The State Of The Art InThe State Of The Art InThe Field Of Quality ImprovementThe 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

Standards/Guidelines

SYNERGY OF INTERVENTIONS

Creating A Norm of Access and Quality

Organization of Work

Community Engagement

Provider Rewards/Engagement

Client Engagement

Leadership/Management

Training

Job Aids

Supplies/Logistics/Environment

Supportive Supervision

Evaluation/Certification

Problem Solving & Tools

Why should I care about Why should I care about “Quality Improvement”?“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

Why care about QI, continuedWhy 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

Improving Health Care Quality Improving Health Care Quality in the Russian Federationin the Russian Federation

Kerry Pelzman, MPH

Chief of Health Division, USAID Moscow

Three Phases of the QAP/RussiaThree Phases of the QAP/Russia

1998-1999: Demonstration Improvements in Facilities

2000-2001: Oblast-wide implementation

2002: National Scale-Up

Phase I: QA DemonstrationPhase I: QA Demonstration ProjectsProjects

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)

Key Changes Made in the Care for Key Changes Made in the Care for Women with PIH in TverWomen 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

Key Results in the Care for Women with Key Results in the Care for Women with PIH in Tver (3 hospitals 1998-2001)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

Key Changes Made to the System of Care Key Changes Made to the System of Care for Neonates with RDS in Tverfor 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

Re(Designing) the System of Care for Newborns Re(Designing) the System of Care for Newborns Suffering from Respiratory Disease SyndromeSuffering from Respiratory Disease Syndrome

Neonatal

Resuscitation

Neonatal Transportation

Neonatal I.C.U.

Neonatal

Resuscitation

Neonatal

Resuscitation

Key Results of (Re)Designing the System of Key Results of (Re)Designing the System of Neonatal Care in Tver (5 hospitals 1999-2001)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

Key Changes Made to the System of Care Key Changes Made to the System of Care for Patients with AH in Tulafor 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

Key Results in Improving the System of Key Results in Improving the System of Hypertension Care in Tula (5 clinics 1998-2001)Hypertension Care in Tula (5 clinics 1998-2001)

Number of patients managed at the primary care level increased by Number of patients managed at the primary care level increased by

7.6 times 7.6 times

BP stabilization achieved in 69.4% of patients BP stabilization achieved in 69.4% of patients

Hypertension related hospitalizations decreased by 85% Hypertension related hospitalizations decreased by 85%

Hypertensive crises decreased by 60% Hypertensive crises decreased by 60%

Economic analysis:Economic analysis:

– Cost of hospital care reduced by 41%Cost of hospital care reduced by 41%

– Cost of care at the primary care level increased by 39%Cost of care at the primary care level increased by 39%

– Overall reduction in the cost of care of 23%Overall reduction in the cost of care of 23%

Phase II: Oblast-wide Phase II: Oblast-wide Implementation 2000-2001Implementation 2000-2001

PIH from 3 to 42 maternity hospitals

RDS from 5 to 42 maternity hospitals

AH from 6 – 500 clinics

Results Large-Scale Implementation Results Large-Scale Implementation NRDS (42 hospitals 2000-2001)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)

Phase III: National Scale-Up 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

Improving the Quality of Health Care:- Improving the Quality of Health Care:- Principles and FrameworksPrinciples and Frameworks

M. Rashad Massoud, MD, MPH

Associate Director, QA/WD, Bethesda, MD

What Do We Mean By Quality Health Care?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

How Does Quality Improve?How Does Quality Improve?

Scientific DiscoveryMasteryTrial & ErrorCoincidenceImprovement Methodology

The Fundamental Concept of ImprovementThe Fundamental Concept of Improvement

“Every System is Perfectly

Designed to Achieve Exactly the

Results it Achieves”

… Don Berwick

Principles of ImprovementPrinciples of Improvement

1- Understanding health care delivery in terms of systems and processes

The System of Care for Patients Suffering The System of Care for Patients Suffering from Hypertension in Tula Oblastfrom Hypertension in Tula Oblast

Clinical Content

Screening Organization of care

Health Promotion

Policy/ Regulation

Resource Allocation

Principles of ImprovementPrinciples of Improvement

2- Working in Teams2- Working in Teams

Principles of ImprovementPrinciples of Improvement

3- Customer Focus

4- Scientific Method

Percent Neonates Arriving to the NICU w ith Hypothermia

42.9

54.5

77.880.0

55.650.0

61.1

77.875.0

54.5

66.7

40.0

23.1

0.00.00.00.00.00.00.05.6

0.05.9

0.00.00.00.00.00.00.00.03.40.00.00.04.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

%

Intervention Started

The Quality Improvement MethodologyThe Quality Improvement Methodology

1 .I de nt i f y

2.Analyze

3.Develop

Plan

Study

Act D o4.

Test andImplement

Content of Care

Evidence-based:•Standards•Protocols•Guidelines

Process of Care

Quality Improvement Methodology

+

TraditionalQuality Improvement

Continuous Quality Improvement

Adapted from:Paul Balalden, Patricia StoltzA Framework for Continual Improvement in HealthcareThe Joint Commission Journal on Quality ImprovementOctober 1997

The Framework for Clinical Quality The Framework for Clinical Quality ImprovementImprovement

The Cost of Poor QualityThe Cost of Poor Quality

patients

Death

THE TIP OF THE ICEBERG

THE REST OF

ICEBERG

illness

patients

drugs/antibioticstreatment

materialstime

infectiousness

productivityservices

Frustrated

workers

managers

community

Concluding Remarks on Quality ImprovementConcluding 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

QAP – Russian PerspectivesQAP – Russian Perspectives

Elena Gurvich, MD, PhD, DSc, CTO QA/WD, USAID Moscow

QAP – Russian PerspectivesQAP – Russian Perspectives

Powerful Methodology for Health Reform

Two Key Success Factors:– Motivated Health workers– Committed Health leadership

Bottom Up Health Care ReformNational Demand for Dissemination