Use of Clinical Standards for improved Quality of Maternal and Newborn Care

Dr.Somesh Kumar Team Leader: Maternal Health/Family Planning MCHIP/India

GMHC, Arusha 16th January 2013

Objectives of the presentation

Give an overview of the approach and process adopted Share the results from the program

Need..
Tremendous increase in institutional deliveries in Indiafrom 700,000 (2005) to 1.1 Million (2012) Increased load on existing public health facilities Compromise in QoC, observed in multiple studies/ assessments Gap in translation of protocols/guidelines/trainings to practice Even the facilities teaching midwifery do not adhere to the protocols Need for a practical, cost-effective programmatic approach to improve adherence to protocols in labor rooms

The approach: Standards Based Management and Recognition

Translation of protocols into an easy to use tool, containing standards & their verification criteria Use of performance assessment tool to measure actual level of performance (Baseline assessment) Compare to desired level of performance Identify gaps/causes Desired
performance

Devise site specific customized action plan Implement the action plan Conduct Periodic Internal assessments ( 3-6 month )

Gap

Cause analysis

Actual performance

Intervention identification & 4 implementation

Guiding Principles
Applied at the level of facility Includes the highest impact interventions for ante-,intra- and immediate postpartum care Has components related to Inputs: commodities, equipments and infrastructure Evidence based practices Needs an on-site clinical update of the providers for its implementation Should be implemented in through a inclusive process

The Process

Share the clinical standards with the stakeholders

Orient the clinical providers to the 21 standards

Conduct baseline assessment of facility with the providers

Provide Clinical Update

Support the implementat ion of clinical standards

Periodic assessments of facility with providers using same standards

Clinical standards
21 clinical standards applied at the clinical practice sites of the health facilities linked to nursing-midwifery institutions They can be broadly classified into: Area
Antenatal Care Labour room: Intra-partum Family planning Equipments at the clinical site Total

Number of standards
4 12 1 4 21

Standard 10: AMTSL

The provider performs active management of the third stage of labor. Observe two women during a delivery and determine whether the provider (in the labor or delivery rooms): Palpates the mothers abdomen to rule out the presence of a second baby Tells the woman that she will receive an injection, and administers 10 IU of oxytocin IM Clamps the cord near the perineum and Holds the cord and clamp with one hand Places the other hand just above the womans symphysis pubis (over the sterile towel) and gently exerts pressure upwards Maintains gentle but firm traction on the cord and waits for the uterus to contract Upon contraction, applies gentle but firm and sustained downward traction on the cord with counter force above the pubis to guard the uterus, until the placenta is expelled Once the placenta bulges at the vaginal introitus, assists its expulsion with both hands, by turning it clockwise over in the hands, without applying traction, teasing out the membranes to roll them out Checks whether uterus is contracted Massages the uterus with one hand on a sterile cloth over the abdomen, until it contracts firmly

Standard 11: ENBC

The provider properly conducts a rapid initial assessment and provides immediate newborn care. . In the labor or delivery rooms, observe two women with their newborns in the immediate postpartum period and determine whether the provider : Receives and dries the baby vigorously with a sterile dry towel from head to feet, cleans the babys eyes with sterile gauze, and determines whether the baby is breathing Discards the used towel and covers the baby, including the head, with a clean, dry towel If the baby does not begin breathing or is breathing with difficulty, asks assistance, rapidly cuts and ties the cord, and initiates resuscitation If the baby is breathing normally, places the baby in skin-to-skin contact on the mothers chest or abdomen and encourages immediate breastfeeding Informs the mother of the babys condition Clamps and cuts the cord using sterile instruments as soon as the cord has stopped pulsating Places an identification bracelet on the baby

Improvement in Clinical Standards

Baseline
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 14% 5%
CMC, GCON, Ludhiana Vadodara CMC, Vellore NRSM, Kolkatta St District District District District District Stephes Hospital Hospital, Hospital, Hospital, Hospital, Hospital, Chaibasa Giridih Simdega Gadarpur Ranipokri Delhi

Current status (Dec 2012)

90% 95% 80% 70% 85% 81% 71%

90% 81% 81%

52% 40% 33% 14% 15% 15% 20% 40%

Improvement in Practices
Baseline
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
0%
Educating women on warning signs during pregnancy

Current status (December 2012)

100% 90% 90% 100% 90%

100% 90%

100%

70%

50%

30% 20% 10% 0%

Birth preparedness development of a birth plan Includes member of family for antenatal counseling

0%
Use of partograph Provider Cord clamping Initiating Prepration of performs AMTSL within 1 to 3 Breastfeeding Chlorine properly minutes within 1st hour of Solution for birth decontamination

Improvement in Practices
Baseline
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 90% 80% 70% 70%

Current Status (December 2012)

90% 80% 80% 90%

50% 40% 40% 20% 10% 10% 0%

Receiving the Manangement Provision of Monitoring the Verification of Properly Infection woman in of PPH as per essential newborn till resuscitation performs prevention labor in GoI protocols newborn care discharge equipment for resuscitation practices cordially appropriately functionality of the followed newborn appropriately Emergency drug tray is available

40%

The Framework For Improving Quality of Care Through Checklist Use

Adherence to practices

Accountability

SCC

Supervision

Supplies

Quality of Care

Successes
Demystifies the concept of quality for the frontline providers/faculty It is a self assessment approach and hence is self motivating. Enables the providers/faculty to operationalize quality improvement processes It is very objective It is a simple and easy to understand tool. It shows what to do and how to do things for quality improvement. It is measurable and quantifiable Provides a framework for infrastructural/HR improvements Provides a framework for supportive supervision Recognition is an integral part of the process which motivates for quality improvement

Contributions
Dr.Bulbul Sood Dr.Sudarshanam Balasubranyam Ms.Princy Fernando Dr.Rashmi Asif and the entire MCHIP India team.

Thanks