by female health workers • Adequacy of essential supplies and equipment • Provides comprehensive care and linkages to other RH services • Provides for continuity of care and follow-up

7. Criteria of good quality maternal health services continued • Staffed by technically competent health care providers who rely of clear guidelines and protocols for treatment • Staffed by workers who provide respectful and non-judgmental care • Service site provides information and counseling for clients on their health and health needs • Involves clients in decision-making • Offers economic and social support to health care providers to motivate them to do the best job they can

8. Why is Quality of Care important? • Quality of care is important because good quality services: • are cost-efficient • are equitable • are effective • improve staff morale • save women’s lives

9. Sample list of Quality Improvement Methods • Quality assurance • Total Quality Management • Continuous Quality Improvement • Performance Improvement • Supportive/Facilitative supervision • Standard-Based Management and Recognition (SBM-R) Approach

10. What is SBM-R? • Practical management approach for improving performance and quality of health services • Based on use of operational, observable performance standards for on-site assessment • Must be tied to reward or incentive program • Consists of four basic steps

11. The Four Steps of SBM-R

12. Step One: Set the Performance Standards

13. Steps to Setting Standards • Identify area of services to be improved • Define core support and supply processes to provide these services • Develop performance standards based on international guidelines, national policies or guidelines, and site-specific requirements • Consider providers’ input and clients’ preferences

14. “Operationalization” of Standards National Guidelines (“Reference” standards) Assessment tool (“Operational” standards plus indicators)

15. Performance Standards The standards tell providers not only what to do but also how to do it

16. Area: Pregnancy Care Y, N, NA Verification Criteria Comments Perf. Standard • Observe in the reception area or waiting room if the person who receives the pregnant woman: • Asks if she has or has had: • Vaginal bleeding • Headache or visual changes • Breathing difficulty • Severe abdominal pain • Fever • Immediately notifies the health provider if any of these conditions are present • The facility conducts a routine rapid assessment of pregnant women Sample Performance Assessment Tool (1) See other examples in Nigerian Standards

17. Assessment tool areas for EMNOC: Nigerian Hospitals See Page v of Nigerian Standards

18. Assessment tool areas for EMNOC: Nigerian PHCs

19. Step Two: Implement the Standards

20. Steps to Implement Standards • Do baseline assessment • Identify performance gaps • Identify causes of gaps and interventions to correct them • Implement interventions • Begin and support change process

21. Desired performance Cause analysis Gap Actual performance Intervention identification & implementation Implementation Cycle Model Adapted from the International Society for Performance Improvement

22. Baseline Assessment • Determines actual level of performance using the performance assessment tool • Helps to identify performance gaps • Once gaps are identified, identifies their causes

23. Baseline SBM-R Scores in Kano and Zamfara Hospitals: Aug. 2007

24. Baseline SBM-R Scores in Kano and Zamfara PHCs: Aug. 2007

25. Defining the performance gap: Example 100% of pregnant women attending the ANC deliver with a skilled birth attendant • Define the performance gap for each task (in quantitative or qualitative terms) 58% of pregnant women attending the ANC did NOT deliver with a SBA Gap 42% of pregnant women attending the ANC deliver with a skilled birth attendant

26. In order to perform, a performer needs to: Know how to do + Be enabled to do + Want to do

27. Capability (Know how to do) Knowledge, skills, information Opportunity (Be enabled to do) Resources, tools, capacity Motivation (Want to do) Inner drive, incentives

28. Intervention Identification and Implementation • Once gaps are identified, do rootcause analysis to identify corrective interventions • Interventions should match the root cause of the gap • Implement selected interventions

29. 100% 75% 50% 25% Pareto Graph for “Reasons for Not Delivering in the Hospital” (Uganda) • Food not culturally appropriate • Husband objects • Rude staff • Afraid • Language differences • Lack of privacy • Lack of knowledge • Hospital too far • Dirty hospital • Long waiting • Too crowded 160 140 120 100 80 60 40 20 0 150 149 148 146 144 134 122 89% 107 81% 71% 90 60% 70 47% 42 28% 28 20 17 15 12 10 2 2 1 1 C F H J D A E K G I B

30. INCENTIVES MOTIVATION Strengthening of Management Systems, Provision of Resources Resources, Capacity Knowledge, Skills, Information Training, Information Intervention Identification Type of problem Type of solution

31. Lack of tools and equipment Lack of knowledge and skills Training Lack of motivation and incentives Lack of data and information Lack of financial transparency “If all you have is a HAMMER…everything looks like a NAIL.” There is an epidemic of “workshopitis” in Nigeria

32. Effort = Performance / Effort is NOT the same thing as Performance

33. Change Management Strategy • Implementation of change can be difficult (business as usual mentality is rampant) • Performance standards are a tool for initiating and sustaining change • Important to focus on actions and achievement of early results to help ease the change process • Individuals can be powerful agents for or against change

34. Change Management Strategy • The standards in the tools represent easy and hard challenges • Changes start with the “low-hanging fruit” • Managers and providers should start with the easiest tasks and then move to more difficult tasks, as they develop and increase their change management skills • Observe change process to identify new developments, initiatives and behaviors

35. “Multidimensional” Supervision and Support • SBM-R process uses a variety of ways to supervise and support change process: • Self/internal assessment • Peer/benchmarking • Supportive supervision (on demand), external assessment • Client involvement and community participation (e.g. HFDC with community membership) • Bottom-up approach: based on local control, empowerment, motivation, advocacy, resource mobilization

36. Step Three: Measure Progress

37. Steps to Measure Progress • Encourage providers to self-assess • Measure progress (internal monitoring) • Bring facilities together to share challenges and successes

38. Example: Total Results by Hospital, Honduras 2001-2004

39. Results from Seven Hospitals in Malawi

40. PROQUALI, Brazil Compliance with standards of reproductive health care 13th Health Center-Bahia

41. PROQUALI Brazil: Results from Five Pilot Clinics

42. Qualitative results

46. Step Four: Recognize and Reward Achievements

47. Steps to Recognize Achievements • Address motivational issues • Decide upon incentives • Implement incentive programs

48. Ways to Enhance Motivation • Empowerment: Giving the tools to self-assess and implement • Challenges: Establishing a clear goal • Achievements: Easy to show results • Healthy competition: Grouping facilities encourages sharing of experiences and some competition to succeed

49. Recognition methods (as an Incentive) • Feedback (verbal, written) • Social recognition • Material recognition