Dr. Nigel Livesley, USAID ASSIST Project

Making changes in the health facility:
skills for improving the care of mothers and

babies
Nigel Livesley, MD, MPH
India Project Director
USAID ASSIST Project
South Asia Regional Director
University Research Co.
1
Three useful ideas
USAID Applying Science to Strengthen and Improve Systems
Degrees of implementation
(Fixsen DL et al 2005)
Paper implementation
The new idea remains in paper form
Process implementation
The superficial processes associated with a new idea are
put in place
Performance implementation
The new idea actually leads to improved benefit
Paper implementation
Guidelines and standards
put in place
People are trained
Monitoring of quality of care
Decreased mortality and morbidity
Paper implementation (90% of efforts)
put in place
Improving health service delivery organisational performance

in health systems.
Pallas et al. International Health 4 (2012) 2029
Leadership and management

(supervision)
Organisational structure
Standards and guidelines
(accreditation)
Knowledge and skills enhancement

Incentives
Process re-engineering
Organisational culture
People mean different things when they say

quality improvement
1. Management approach for front line workers to
improve processes (Juran)
2. Organizational development approach based
on systems and complexity theory (Deming)
People mean different things when they say

quality improvement
1. Management approach for front line workers to
improve processes (Juran)
2. Organizational development approach based
on systems and complexity theory (Deming)
3. Specific interventions that come out of
definition 1
4. Quality assurance=quality improvement
5. Anything that can improve quality of care
Implementation at a single facility

Focusing on what didnt work
Lessons for implementation
Implementation at large scale

ASSIST overview
Selected results
Integrating into existing government systems

Chamba district, India
General approach
Maternal mortality in a Delhi hospital in 2013

5854 deliveries
Pt.
Cause
1.
Age of the Time of death after

patient
delivery
22
96 hrs
2.
20
20 hrs
PPH
3.
21
6 hrs
PPH
4.
22
4 hrs
PIH
5.
21
24 hrs
PPH
PPH
Women assessed only twice in six hours

after delivery
9
# of times vitals taken
8
7
6
5
4
3
2
1
0
Jan-wk1
Jan-wk3
Feb-wk1
Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1
Apr-wk3 May-wk1 May-wk3
Ju-wk1
Ju-wk3
Average number of times vitals recorded within first 6 hrs of birth

What changes could the team make?
How can higher levels support change?
First idea: management directive
9
8
Change idea: Letter from medical

superintendent instructing labour and
delivery room staff to assess women 6 times
in the first 6 hours. Week 4, January 2014
6
5
4
3
2
1
0
Jan-wk1
Jan-wk3
Feb-wk1
Ju-wk1
Ju-wk3

Success!
9
8
7
6
5
4
3
Letter from
superintendent
Week 4, January 2014
2
1
0
Jan-wk1
Jan-wk3
Feb-wk1
Ju-wk1
Ju-wk3

Success! Or is it?
Massive overcrowding
in labour room
7
6
5
4
Tools:
Leadership
Standards
Incentives
3
2
1
0
Jan-wk1
Jan-wk3
Feb-wk1
Ju-wk1
Ju-wk3

What feedback should you give to the

team?
Success! Or is it?
9
8
Massive overcrowding
No action to address
crowding for 1 week
6
5
4
3
2
1
0
Jan-wk1
Jan-wk3
Feb-wk1
Ju-wk1
Ju-wk3

