Evaluation of a quality improvement intervention for obstetric and neonatal care in selected public health facilities across six states of India.

BACKGROUND: While increase in the number of women delivering in health facilities has been rapid, the quality of obstetric and neonatal care continues to be poor in India, contributing to high maternal and neonatal mortality. METHODS: The USAID ASSIST Project supported health workers in 125 public health facilities (delivering approximately 180,000 babies per year) across six states to use quality improvement (QI) approaches to provide better care to women and babies before, during and immediately after delivery. As part of this intervention, each month, health workers recorded data related to nine elements of routine care alongside data on perinatal mortality. We aggregated facility level data and conducted segmented regression to analyse the effect of the intervention over time. RESULTS: Care improved to 90-99% significantly (p < 0.001) for eight of the nine process elements. A significant (p < 0.001) positive change of 30-70% points was observed during post intervention for all the indicators and 3-17% points month-to-month progress shown from the segmented results. Perinatal mortality declined from 26.7 to 22.9 deaths/1000 live births (p < 0.01) over time, however, it is not clear that the intervention had any significant effect on it. CONCLUSION: These results demonstrate the effectiveness of QI approaches in improving provision of routine care, yet these approaches are underused in the Indian health system. We discuss the implications of this for policy makers.

Creating and sustaining a digital community of practice for quality improvement in South-East Asia during the COVID-19 pandemic.

INTRODUCTION: Ensuring quality of care in Low and Middle Income countries (LMICs) is challenging. Despite the implementation of various quality improvement (QI) initiatives in public and private sectors, the sustenance of improvements continues to be a major challenge. A team of healthcare professionals in India developed a digital community of practice (dCoP) focusing on QI which now has global footprints. METHODOLOGY: The dCoP was conceptualised as a multitiered structure and is operational online at www.nqocncop.org from August 2020 onwards. The platform hosts various activities related to the quality of care, including the development of new products, and involves different cadres of healthcare professionals from primary to tertiary care settings. The platform uses tracking indicators, including the cost of sustaining the dCoP to monitor the performance of the dCoP. RESULT: Since its launch in 2020, dCoP has conducted over 130 activities using 13 tools with 25 940 registration and 13 681 participants. From April 2021, it has expanded to countries across the South-East Asia region and currently has participants from 53 countries across five continents. It has developed 20 products in four thematic areas for a targeted audience. dCoP is supporting mentoring of healthcare professionals from five countries in the South-East Asia region in their improvement journey. Acquiring new knowledge and improvement in their daily clinical practice has been reported by 93% and 80% of participants, respectively. The dCoP and its partners have facilitated the publication of nearly 40 articles in international journals. CONCLUSION: This dCoP platform has become a repository of knowledge for healthcare professionals in the South-East Asia region. The current paper summarises the journey of this innovative dCoP in an LMIC setting for a wider global audience.

Improving handwashing among parent-attendants visiting a newborn unit practising family participatory care.

In our newborn intensive care unit (NICU), we practise family participatory care, where the unit staff encourage parents and attendants of sick newborns to partner with them and be involved in care for their babies. There remains a concern that this practice may increase the risk of nosocomial infections being carried into the unit by parent-attendants. Staff observed that handwashing behaviours were suboptimal and inconsistent among parent-attendants. With facilitation from an improvement coach, we formed a quality improvement team of NICU staff to improve hand hygiene practices among attendants. From a baseline estimate of around 20% of attendants adhering to hand hygiene standards, the team planned to reach a target of 80% over 8 weeks by introducing a series of changes. At the end of 9 weeks, 80% of attendants were following standard hand hygiene practices.

Development of a framework of intervention strategies for point of care quality improvement at different levels of healthcare delivery system in India: initial lessons.

BACKGROUND: Inadequate quality of care has been identified as one of the most significant challenges to achieving universal health coverage in low-income and middle-income countries. To address this WHO-SEARO, the point of care quality improvement (POCQI) method has been developed. This paper describes developing a dynamic framework for the implementation of POCQI across India from 2015 to 2020. METHODS: A total of 10 intervention strategies were designed as per the needs of the local health settings. These strategies were implemented across 10 states of India, using a modification of the 'translating research in practice' framework. Healthcare professionals and administrators were trained in POCQI using a combination of onsite and online training methods followed by coaching and mentoring support. The implementation strategy changed to a fully digital community of practice platform during the active phase of the COVID-19 pandemic. Dashboard process, outcome indicators and crude cost of implementation were collected and analysed across the implementation sites. RESULTS: Three implementation frameworks were evolved over the study period. The combined population benefitting from these interventions was 103 million. A pool of QI teams from 131 facilities successfully undertook 165 QI projects supported by a pool of 240 mentors over the study period. A total of 21 QI resources and 6 publications in peer-reviewed journals were also developed. The average cost of implementing POCQI initiatives for a target population of one million was US$ 3219. A total of 100 online activities were conducted over 6 months by the digital community of practice. The framework has recently extended digitally across the South-East Asian region. CONCLUSION: The development of an implementation framework for POCQI is an essential requirement for the initiative's successful country-wide scale. The implementation plan should be flexible to the healthcare system's needs, target population and the implementing agency's capacity and amenable to multiple iterative changes.

