Recording and materials from the webinar: Quality improvement for newborn health - from local solutions to national network

Sunita Devi, (right) with her newborn baby at Government community health center (CHC) in Chanho, District Ranchi, Jharkhand, India, in October 2012. ©UNICEF/Sing

6.10.17

The Network for Improving Quality of Care for Maternal and Newborn Health (Quality of Care Network) just organized a webinar on ‘Quality improvement for newborn health: from local solutions to national learning network’.

Listen to the recording

See the presentation

Dr Vikram Datta, Director Professor, Department of Neonatology, Lady Hardinge Medical College, New Delhi, presented how a medical college in New Delhi started using quality improvement (QI) techniques to address hypothermia in newborns and subsequently reduce newborn mortality. He explained how his team then gradually connected with other health professionals and spread its learnings and know how to create a self sustained learning network dedicated to QI for newborns.

To date, the National Quality of Care Network  in India includes nine states and is working to expand its reach. 

Dr Datta explained the prerequisites to establish such a network and encouraged participants to start their quality improvement work without waiting for more resources, staff or time. 

His presentation was followed by a Q&A session, which we will shortly include below.  

 

Comments

Is Lady Hardinge Medical College a govenment hospital or a private one?

ANSWER: It is a Government facility directly under the  Government of India.

How did you motivate healthcare staff and other staff to improve the quality of care?

ANSWER:

We involved all cadres of healthcare workers in the improvement process and thereby increased their self-esteem and motivation level. They received ongoing coaching support and were connected to each other via virtual platforms as well. Initial results from KSCH with decline in mortality was a significant motivational factor for other teams who wanted to achieve similar results in their settings.

I am interested to hear when you refer to no added resources what internal resources you had to mobilise - in terms of the time and effort of existing staff in your facility and elsewhere - to make this progress

ANSWER:

The internal resources we had to mobilise were our time and efforts to start and sustain the quality improvement (QI) projects .The staff learnt efficient ways of working and the satisfaction of fixing their problems themselves made them walk that extra mile to implement the QI processes in the unit. The major effort required from our side to make this progress was to have an open and effective communication with all team members.

How important do you feel it has been to have travel between your centre and the ones you are improving (and how did you pay for any travel?)

 

ANSWER:

Well, I have addressed this in my coaching finances slide. The facilities paid for the onsite coaching. It is very important for onsite coaching to occur initially, but later it can be replaced with virtual coaching via Zoom or Webex or Whats App to save time and money. In case finances are available or facilities are close to your set up onsite mentoring is desirable.

How you have calculated Patient Days?

ANSWER:

We calculated it as follows:

Numerator was the event e.g. death or LONS

Denominator was the total exposed during the specified period e.g. Sum total of the Census of the in patient facility for that specified period.

This was multiplied by 1000 to give rate per 1000 patient days.

Of course it is a remarkable reduction (in newborn deaths). Any analysis to show how much of this mortality reduction was due to reductions in hypothermia?

ANSWER:

We started another QI project on LONS reduction by intensive hand washing using glogerm solution as a monitoring tool from 23 Jan 2017 along with the ongoing hypothermia project. Hence , the effect on mortality reduction reflected here is cumulative for both changes. Due to paucity of time the other dataset was not discussed here.

Is hypothermia the most common cause of neonatal death in India? Is that why you did QI for it?

ANSWER

No, the most common cause according to contemporary data is neonatal sepsis followed by birth asphyxia and prematurity. Hypothermia is a common finding across all neonatal units world over. It is a great improvement project for initial projects as it is objectively measurable and relatively easy to fix. The early results help improvement teams to embark on the journey of QI more enthusiastically.

Instead of expand, you better say scale up as it is an appropriate QI terminology.

 

ANSWER

Thanks, I agree.

It is really very nice to know...Sensitisation, pre-warmed towel and transporting incubator worked to reduce moderate hypothermia. How you are planning to expand in Bihar (and till which level- Tertiary or till Primary health care centres)?

