Quality improvement in maternal health care in Tanzania: steady but slow improvement in regional hospitals

Rose Mnzava
Quality Improvement Advisor Jhpiego/MAISHA Tanzania

Presentation Outline
1. Background 2. SBM-R assessment findings from baseline to date in MAISHA-supported regional hospitals 3. Challenges/ lessons leant and summary

Background
Quality improvement in Tanzania is a process to improve quality of maternal and neonatal care Measures actual performance and quality of services in a facility

Background
The National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths 2008 - 2015

Strategies include:

Improving access to quality MNH care Strengthening the referral system Strengthening MNH district health planning& management of Advocating for increased commitment & resources for MNH Fostering partnerships Promoting the household to hospital continuum of care Empowering communities

How does QI fit into National Roadmap?

MAISHA provides technical assistance to MOHSW to implement the strategies through development and use of BEmONC standards; Goals: Universal access to BEmONC at facilities with skilled providers managing obstetric complications Reducing life-threatening delays Well staffed health facility Well equipped health facility: equipment and supplies

BEmONC SBM-R Quality Improvement Approach

Practical management approach for strengthening 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

Standards
Normal labour delivery & immediate newborn care (NLD) Management of antenatal, intrapartum and postpartum complications (MCLD) Postpartum care (PNC) Infrastructure& human resources (IHR) IEC & Community participation (IEC) Support systems (SS)

Hospitals
20 15

Health Center/ Dispensary

18 12

10 11 4 17

8 7 13

Total

77

58

Implementing Standards: A continuous process Used performance standards to Identify quality of care gaps Share results with technical personnel to guide program plans and implementation to address the identified gaps

Intervention Identification
PERFORMANCE FACTORS Capacity GAP
Knowledge/ skills & information

INTERVENTION Training Information

Opportunity

Resources / Tools

Management system Resources

Rewards Disincentives

Motivation

Inner drive Incentives

Linking SBM-R and Supportive Supervision to build quality of care culture

Developed a network of SBM-R promoters and facilitators Strengthening use of standards based management and recognition approach to quality of care in HFs Supporting Quality Improvement Teams (QITs) to Link up with Health Facility Management Teams (HMTS) Promoting the use of SBM-R performance standards tool for Supportive Supervision

6 hospitals: cumulative performance score overtime

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Ligula

Sokoine
Baseline

Mt. Meru

Mawenzi
3rd Internal

Iringa
4th Internal

Kigoma

1st Internal

2nd Internal

8 hospitals: Cumulative performance score overtime

80% 70% 60% 50% 40% 30% 20% 10%

0%
Babati Tumbi Songea Baseline Kitete 1st Inter Morogoro 2nd Inter Temeke 3rd Inter M'nyamala Amana

Measuring Progress in technical areas (1)

Core criterion: Communication skills Assessment& management Partograph use Clean and safe delivery (IPC) AMTSL Immediate neonatal care including HBB

Normal Labor & delivery

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

hospital 1
Baseline 1st internal 2nd internal

hospital2
3rd internal

hospital3

Measuring Progress in technical areas (2)

Pre-eclampsia/Eclampsia Postpartum haemorrhage Management of prolonged/obstructed labor Management of incomplete abortion

Management of maternal & newborn complications

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

hospital 1 hospital2 hospital3

Baseline 1st internal 2nd internal 3rd internal

Measuring Progress in technical areas (3)

Core criterion: Immediate postpartum assessment and care for mother and neonate in the first 24 hrs Breast feeding Danger signs checked & addressed Information Education and Counseling
90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Postpartum Care

hospital 1
Baseline

hospital2

hospital3
3rd internal

1st internal

2nd internal

Improvement in technical areas

Achievements cont.
All hospitals have shown performance improvement overtime Task shifting noticeable

Facilities are reaching verification for recognition

Ownership leading to institutionalization

Factors Responsible for Quality Improvement

Training of facility staff; knowledge and skills Support facilities with equipment and supplies Supportive supervision Increased number of skilled clinical providers (midwives, physicians)

Recognize & Rewarding Achievement Feedback Social recognition Material recognition

Challenges
Shortage

of skilled human resource Provider attitude Shortage of equipment and supplies Drug stock outs High staff turnover

Lessons Learnt
Supportive supervision is an integral part of SBMR Involvement of stakeholders and getting their buy-in & commitment Building the capacity of RHMTs, CHMTS HMTs and supervisors on supportive supervision Strengthening and linking health facilities with communities Post training follow up ensure translation of trainings into services Use of systemic holistic approach

CONCLUSIONS
Providing clearly defined MNH performance standards results Putting simple and easy to use QI approaches into the hands of providers Steady performance has been documented Providers competence improved

Summary
Tanzania EmONC/BEmONC QI process has illustrated a shift from policy to practice with an important lesson that it is a managerial tool. Application of the tools lead to identification and addressing performance gaps which has shown improvement in quality of EmONC/BEmONC Multisectoral strategies are required to promote shared responsibilities in order to achieve quality of care especially where external support is required.

Acknowledgements
Authors: Rose Mnzava, Gaudiosa Tibaijuka, Marya Plotkin, Dunstan Bishanga, Maryjane Lacoste
Institutions: Jhpiego Tanzania
This presentation is made possible by the generous support of the American people through the United States Agency for International Development (USAID) Cooperative Agreement No. 621-A-00-08-00023-00. The contents are the responsibility of the Mothers and Infants, Safe Healthy Alive (MAISHA) program and do not necessarily reflect the views of USAID or the United States Government.