Ensuring the Fundamentals of Care in Family Planning and Reproductive Health Services MODULE 2 Facilitative Supervision for Quality Improvement Curriculum 2008

Fundamentals of Care They are a set of essential, basic elements that must be attended to if health care interventions are to be successful and sustainable. They are routine and basic; their finer points are not often well appreciated or understood. They require constant attention to ensure institutionalization with each new generation of providers and with each service or innovation introduced.

Main Areas of Focus Ultimate goal  Client and staff satisfaction CHOICE Ensuring informed and voluntary decision making SAFETY Assuring safety for clinical techniques and procedures QUALITY Providing a mechanism for ongoing quality assurance and management

Origins of Fundamentals of Care Evolved from the experience of technical assistance agencies in family planning (FP) and reproductive health (RH) interventions Underlie successes and lessons learned of past FP efforts Are built on the framework of clients’ rights and staff needs Draw heavily on quality improvement (QI) and performance improvement (PI)

What Value Do the Fundamentals of Care Add? Without giving the fundamentals of care sustained attention, no amount of innovation, evidence, or best practice can be integrated into programs and sustained. They can contribute to synergies between FP/RH interventions and services for HIV and sexually transmitted infections (STIs) and maternity care.

1: Ensuring Informed and Voluntary Decision Making How do you define informed and voluntary decision making? What must a client have, to be able to make an informed choice about his or her RH?

1: Ensuring Informed and Voluntary Decision Making (2) It is a process by which an individual arrives at a decision about health care, based on options, information, and understanding. To make an informed choice about his or her RH, a client must have access to service options and receive and understand the information relevant to making a decision.

1. Ensuring Informed and Voluntary Decision Making (3) What needs to be in place to ensure informed and voluntary decision making?

1. Ensuring Informed and Voluntary Decision Making (4) 1. Service options are available and accessible. 2. Providers give clients accurate information to aid them in the decision-making process. 3. Providers ensure effective counseling and client provider interaction. 4. Providers enable a voluntary decision-making process.

2: Assuring Safety for Clinical Techniques and Procedures Medical safety: –Is a critical issue for both clients and providers. –Relates to the procedures that are conducted and the clinical environment in which they are carried out.

2: Assuring Safety for Clinical Techniques and Procedures (2) What helps to assure safety for clinical techniques and procedures?

2: Assuring Safety for Clinical Techniques and Procedures (3) Clinical techniques and procedures are considered safe when: –Skilled providers practice according to updated, evidence based-standards and guidelines and infection prevention protocols. –Procedures are performed within a physical structure appropriate for managing clinical and surgical services.

2: Assuring Safety for Clinical Techniques and Procedures (4) Important steps for assuring safety: 1. Written medical guidelines, protocols, and standards are regularly updated and consistently implemented. 2. Providers perform FP/RH services according to up-to- date national standards 3. Providers correctly implement all infection prevention practices and procedures to protect clients and themselves.

2: Assuring Safety for Clinical Techniques and Procedures (5) Important steps for assuring safety (cont.): 4. Providers appropriately handle emergency situations. 5. Supervisors regularly conduct medical monitoring at the facility level to assess the readiness and the processes of service delivery and make recommendations for improvement. 6. Service statistics data are collected and used for decision making at the service-delivery level.

3: Providing a Mechanism for Ongoing Quality Assurance (QA) and Management What does it mean to have a mechanism for ongoing QA and management? Why is it important to have such a mechanism in place?

3: Providing a Mechanism for Ongoing QA and Management (2) Ensuring high-quality services is a continuous process requiring strong management mechanisms to create a positive enabling environment for service delivery. A well-managed organization is one in which systems for supervision, training, logistics, and monitoring and evaluation function effectively to provide high-quality services that satisfy its clients and increase demand.

3: Providing a Mechanism for Ongoing QA and Management (3) 1. QA mechanisms are implemented at the facility level to analyze and address service delivery issues. 2. Facilities and providers receive supportive supervision to create an enabling environment for service provision. 3. Providers have adequate knowledge and skills to perform their job.

3: Providing a Mechanism for Ongoing QA and Management (4) 4. Facilities have adequate infrastructure, supplies, and equipment to deliver quality services. 5. Providers have clear job expectations. 6. Providers regularly receive feedback on their performance. 7. Providers are adequately motivated to perform according to standard.

Why Are the Fundamentals of Care Important? They are the basic ingredients for the success and sustainability of FP/RH programs. People use FP longer if they choose methods for themselves, and access to a range of methods makes it easier for people to choose a method they like and to switch methods when they want. [1] [1] [1] Upadhyay, U.D Informed choice in family planning: Helping people decide. Population Reports, Series J, No. 50. Baltimore: Johns Hopkins University Bloomberg School of Public Health, Population Information Program.

Why Are the Fundamentals of Care Important? (2) Good quality of care offers practical benefits to FP/RH clients, service providers, and programs: [2][2]Kols, A. J., and Sherman, J. E Family planning programs: Improving quality. Population Reports, Series J, No. 47. Baltimore: Johns Hopkins University School of Public Health, Population Information Program. – Safety and effectiveness – Client satisfaction – Longer continuation – Expanded access to services [2][2] – Wider use of contraception – Job satisfaction for staff

The Resource Package What is it? How is it used? Why is it used?

How Is the Resource Package Used? Although for ease of use they are presented as separate guides, the fundamentals of care should be considered as a complete set and must be practiced together—it is not enough to have one without the others. The first column is a list of elements that comprise each fundamental of care. The elements are worded as performance statements.

How Is the Resource Package Used? (2) The second column lists the components of each element (i.e., what to look for to know that the “element” in the first column is in place). They can be converted into indicators for assessment, monitoring, and evaluation needs The third column lists tools and instruments to assess whether the different aspects of the fundamentals are being implemented. These materials can help in identifying performance gaps, calling for the need to implement appropriate interventions to address those gaps. The tools should be adapted appropriately to the specific context in which they would be used. –Consider locally developed tools, also.

Uses of the Resource Package Situation or needs assessment Programming (to plan and design interventions) Development of indicators to monitor interventions Monitoring and evaluation of the progress of changes Self-assessment of performance and of quality of services by staff/programs Checklist or guidance for supervisors Policy or standards development

Uses of the Resource Package

Fundamentals of Care: Exercise Work in three groups Group 1—Informed and voluntary decision making Group 2—Safety for clinical techniques and procedures Group 3—Mechanism for ongoing quality assurance and management

Fundamentals of Care: Exercise (2) In your small group, review the table corresponding to your assigned fundamental of care. Answer the following questions in relation to the your facility/subdistrict/district context: Which of the elements and descriptors have been the most difficult to ensure? With which of the elements or components have you had the most success?