ANSWER

Thanks. We have visited Bihar in connection with SNCU monitoring visits and have proposed to concerned officials the need for QI in Bihar SNCUs. If invited by State Health Society, NQOCN will be happy to assist in rolling out QI across the state in a phased manner.

Thank you Dr.Datta. Did you require ethics approval for your work?

 

ANSWER

The Ethics committee was informed in advance about the ongoing hypothermia reduction and LONS reduction works. It was mentioned by them that as it is routine improvement work it does not come under the ECHR (Ethics Committee for Human Research) purview.

It is good that you suggested there is no need to wait for executive order for QI. But if financial & other support is needed, is that not good to work with the leadership from the very beginning?

 

ANSWER

Yes we agree, the leaders need to be on board from the start. In our case they are on board, the Child Health Division of the Government of India is involved in all our workshops, the Advisors of NHM , Directors of Lady Hardinge Medical College, GMC Aurangabad, Heads of Departments of all medical college of New Delhi and Chairpersons of QI Cell of KSCH have been a part of the process from initiation. Financial support is something which comes only when the leadership is on board .When I said we need not wait for an executive order to start QI I meant picking up your problems, forming a team, writing an aim, doing a root cause analysis, analysing the problem and conducting PDSA cycles. None of these require any approval. But if you wait for some written order from your facility’s head asking you to start QI work it will be too late.

Can QI be a part of accreditation process of a hospital? If yes, do we have some such successful models?

ANSWER

QI is the next logical step after quality assurance (QA). We have proved this with our work in Meghalaya State.

Major accreditation documents have a section on processes but they are assessed in a snapshot view. No ongoing assessment is done, no coaching and mentoring is done. Hence, making it a part of the current accreditation process may be inaccurate.

Each unit practicing QI has its unique milieu, assessing them accurately requires constant and long term connect with the unit. This is not possible with an accreditation process which occurs once in 2-3 years. Units have a tendency of falling back in improvement processes if left unmonitored or without adequate system strengthening.

Do you have national clinical practice guidelines for neonatology in India?

 

ANSWER

Yes, we have National Clinical Guidelines. The most widely followed guidelines are the Facility Based Newborn Care (FBNC) guidelines of Government of India.

How did you mobilise the Govt of Madhya Pradesh & Meghalaya to pull out resources meanwhile the Govt is completely focused on Quality Assurance Work i.e. National Quality Assurance Standard?

 

ANSWER

Like I have mentioned before, they had no funds in PIP for QI related works. In MP we piggybacked on the mentoring budget and added the QI components during my visits to Katni and Jabalpur SNCUs. In Meghalaya, the initial thrust was provided by USAID ASSIST which partially funded the coaching support. NHM Meghalaya had some funds under the training heads and QA programs which were used for capacity building of the SNCU staff.

I wanted to know whether results were shared between different QI teams in the network, and if so - did the members of the teams perceive this as motivating?

ANSWER

Yes, as I have mentioned we had a major experience sharing meeting in New Delhi in March and Hubli in January. Besides this we are having a major South India experience sharing meeting in Bangalore on 15 October. We also have monthly QI meetings in New Delhi where teams share their experiences. Such meetings also have webinars and guests attending remotely.

This is very motivating for the participants and cross-learning is facilitated.

Does the NQOCN host the data from the member facilities and if so do you have a formal data governance structure in place?

ANSWER
NQOCN is planning to host a National Registry of improvement data soon. This will be on purely voluntary basis. A data governance plan will be in place before data reporting and hosting on the registry is started. Currently, only that data is shared which has been authorised to be shared by the host facility.

What system do you have in place to ensure validity and quality of the QI data?

 

ANSWER

The validity and quality of data is monitored by onsite coaches and team leaders. It is randomly checked from source documents if need arises.

Do you have a data dictionary and standard operating procedures to standardise data collection across the participating facilities?

 

ANSWER

The participating facilities follow the basic data collection and reporting format as has been developed and mentioned in the WHO Point of Care Quality Improvement manual. All units follow that.

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