Social and Behavior Change, Provider Behavior, and Quality of Care

CORE Group Meeting May 19, 2016

Chelsea Cooper On Behalf of:

MCSP Quality Team

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• Growing global body of QI approaches, but evidence still needed (esp around effective & sustainable approaches)

• Under-focused area of SBC – need for more applications of SBC lens, as much of QoC work has behavioral and interpersonal dimensions

• Improve health outcomes by providing respectful and technically sound services, delivered according to standards known to maximize health impact.

• Client and community perceptions of quality can affect utilization of services.

Why Quality and Provider Behavior?

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• health care delivery occurs as part of an interaction between a health care provider and the client and community;

• provider performance is affected and motivated by a wide range of factors in the provider’s immediate environment;

• the health system is responsible for providing inputs and processes that service providers need to deliver quality services, including infrastructure, supervision, and management

Underlying Considerations

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Quality Aims for MCSP

High quality care is: Effective: Adherent with evidence-based standards Safe: does not harm patients Timely: care provided when needed People centered: Respectful of patient needs, values & preferences Coordinated: services for a single client are coordinated across time and levels of care Institute of Medicine, 2001, Crossing the Quality Chasm

A Framework for Continuously Improving Quality of Care

Conceptualizing Quality:

Moving beyond Inputs and building blocks…. (Source: Donabedian)

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1. What is done

2. How it is done

• Patient health status/outcomes

• Change in health behavior

• Patient perception and experience of care

• Human resources

• Infrastructure • Materials

(i.e. vaccine) • Information • Technology

Structure (inputs)

Process

Outcomes

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STANDARDIZATION FOCUSED PROBLEM-SOLVING

OPEN PROBLEM-SOLVING

PROCESS REDESIGN

GOVERNANCE

PURPOSE Regularity Improvement towards target

Find solutions to complex problems

Optimize flow of activities

Whole organization involvement

PROCESS SDSA PDSA PDSA Reengineering Systemic improvement

TOOLS Process mapping, check-lists, assessment tools

Root-cause analysis, team implementation

Appreciative enquiry, collective solutions

Process-mapping, quality function deployment

Education, clinical audit, risk management, openness, research

POTENTIAL BEST FIT

New programs, no best-practices in place, multiple issues

Need to address key specific issues

Multiple complex issues with limited evidence (e.g. community)

Need for efficiency and value-added gains

Multi-level system improvement

EXAMPLES SBM-R, accreditation, certification, 5-S, check-list

TQM/CQI (Kaizen), Six Sigma, BSC, Health/QUAL, “collaboratives”

PDQ, Citizen Voice and Action, Community Score Card

Lean, reengineering

CCM, Clinical governance, REC-QI, RAPID

Adapted by Edgar Nocea from S. Hacker, B. Jouslin de Noray, and C. Johnston, European Quality, European Quality Publications, Ltd; London; 2001

Ilustrative Taxonomy of Quality Approaches

MCSP QI Principles

• Measurable clear aims focused on important health outcomes for which high-impact interventions exist

• Prioritization of needs, values and desires of clients • Engaging health worker hearts and minds to improve care –

Motivation; leadership, QI, clinical, management skills

• Focus on understanding and overcoming critical gaps (bottlenecks) in local care processes and health systems

• QI team work - representatives all system functions

• Change management strategy driven by local actors

• Real-time use of data (i.e. tracking process and outcome measures.)

• Regular shared learning to accelerate improvements at scale

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SBC(C) and Quality of Care

In terms of….

• Provision of care

• Experience of Care

WHO Quality of Care Framework for Childbirth

Source: BJOG 2015

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Identified QI Implementation Interventions

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The implementation interventions identified were then consolidated into 11 categories as follows:-

1. Leadership of quality 2. Planning, designs and policies for implementation or scale-up 3. Financial strategies to support improvement 4. Assessment and provision of resources 5. Engaging women, families, communities in their care 6. Education and training for clinical and system activities 7. Supportive supervision of clinical and system activities 8. Adaptive designs for implementation or scale up 9. Data to support improvement 10. Learning communities for accelerating improvement 11. Governance of quality

Lessons from MCHIP

Guinea SBM-R • Three urban health

facilities already implementing SBM-R for MNH/FP.

