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Change agent or troublemaker – engaging stakeholders and making change.

Change agent or troublemaker – engaging stakeholders and making change. Implementing Change in northern India . Umass -Boston Oct 21, 2014. Robyn Churchill, CNM, MSN. Goals of this presentation: Understand barriers to change Learn one framework for building lasting change

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Change agent or troublemaker – engaging stakeholders and making change.

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  1. Change agent or troublemaker – engaging stakeholders and making change. Implementing Change in northern India. Umass-Boston Oct 21, 2014 Robyn Churchill, CNM, MSN

  2. Goals of this presentation: Understand barriers to change Learn one framework for building lasting change Draw lessons learned from India and apply to case study • Plan for today: • Using 5 element framework for implementing systems change: • Review experience of BetterBirth project in northern India • Use lessons learned to address implementation plan for case study

  3. What is needed for change? • Supportive Environment • Knowledge • Skills • Resources • Motivation

  4. Barriers-Resistance Initial Response to Resistance

  5. Barriers Expect Resistance

  6. Barriers Understand Resistance by Listening

  7. Barriers-Resistance Outsmart Resistance Increase Drivers Decrease Resistance

  8. Framework for Implementing Change • Engage Stakeholders • Make local modifications • Identify team and champions • Collect and USE data to learn and iterate • Build capacity/plan for sustainability

  9. Approach to Implementing Change • Make local modifications Understand processes (map them) Adapt to local policy and standards Consider resources and barriers

  10. Approach to Implementing Change • Identify team and champions Who needs to be involved Identify early adopters Consider role for resistors Recognize and develop champions Build coaches/on going mentors

  11. Approach to Implementing Change • Collect and USE data to learn and iterate Identify metrics of importance inputs process outputs outcomes Create meaningful and individual reports regular customized real-time Develop system for regular review with front line staff show what you know (successes, areas for improvement) learn from front line experience

  12. Approach to Implementing Change • Build capacity/plan for sustainability Identify existing structure to plug into Identify owners of process Locate systems for funding, supervision, monitoring Create policy-facility, regional, national

  13. BetterBirth Safe Childbirth Checklist Implementation Uttar Pradesh India

  14. Moments of Greatest Risk Maternal & neonatal mortality risk Delivery Discharge from birth facility Admission to birth facility 28 days Antenatal period 42 days Conception Time

  15. Moments of Greatest Risk Check point #2 Just before pushing (or before Cesarean) Check point #3 Soon after birth (within 1 hour) Check point #1 On admission Maternal & neonatal mortality risk Check point #4 Before Discharge Delivery Discharge from birth facility Admission to birth facility 28 days Antenatal period Conception 42 days Time

  16. Safe Childbirth Checklist Program

  17. Safe Childbirth Checklist Program

  18. Gokak Pilot Study Objective: Measure health worker performance Adherence to 29 essential processes linked with improved maternal, fetal, and neonatal health outcomes Intervention: Introduction of checklist supported by coaching Methods: Prospective, pre-post-intervention study over 6 months in single sub-district level hospital in south India using observations by independent data collectors

  19. Gokak Pilot Study

  20. Safe Childbirth ChecklistSingle center pilot, Karnataka, India PLoS One 2012;7(4):e35151

  21. Stakeholders Government of Uttar Pradesh Government of India World Health Organization Gates Foundation Ariadne Labs (BWH/HSPH) Population Services International Community Empowerment Lab, Lucknow JNMC Medical College, Belgaum

  22. Stakeholders District Leaders Facility Leaders Medical Officers Nurses ANMs (Auxiliary Nurse Midwives)

  23. Stakeholders District Leaders Facility Leaders Medical Officers Nurses ANMs (Auxiliary Nurse Midwives) Ward Ayas Sweepers ASHAs Women Mothers in law

  24. Stakeholders

  25. Local Modifications What factors would you consider in making local modifications? Whose input counts?

  26. Team and Champions Team Leader Coach • Building relationships is key to getting buy-in and making changes • Leader to Leader • Coach to Health Care Worker • Many staff contribute to checklist adoption • Ayas, ASHAs • Sweepers

  27. Data • Study Measures • Outcome measures (7 days postpartum) • Call center • Home visits • Practice behaviors • Observers • Monitoring and Evaluation • Implementation team • Implementation processes • Facility adoption • Process observation • Facility champion-Childbirth Quality Leader

  28. Sustainability What is needed to build sustainability?

  29. Measurement • Study Measures • Outcome measures (7 days postpartum) • Call center • Home visits • Practice behaviors • Observers • Monitoring and Evaluation • Implementation team • Facility champion-Childbirth Quality Leader

  30. Digital Data Collection (Apps)

  31. The Goal: for learning and improvement Program management M and E Data* Improvement in implementation Implementation of intervention and of researchactivities *M and E data include inputs, activities, outputs and selected short term outcomes from routine program data

  32. Our intervention team’s two key tasks • Discovering why she hadn’t followed a given practice (e.g., skin-to-skin). • Had the knowledge. • Effect seems invisible. No thermometer. • Requires skill in persuading mothers. • Using consistent methods to persuade her and others to change. • Required multiple visits. • But after a relationship with the coach was created, she changed.

  33. Sustainability • Make it work there: Local adaptation and modification • GoI Checklist • Identify local owners • Identify birth team (official and unofficial)

  34. Sustainability • Don’t reinvent the wheel: Integration into existing systems • Build on Quality Improvement systems • Build and support local ownership

  35. Coordinating with GoI QA: Childbirth Quality Improvement Structure BetterBirth Team (PSI/HSPH) supplies quality/progress data BB (COP/DCOP/HSPH) supplies data/support for problem-solving in study sites Q3mo. BB (DCOP/TLs/DQA/HSPH M&E) supplies data/support for problem-solving Q1mo. BB (TLs/Nurse Coaches) supplies data/support for problem solving Q weekly

  36. The MOH of Odyssia has invited you in to direct implementation of an immunizationprogram in an urban slum • Population unknown but estimated at ~1m souls. • Overall vaccination coverage is estimated at ~50%. • Literacy rates: ~80% men and ~60% women. • Local health facility has 50 beds in 4 rooms—5 nurses, 1 radiologist, 1 anesthetist, 1 traditional healer/doctor • Questions: • What other information would be useful? • Who do you talk with first? • Identify the first 3 steps you would take

  37. What do you do?

  38. Task Shifting Or Task Sharing a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers

  39. Framework for Implementing Change • Engage Stakeholders • Make local modifications • Identify team and champions • Collect and USE data to learn and iterate • Build capacity/plan for sustainability

  40. Stakeholders

  41. Local Modifications What factors would you consider in making local modifications? Whose input counts?

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