Change agent or troublemaker – engaging stakeholders and making change.
Implementing Change in northern India.Umass-BostonOct 21, 2014
Robyn Churchill, CNM, MSN
Goals of this presentation:
1. Understand barriers to change2. Learn one framework for building lasting
change3. Draw lessons learned from India and apply to
case study
Plan for today:
Using 5 element framework for implementing systems change:
1. Review experience of BetterBirth project in northern India
2. Use lessons learned to address implementation plan for case study
What is needed for change?
Supportive Environment
Knowledge
Skills
Resources
Motivation
Barriers-Resistance
Initial Response to Resistance
Barriers
Expect Resistance
Barriers
Understand Resistance by Listening
Barriers-Resistance
Outsmart Resistance
Increase Drivers
Decrease Resistance
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
Approach to Implementing Change
Make local modifications
Understand processes (map them)Adapt to local policy and standardsConsider resources and barriers
Approach to Implementing Change
Identify team and champions
Who needs to be involvedIdentify early adoptersConsider role for resistorsRecognize and develop championsBuild coaches/on going mentors
Approach to Implementing ChangeCollect and USE data to learn and
iterate
Identify metrics of importanceinputsprocessoutputsoutcomes
Create meaningful and individual reportsregularcustomizedreal-time
Develop system for regular review with front line staffshow what you know (successes, areas for improvement)learn from front line experience
Approach to Implementing Change
Build capacity/plan for sustainability
Identify existing structure to plug intoIdentify owners of processLocate systems for funding, supervision, monitoringCreate policy-facility, regional, national
BetterBirth Safe Childbirth Checklist Implementation
Uttar Pradesh India
Moments of Greatest Risk
Conception
Antenatal period
Admission to birth facility
Delivery
Discharge from birth facility
28 days
42 days
Mat
erna
l & n
eona
tal m
orta
lity
risk
Time
Moments of Greatest Risk
Conception
Antenatal period
Admission to birth facility
Delivery
Discharge from birth facility
28 days
42 days
Mat
erna
l & n
eona
tal m
orta
lity
risk
Time
Check point #1 On admission
Check point #2Just before pushing(or before Cesarean)
Check point #3 Soon after birth (within 1 hour)
Check point #4 Before Discharge
Safe Childbirth Checklist Program
Safe Childbirth Checklist Program
Objective: Measure health worker performanceAdherence 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
Gokak Pilot Study
After
Before
0 5 10 15 20 25 30
9.8 (9.4, 10.1)
Essential childbirth practices delivered (n=29)
25 (24.6, 25.3)
Gokak Pilot Study
Safe Childbirth ChecklistSingle center pilot, Karnataka, India
Indicator (selection) Baseline Post-Intervention
Hand washing and gloving 1.3% 97.8%
Breastfeeding initiation within one hour of birth 50.4% 90.6%
Routine administration of Oxytocin within 1 minute after birth
8.4% 68.9%
PLoS One 2012;7(4):e35151
Stakeholders
Government of Uttar PradeshGovernment of India
World Health OrganizationGates Foundation
Ariadne Labs (BWH/HSPH)Population Services International
Community Empowerment Lab, LucknowJNMC Medical College, Belgaum
Stakeholders
District LeadersFacility LeadersMedical Officers
NursesANMs (Auxiliary Nurse Midwives)
Stakeholders
District LeadersFacility LeadersMedical Officers
NursesANMs (Auxiliary Nurse Midwives)
Ward AyasSweepers
ASHAsWomen
Mothers in law
Stakeholders
Local Modifications
What factors would you consider in making local modifications? Whose input counts?
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
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
Data
Sustainability
What is needed to build sustainability?
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
Digital Data Collection (Apps)
M and EData*
Improvement in implementation
The Goal: for learning and improvementProgram management
Implementation of intervention and of research activities
*M and E data include inputs, activities, outputs and selected short term outcomes from routine program data
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.
Sustainability
Make it work there: Local adaptation and modification• GoI Checklist• Identify local owners• Identify birth team (official and unofficial)
Sustainability
Don’t reinvent the wheel: Integration into existing systems
• Build on Quality Improvement systems
• Build and support local ownership
Coordinating with GoI QA: Childbirth Quality Improvement Structure
NRHM – GoI
NRHM – GoUP (State QA Comm)
CMO/DHO (forms District QA Comm)Nodal officer/nurse mentor
MOIC (forms internal QA Comm)LMO, Childbirth Quality Nurse = Sr. Nurse
Nurse/ANM/Other staff
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
The MOH of Odyssia has invited you in to direct implementation of an immunization program 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:1. What other information would be useful?2. Who do you talk with first?3. Identify the first 3 steps you would take
What do you do?
a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers
Task ShiftingOr
Task Sharing
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
Stakeholders
Local Modifications
What factors would you consider in making local modifications? Whose input counts?
Team and Champions
How do you select your team (trainers, first trainees, supervisors?)
Data
How do you use it?
Why is it important?
What data do you collect?
Sustainability
What is needed to build sustainability?