9
8
A Letter from the Boss doesnt affect

systemic issues
7
6
5
4
3
2
1
0
Jan-wk1
Jan-wk3
Feb-wk1
Ju-wk1
Ju-wk3

9
8
A Letter from the Boss doesnt affect

systemic issues
Not testing the letter led to a week of

problems
6
5
4
3
2
1
0
Jan-wk1
Jan-wk3
Feb-wk1
Ju-wk1
Ju-wk3

Addressing overcrowding
9
8
7
6
Clarified that women should be

discharged to ward
Made some changes in efficiency

of assessment
4
3
2
1
0
Jan-wk1
Jan-wk3
Feb-wk1
Ju-wk1
Ju-wk3

Sustained improvement!
9
8
7
6
5
4
3
2
1
0
Jan-wk1
Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3
Ju-wk1
Ju-wk3


team?
Sustained improvement! Or is it?
9
8
7
6
5
What are we trying to accomplish?
Doing assessments or identifying and

managing women in danger?
3
2
1
0
Jan-wk1
Ju-wk1
Ju-wk3

0.16% of women identified with

complications
9
8
7
6
5
4
3
2
1
0
Jan-wk1
Ju-wk1
Ju-wk3
Number of women with danger signs identified in PNC ward

0.16% of women identified with

complications
9
8
7
6
5
4
3
2
Lots of change in assessment;

not much improvement in care
1
0
Jan-wk1 Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3 Ju-wk1
Ju-wk3


team?
What changes could the team make?
How can higher levels support change?
Improving ability to identify and

management women with complications
9
8
7
6
5
What the team did differently:
4
3
2
1
0
Ju-wk3


9
8
7
6
5
4
3

Identified the root cause of
poor assessment
2
1
0
Ju-wk3


9
8
7
6
5
4
3
2

poor assessment
Used small scale tests to
learn what works
1
0
Ju-wk3


9
8
7
6
5
4
3
2
1

poor assessment
Used small scale tests to
learn what works
Focused on the aim
Ju-wk3

Women with complications are now 12

times more likely to be identified early
New system
of care
9
8
Observation
room
6
5
Partnering
with patients
4
3
2
1
0
Ju-wk3

Sustained improvement and NO MATERNAL

DEATHS in post partum ward
3.0%
number of times women were assessed

in first 6 hours
2.5%
2.0%
5
1.5%
4
% of women identified with

complications and managed
appropriately
1.0%
2
0.5%
1
0.0%
Jan
Feb
March
April
May
June
July
Aug
Sept
Oct
Sustained improvement and NO MATERNAL

DEATHS in post partum ward
Tools:
Leadership
Standards
Incentives
9
3.0%
Process redesign
Organizational culture
2.5%
number of times women were assessed

in first 6 hours
2.0%
5
1.5%
4
% of women identified with

complications and managed
appropriately
1.0%
2
0.5%
1
0.0%
Jan
Feb
March
April
May
June
July
Aug
Sept
Oct
Lessons learned
1. Standards and instructions from management
dont fix all problems
2. Small scale testing is necessary for solving some
problems
3. Focus on the right aim
1. so what?
General principles for problem solving
Subject
knowledge
Context
knowledge
Change
method
ASSIST overview
USAID Applying Science to Strengthen and Improve

Systems (ASSIST) is a five-year project of the Office
of Health Systems of the USAID Global Health Bureau
designed to:
Improve health and social services at scale
Strengthen host country capacity to improve care
Learn and share knowledge about improvement
globally
ASSIST has worked in 24 countries
Scale of USAID ASSIST Activities, FY13-FY14
222 government and

implementing partners
4,339 facility based

improvement teams
994 community based improvement

teams
124 million catchment population
ASSIST India
349 improvement teams
12-17,000 deliveries
per month
30% of deliveries in
27 High Priority
Districts
Births per country in 2010

(1000s of births)
Tajikistan
194
193
184
181
180
179
Eritrea
Azerbaijan
Netherlands
India supportedsites
sites
ASSIST ASSIST
India supported
Tunisia
Paraguay
Liberia
Israel
Central African Republic
Jordan
Congo
Libya
Lao People's Democratic Republic
Nicaragua
State of Palestine
Kyrgyzstan
El Salvador
Belgium
Mauritania
Greece
Czech Republic
Sweden
Serbia
Cuba
Turkmenistan
158
157
156
156
154
145
144
140
138
137
131
126
123
118
117
116
113
110
110
109
If ASSIST-supported
sites in India were their
own country, they
would rank 88th out of
180 countries in the
world in total deliveries,
just behind Azerbaijan
and the Netherlands
What we do
Support team-based problem solving at facility and