Development of a hub and spoke model for quality improvement in rural and urban healthcare settings in India: a pilot study.

OBJECTIVE: Hub and spoke model has been used across industries to augment peripheral services by centralising key resources. This exercise evaluated the feasibility of whether such a model can be developed and implemented for quality improvement across rural and urban settings in India with support from a network for quality improvement. METHODS: This model was implemented using support from the state and district administration. Medical colleges were designated as hubs and the secondary and primary care facilities as spokes. Training in quality improvement (QI) was done using WHO's point of care quality improvement methodology. Identified personnel from hubs were also trained as mentors. Both network mentors (from QI network) and hub-mentors (from medical colleges) undertook mentoring visits to their allotted facilities. Each of the participating facility completed their QI projects with support from mentors. RESULTS: Two QI training workshops and two experience sharing sessions were conducted for implementing the model. A total of 34 mentoring visits were undertaken by network mentors instead of planned 14 visits and rural hub-mentors could undertake only four visits against planned 18 visits. Ten QI projects were successfully completed by teams, 80% of these projects started during the initial intensive phase of mentoring. The projects ranged from 3 to 10 months with median duration being 5 months. DISCUSSION: Various components of a health system must work in synergy to sustain improvements in quality of care. Quality networks and collaboratives can play a significant role in creating this synergy. Active participation of district and state administration is a critical factor to produce a culture of quality in the health system.

Reducing hypothermia in newborns admitted to a neonatal care unit in a large academic hospital in New Delhi, India.

Neonatal hypothermia is a common and dangerous condition around the world. 70% of neonates born in Kalawati Saran Children's Hospital in New Delhi, India, and subsequently admitted to the neonatal intensive care unit (NICU) had a temperature below 36.5°C on admission. In July 2016, we formed a team of staff from the labour room, NICU and auxiliary staff to reduce hypothermia in babies transported to our NICU using quality improvement methods. We identified problems related to staff awareness of hypothermia and its dangers, environmental factors and supply issues in the labour room, and challenges with rapidly and safely transferring sick newborns to the NICU. We used the Plan-Do-Study-Act cycles to test and adapt solutions to these problems. Because infection is a common complication of hypothermia, we also instituted a training programme to improve handwashing skills among parents and health workers. Within 9 months of starting our quality improvement project, the proportion of neonates who were normothermic on admission increased from 27% to 75%, the number of cases of late-onset neonatal sepsis decreased from 15.2 to 5 cases/1000 patient days, and all-cause mortality fell from 4.2 to 2.6 neonatal deaths per week. Multiple factors can lead to neonatal hypothermia, and the most important factors will differ from facility to facility. Quality improvement methods provide health workers with the skills to identify the key factors contributing to hypothermia in their facility and to develop strategies to address them. Addressing processes of care can lead to improved thermal care and save lives.

The Mixed Nature of Incentives for Community Health Workers: Lessons from a Qualitative Study in Two Districts in India.

Incentives play an important role in motivating community health workers (CHWs). In India, accredited social health activists (ASHAs) are female CHWs who provide a range of services, including those specific to reproductive, maternal, neonatal, child, and adolescent health. Qualitative interviews were conducted with 49 ASHAs and one of their family members (husband, mother-in-law, sister-in-law, or son) from Gurdaspur and Mewat districts to explore the role of family, community, and health system in supporting ASHAs in their work. Thematic analysis revealed that incentives were both empowering and a source of distress for ASHAs and their families. Earning income and contributing to the household's financial wellbeing inspired a sense of financial independence and self-confidence for ASHAs, especially with respect to relations with their husbands and parents-in-law. In spite of the empowering effects of the incentives, they were a cause of distress. Low incentive rates relative to the level of effort required to complete ASHA responsibilities, compounded by irregular and incomplete payment, put pressure on families. ASHAs dedicated much of their time and own resources to perform their duties, drawing them away from their household responsibilities. Communication around incentives from supervisors may have led ASHAs to prioritize and promote those services that yielded higher incentives, as opposed to focusing on the most appropriate services for the client. ASHAs and their families maintained hope that their positions would eventually bring in a regular salary, which contributed to retention of ASHAs. Incentives, therefore, are both motivating and inspiring as well as a cause dissatisfaction among ASHAs and their families. Recommendations include revising the incentive scheme to be responsive to the time and effort required to complete tasks and the out-of-pocket costs incurred while working as an ASHA; improve communication to ASHAs on incentives and responsibilities; and ensure timely and complete payment of incentives to ASHAs. The findings from this study contribute to the existing literature on incentivized CHW programs and help throw added light on the role incentives play in family dynamics which affects performance of CHW.