• Six months • 34 performance standards.

Zimbabwe SBM-R • Adapted one year after SBM-R

was introduced for MNH • Implemented in 21 health

facilities • Three years 2011 to 2013 • 38 standards

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Evidence of immediate positive influence on provider’s adherence to agreed performance standards.

No firm conclusions on SBM-R’s scalability and sustainability

Case Study: Respectful Maternity Care in Ethiopia

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The Maternal Child Health Integrated Program in Ethiopia

• Service delivery interventions: Integrated Maternal & Newborn health (MNH) in 4 regions = 119 facilities (104 Health Centers, 12 hospitals) from 2011 – 2013

• Package of interventions centered on Quality Improvement Approach –Standards-Based Management and Recognition™ (SBM-R): Verifiable, objective standards to measure performance (RMC practices

integrated into quality standards) Providers & managers measure actual performance against standards &

identify gap filling to reach desired performance Competency-based skills training to ensure essential package of MNH

services Development of job aids, posters District health offices provided with small grants to support &

facilitate SBM-R

Integrated into existing training, supervisory support 15

Findings & Recommendations • Quality Improvement i.e. SBM-R intervention facilities

performed better in provision of RMC practice from observation (e.g. respectful reception, explaining every step, encouraging questions, woman allowed to give birth in position of choice, woman never left alone during labor, privacy ensured)

• No difference found between study groups on disrespect and abuse experienced

Recommendations: • Quality improvement approaches should look at integrating

RMC as part of MNH care • RMC needs to take clients’ views into consideration when

designing and promoting care; more attention to “experience” of care

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Low Dose, High Frequency Training in Ghana (Jhpiego)

Traditional Approach • Off-site group-based training • 12-day BEmONC package • Limited number from each

facility

LDHF • “On-the-Job, on-site training” • Shorter training, repetition

(high frequency) • Local ownership, whole team

participation • Simulation and training with

low-cost models • Supportive use of technology • Mentorship, master mentors • On-site peer support and

practice post training

Reinforcement and reminders: mMentoring

• Text messages and quiz questions sent to all training participants

• Option to “opt out” • Messages are sent Monday – Friday • 16 thematic areas over 6 month period • PPCs receive mentoring phone calls

from Master Mentors • Master Mentors receive mentoring

phone calls from Jhpiego team

Performance of Master Mentors, 3 Regions, September 2014 – September 2015

79%

56%

91% 91% 95% 95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Knowledge Assessment OSCE

Pre-training Post-training 1 year post intervention

Performance of Service Providers: 10 facilities, September 2014 – September 2015

84%

47%

94% 90%

93%

71%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Knowledge Assessment OSCE

Pre-training Post-training 1 year post intervention

Coming Soon: Age and Stage in Nigeria • Health workers will be supported with age- and

stage-specific counseling tools for each type of contact in a health facility with young people.

• Health workers will be oriented on adolescent development, best practices, and age-specific counseling skills to address adolescents’ needs.

• Young people will be actively engaged in quality improvement process through Partnership Defined Quality for Youth (PDQ-Y). Girls and boys will define and support a quality improvement process in collaboration with community leaders and health workers.

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Takeaways

• Quality improvement is a behavior change intervention! • SBC(C) and QoC in terms of provision of care and experience

of care [further efforts needed around experience of care] • Need for further cross-fertilization between SBC and QoC

practitioners; apply SBC evidence, principles, processes

• Need for more focus on SBC(C) at point of service delivery • Consider respectful, client centered care approaches beyond

RMC • Explore opportunities to strengthen “change agency” role of

health workers • Pair QI efforts with HSS

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For more information, please visit www.mcsprogram.org

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not

necessarily reflect the views of USAID or the United States Government.

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