community level
Support peer-to-peer learning between networks of
teams
Support government to incorporate these
approaches into their systems
Seven steps to support team-based

problem solving
Decide what problem you want to fix

Get a team together to fix it
Identify the causes of the problem
Develop a simple measurement system
Come up with some possible solutions
Test the solutions on a small scale
Implement the effective solutions
Support networks between teams based on

peer-to-peer learning
Multiple sites simultaneously
testing changes, common
indicators, peer learning
about how to improve that
area of care
Learning
Session
Collaborative-level sharing
and synthesis of best
practices
Site-level summary
QI team
representative
QI team
QI team
site
site
QI team
site
QI team
QI team
site
site
QI team
QI team
site
site
QI team
site
QI team
site
QI team
site
Site-level testing of changes

and analysis of results
Continuum of care
Aims
District Hospital
Community
Health Centre
Primary Health
Centre
Sub-centre
Community
Routine care
- Active management of
3rd stage of labor
- Essential newborn care
- Improving ANC
- Improving PNC
Complication
care
- Management of anemia
- Neonatal resuscitation
- PPH management
- Management of pre/ -eclampsia
- Prevention and control
of infection
- Other
- Improving ANC (BP, Hb, weight, counseling)

- Early registration
- Identification of danger signs
- Identification of severe anemia
- Promotion of institutional delivery
Improving routine care for over 15 000

pregnancies and deliveries per month
100%
Newborns breastfed in first hour

90%
80%
70%
Hb checked
60%
50%
40%
Vitamin K
30%
20%
10%
Oxytocin
0%
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14
Improving routine care for over 15 000

pregnancies and deliveries per month
100%
Newborns breastfed in first hour

90%
80%
70%
Hb checked
60%
50%
40%
Vitamin K
30%
Tools used:
- Standards
- Process re-engineering
- Culture change
20%
10%
Oxytocin
0%
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14
Improvement in recording and drug

management
Refrigerator
Oxytocine
Room temp
50 USAID Applying Science to Strengthen and Improve Systems
Improved organization and cleanliness
51 USAID Applying Science to Strengthen and Improve Systems
After building improvement

skills on routine care, teams
move on to complications care
52
Practice of ENC in 11 facilities in Delhi
Delivering baby on mothers

abdomen
1,9
Kangaroo Mother Care
0,0
Immediate drying
11,11
Inj. Vit K to all newborns

10,10
Delayed cord clamping

0,9
Breast feeding within 1 hour

of birth
9,11
Sterile cord clamping

11,11
Avoid prelacteals
11,11
No. of Facilities practising before training
Improvement after mentorship/process

improvement support
abdomen
1,9
0,0
Immediate drying
11,11

10,10

0,9

of birth
9,11

11,11
Avoid prelacteals
11,11

No. of facilities practising after 1 month
Tools for improvement

abdomen
1,9
0,0
Immediate drying
11,11

10,10

0,9

of birth
9,11
Avoid prelacteals
11,11

No. of facilities practising after 1 month

11,11
Tools used:
- Skills building
- Process reengineering
- Culture change
NR equipment readiness
Availability of mucous suckers
6.9
Practice of cleaning/disinfecting
Availability of masks & bag
after every use
11,11
1,9
Practice of checking before
every delivery
0,4
Ready to use masks & bag

5,9
Use of NB care unit

10,9
Tubing for Oxygen

10,11
Functional NB care unit

11,11
Oxygen source
8,11
No. of facilities having before training
Improvement after mentorship/process improvement

support
Availability of mucous suckers
6.9
Practice of cleaning/disinfecting
Availability of masks & bag
after every use
11,11
1,9
Practice of checking before
every delivery
0,4
Ready to use masks & bag

