Improving the quality of maternal & newborn health in Makueni county using small test of change (STOCs):

the case of Kanzokea community unit

Oruko Happiness1, Gitimu Anne1, Karijo Evalin1

1 AMREF Kenya1

Outline• Background

• Rationale

• Methods

• Results

• Conclusions & Recommendations

2

Background • Quality Improvement was initiated in the

manufacturing industry

• STOCs is a process used in quality improvement

• It tests change on small scale, see how it works and refine as necessary before implementing on broader scale

• Applied by Institute of health care improvement, University of Maryland –HIV programs

3

Rationale

• Testing or adopting change

• Implementing an improvement

• To minimize resistance upon implementation

• Spreading the improvements to the rest of the organization

4

5

Map of Makueni County

Background • Kanzokea CU and link facility selected as

first site for implementing Small Test of Change

• (February 2013- January 2014)

6

Problems Identified Inadequate MNCH skills among health workers –Low quality of care

Inaccurate, incomplete & untimely reports by CHWs

Low skilled birth attendance 37.5%

Low ANC attendance (timely four visits) 49.5%

7

PDSA Model

The Model for Improvement was developed by Associates in Process Improvement

Methods Trained:• Two nurses from Kanzokea Health Centre on

BEmONC, and standards of quality care

• Two CHEWs on management of community health units and data quality

• 50 CHWs on basic packages of health and data management (MOH 513 & MOH 514)

8

Methods• Used Partnership Defined Quality (PDQ) model to

improve the quality and accessibility of services

• PDQ- Involved the community in defining, implementing, and monitoring the Quality Improvement (QI) process

• Facilitated formation and institutionalization of a QI Team (Quality improvement team) of 11 - comprising of SCHMT, facility and community members

9

Methods• Agreed to Monitor two Quality of Service Indicators

a) Use of partograph in the management of labour (correct plotting & Interpretation)

b) Community level data accuracy, timeliness and completeness

• Developed work plans to track progress over a period of twelve months

10

Methods• Together with the SCHMT conducted support supervision

and mentorship:

(i) To health workers on correct plotting and interpretation of partograph

(ii) To CHWs on community level data quality control

(Spot checks, accompanied interviews, and retraining CHWs during data collection)

11

ResultsIndicator 1: Quality of Care by health workers

12

• All health workers use partograph to monitor pregnant women during delivery

• Shows progress of labour, and when HWs should conduct deliveries and referrals if need be

• HWs fill partographs appropriately

F M A M J J A S O N D J0

5

10

15

20

25

30

35

40

STOCs- Kanzokea Health Centre

Skilled de-livery

Use of Par-tograph

Month (Feb 2013- Jan 2014)

Case

s

13

• Timely referral to higher level facilities

“When the health workers from Kanzokea Health centre refer pregnant women, they refer them with the client records as well as partographs. This assists the nurses from Makueni County Hospital to track the progress of labour and also take appropriate actions based on information on the partographs’’ (Angela* Not her real name)

• Kanzokea health centre utilizes the CU data other than population estimates for planning (Annual Work plan)

Results

Results

14

0

50

100

150

200

250

MaternalDeaths

NeonatalDeaths

SkilledDeliveries

ANCattendance

0 4

113

65

0 0

236

107

Case

s

Indicators

STOCs-Kanzokea Health Centre

Before STOCs

After 12 months

• CHWs track pregnant women, malnourished children

• CHWs collect accurate, timely & complete reports

• Skilled attended delivery improved from 37.5 % to 44.2 %

• Four ANC visits improved from 49.5 % to 54.8 %.

Indicator 2: Community level data from CHWs

Conclusions• The outcome of STOCs was positive and was

scaled up to 10 sites

• It’s a rigorous process, but once the QI team learns it becomes part of their work

• County Leadership is needed for continuous support

15

Recommendations • Need for stakeholders to use STOCs to improve

service delivery/quality

• Need to dialogue on impediments towards provision of quality services at the health facilities

(Use of PDQ model)

• Institutionalize the process of quality improvement since it enables to achieve results faster.

 

16

17

QIT members in meeting

Acknowledgements• Donor-Comic Relief

• Amref Health Africa- UK

• Kanzokea Community Unit

• Kanzokea Health Centre

• Ministry of Health- Makueni County

• Makueni Sub County Health Management Team

• Project team members - Mama na Mtoto wa Afrika

18