Building Quality Systems for Scale Nick Pearson

Jacaranda’s approach (1) We design better systems for delivering quality maternity care, (2) test and prove them in our own centers of excellence, (3) and then work with the government and private sector to replicate in the hospitals where most babies are born. Designing and delivering high-quality, cheap, respectful facility-based care – with solutions that address the key drivers of quality.

Jacaranda’s approach to improving Quality QUALITY GAP Hospital systems and processes Nurse/midwife capacity and knowledge Respectful care OUR SOLUTION Clinical excellence and Quality Improvement Empowering the next generation of midwives Patient centered design TOOLS FOR SCALE Lean six sigma Evidence based clinical protocols and checklists Better technology/measurement Onboarding / orientation Mentorship and training Career ladder and specialization Design of services / touchpoints SMS interaction with clients We design and test these tools in our facilities and then work to scale the most replicable ones through partners.

Nurse/midwife capacity and knowledge

Hospital systems and processes

Spaghetti Diagram of Outpatient Flow: Prior State Reception Pharmacy Lab Exam Room1 Exam Room 2 Medical Records Client comes to reception Return with file to enter client records Send client to exam rooms 1 2 3 Send client for lab tests Client return to exam room Check drug availability & pricing Client confirm if can afford drugs Nurse dispenses drugs Client exits 4 Pay bill 10 5 6 7 8 9

Spaghetti Diagram of Outpatient Flow: Current State Cashier Pharmacy Lab Exam Room1 Exam Room 2 Medical Records Clients pulled into exam rooms Go to Lab for tests Client collects drugs from Pharmacy 1 Reception 2 4 5 3 Pay bill

measurement Implementation science: now that the maternal health community knows what maternal health interventions work, we need to measure how to implement them at scale. Systems for monitoring and evaluation Research

Patient respect / patient-centered care

Our theory of Change 1. Jacaranda Maternities 2. Replicate at partner hospitals 3. Scale what works DESIGN BETTER SYSTEMS ADAPT THE BEST INNOVATIONS TOOLS to TEST TOOLS to SCALE BUILD PARTNERSHIPS TEST WITH PATIENTS / NURSES TEST WITH PILOT PARTNERS ITERATE AND IMPROVE ITERATE AND IMPROVE BUILD CAPACITY/PARTNERS TO ROLL OUT MEASURE IMPACT / COST MEASURE IMPACT / COST Lean six sigma Nurse leadership SMS/FP interventions

Our theory of Change: A. Our maternities Jacaranda Maternities Success to date Class-leading health outcomes Increasing sustainability of our facilities Demonstrated effectiveness as an “innovation laboratory” for implementation research DESIGN BETTER SYSTEMS PILOT PACKAGE TEST WITH PATIENTS / NURSES ITERATE AND IMPROVE MEASURE IMPACT / COST 2012-2015 Lean six sigma Nurse leadership SMS/FP interventions

OUR Maternity results: health outcomes and behaviors

OUR Maternity results: health outcomes and behaviors One of 7 SafeCare level 3 hospitals in Kenya Home-based postnatal CHW checklist = mothers 80% more likely to visit healthcare facilities after birth 100% early initiation of breastfeeding. Over 90% still exclusively breastfeeding at 9-week postpartum – nearly 3x the national average. 97% of our clients would recommend us to a family member or friend. Postpartum family planning uptake 56% = 6x higher than the national average. Over 60% of Jacaranda’s clients choose long-term methods. Over 60% of women who receive reminder messages return for visits 78% return for maternal or infant postpartum care in the first six weeks. Increasing conversion from ANC to Delivery – 2x increase in the last year to over 50% PRENATAL CHILDBIRTH POSTNATAL POSTPARTUM FP

Improving sustainability and cost-effectiveness Earned revenue up 6x since a year ago. 2nd clinic 50% breakeven in June. Improved client conversion in retention and delivery – nearly 50% of ANC clients deliver, up from 25% in 2014 Cost per high-quality delivery = <9,000 KES

Our theory of Change 1. Jacaranda Maternities 2. Replicate at partner hospitals 3. Scale what works DESIGN BETTER SYSTEMS ADAPT THE BEST INNOVATIONS TOOLS to TEST TOOLS to SCALE BUILD PARTNERSHIPS TEST WITH PATIENTS / NURSES TEST WITH PILOT PARTNERS BUILD CAPACITY/PARTNERS TO ROLL OUT ITERATE AND IMPROVE ITERATE AND IMPROVE MEASURE IMPACT / COST MEASURE IMPACT / COST Lean six sigma Nurse leadership SMS/FP interventions

Our theory of Change: B. Partner hospitals Replicate at partner hospitals Success to date Kiambu County Partnership Piloting in 3 facilities, doing over 200 deliveries/month Rolled out lean QI engagement. Plan to test our other low-cost innovations through these partners – SMS outreach, nurse training, etc. ADAPT THE BEST INNOVATIONS TOOLS to TEST TOOLS to SCALE TEST WITH PILOT PARTNERS ITERATE AND IMPROVE MEASURE IMPACT / COST Lean six sigma Nurse leadership SMS/FP interventions

What we are excited about Helping support and execute the framework provided by KQMH Building leadership and community in quality improvement in the facility landscape. Working with other partners to replicate our innovations.