5,9
Use of NB care unit

10,9
Tubing for Oxygen

10,11
Functional NB care unit

11,11
No. of facilities having before training
Oxygen source
8,11
No. of facilities having 1 month after training
Tools used:
- Skills building
- Process reengineering
- Culture change
Perinatal mortality all ASSIST supported sites

10 000 15 000 deliveries per month
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Jul-13
Sep-13
Nov-13
Jan-14
Baseline mortality 2.35%
Mar-14 May-14
Jul-14
Sep-14
Nov-14
Jan-15
Current mortality 2.07%
Transfer of improvement
skills into government
systems
59
India: Timeline of activities in Chamba District

Nov
2013
Dec
2013
Jan
2014
Feb
2014
Mar
2014
In December 2013,
ASSIST supported 5
facilities in Chamba
to set up QI teams
Apr
2014
May
2014
In May 2014, the
District Chief Medical
Officer requested
ASSIST support the
rest of the district
They began to
achieve some
impressive results
Impressive!
Timeline of activities in Chamba District

May 2014
Jun 2014
Jul 2014
Aug 2014
In July and August 2014,

ASSIST worked with the district
to plan scale up of activities.
ASSIST
MOHFW
Sep 2014
Oct 2014
Nov 2014
In September 2014,
ASSIST trained 38
new facilities and 10
government coaches
Going forward
Coaches will provide on-site
coaching support to facilities
These 43
facilities cover
35% of the
births in this
district of
540,000 people
2 Block Medical Officers will oversee

the work
Improvement reports will be included
in monthly district meetings
District will organize quarterly
peer-to-peer learning sessions
37 of 38 facilities supported by government

coaches collecting and reporting data and
showing initial signs of improvement
100%
80%
Iron
supplementation
60%
Oxytocin at
delivery
40%
>2gm inc in Hb
20%
ANC Hx and Px
0%
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
General principles of setting up a system

for quality improvement
Facility and community-based improvement
teams
Team support system
Leadership component

teams
Team-based QI
ID problems that need to be solved at other levels
Team support system


teams
Team-based QI
Team support system

Support QI skills development
Spread good ideas between teams
Support multi-level problem solving

teams
Team-based QI
Team support system

Support QI skills development
Spread good ideas between teams
Support multi-level problem solving
Set goals
Encourage problem identification and solving
Fix problems at their level
Encourage learning
For more information and resources please visit:
www.usaidassist.org
Or contact
nlivesley@urc-chs.com
Baseline perinatal mortality in Jama CHC

Dumka District, Jharkhand
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
May.14
Jun.14
Jul.14
Aug. 14
Sep.14
Oct.14
Nov.14
Dec.14
Jan.15
Feb.15
Changes in perinatal mortality in Jama CHC,

4.0%
3.5%
Improvement team working on

neonatal resuscitation and
partograms
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
May.14
Jun.14
Jul.14
Aug. 14
Sep.14
Oct.14
Nov.14
Dec.14
Jan.15
Changes in perinatal mortality in Jama CHC,

4.0%
3.5%

partograms
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
May.14
Jun.14
Jul.14
Aug. 14
Sep.14
Oct.14
Nov.14
Dec.14
Jan.15
Perinatal mortality including when mothers

and babies are referred to other facilities
9
8
Improvement team working

on neonatal resuscitation and
partograms
7
6
5
4
3
2
1
0
May.14
Jun.14
Jul.14
Aug. 14
Sep.14
deaths in hosp
Baseline
2.4% babies died in hospital
2.4% babies died after referral
Oct.14
Nov.14
Dec.14
Jan.15
deaths in ref
After improvement work

1.7% babies died in hospital
1.0% babies died after referral
Improved management and decreased

referrals of moribund babies
0.08
0.07

partograms
0.06
0.05
0.04
0.03
0.02
0.01
0
Jun.14
Jul.14
Aug. 14
Baseline mortality 4.8%
Sep.14
Oct.14
Nov.14
Dec.14
Jan.15
Feb.15
Intervention mortality 2.7%

How does performance compare between facilities with

improvement aims and those without improvement
aims?
100%
90%
Teams NOT TRYING to

improve Hb measurement
80%
70%
60%
50%
40%
30%
20%
10%
0%
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Women attending clinics which are aiming to improve

Hb measurement are now more likely to get their Hb
measured
100%
90%
Teams NOT TRYING to

improve Hb measurement
80%
70%
60%
50%
40%
30%
Teams TRYING to improve

Hb measurement
20%
10%
0%
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Antenatal care in Mandi, Himachal Pradesh
Denominator: Number of ANCs conducted per week in Mandi, Himachel Pradesh (average = 45.6)
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
W-2
W-1
W-3
W-2
W-1
W-5
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-5
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
100
80
60
40
20
0
Mar-14
Antenatal care in Mandi, Himachal Pradesh

Percentage of ANCs during which BP and Hb were measured
in Mandi, Himachal Pradesh, July 2013-March 2014
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
% BP measured
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
W-2
W-1
W-3
W-2
W-1
W-5
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-5
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
% Hb measured
Mar-14
Denominator: Number of ANCs conducted per week in Mandi, Himachel Pradesh (average = 45.6)
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
W-2
W-1
W-3
W-2
W-1
W-5
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-5
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
100
80
60
40
20
0
Mar-14
Mandi, Himachal Pradesh case study

Number of high-risk pregnancies identified and percentage of ANCs during which
BP and Hb were measured in Mandi, Himachel Pradesh
# high-risk identified
% BP measured
% Hb measured
12
100%
90%
10
80%
70%
60%
50%
40%
30%
20%
10%
0%
Jul-13
Aug-13
Sep-13
Oct-13
18 high-risk
pregnancies
identified (1.4%)
Nov-13
Dec-13
Jan-14
Feb-14
W-2
W-1
W-3
W-2
W-1
W-5
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-5
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
W-4
W-3
W-2
W-1
0
Mar-14
39 high-risk
pregnancies
identified (12.3%)

Dr. Nigel Livesley, USAID ASSIST Project

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Making changes in the health facility:

skills for improving the care of mothers and

Three useful ideas

USAID Applying Science to Strengthen and Improve Systems

USAID Applying Science to Strengthen and Improve Systems

USAID Applying Science to Strengthen and Improve Systems

Improving health service delivery organisational performance

Leadership and management

Knowledge and skills enhancement

People mean different things when they say

USAID Applying Science to Strengthen and Improve Systems

People mean different things when they say

USAID Applying Science to Strengthen and Improve Systems

Implementation at a single facility

Implementation at large scale

Integrating into existing government systems

USAID Applying Science to Strengthen and Improve Systems

Maternal mortality in a Delhi hospital in 2013

Age of the Time of death after

USAID Applying Science to Strengthen and Improve Systems

Women assessed only twice in six hours

# of times vitals taken

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Average number of times vitals recorded within first 6 hrs of birth

What changes could the team make?

USAID Applying Science to Strengthen and Improve Systems

How can higher levels support change?

USAID Applying Science to Strengthen and Improve Systems

First idea: management directive

Change idea: Letter from medical

# of times vitals taken

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Average number of times vitals recorded within first 6 hrs of birth

# of times vitals taken

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Average number of times vitals recorded within first 6 hrs of birth

# of times vitals taken

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Average number of times vitals recorded within first 6 hrs of birth

What feedback should you give to the

USAID Applying Science to Strengthen and Improve Systems

# of times vitals taken

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Average number of times vitals recorded within first 6 hrs of birth

A Letter from the Boss doesnt affect

# of times vitals taken

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Average number of times vitals recorded within first 6 hrs of birth

A Letter from the Boss doesnt affect

# of times vitals taken

Not testing the letter led to a week of

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Average number of times vitals recorded within first 6 hrs of birth

# of times vitals taken

Clarified that women should be

Made some changes in efficiency