1. Quality Improvement An Introduction
Rajesh Mehta
Regional Adviser for Newborn, Child and Adolescent Health, WHO-SEARO New Delhi

2. Reduction in Maternal and Child Mortality
Significant reduction in preventable mortality occurred between 1990 and 2015 in SEAR:
Maternal mortality declined by 64%
Child mortality declined by 69%
Neonatal mortality declined by 54%
Decline was not enough to reach MDG 4 and 5 targets despite increased coverage of MNCH interventions
One of the reason is poor quality of care….
Over the last two decades considerable progress was made towards the achievement of the targets set for the Millennium Development Goals (MDGs) 4 and 5 by However, despite the increased coverage of maternal and child health interventions, many women, newborns, and children continue to die from preventable deaths due to poor care practices, even after reaching a health facility.

3. Point of Care Quality Improvement
WHO Collaborating Center for Training and Research in Newborn Care
WHO defines quality of care
“…the extent to which health care services improve desired health outcomes….
Timely, Effective, Safe, Efficient, Equitable, People-centered”.
WHO vision Every mother and newborn receives quality care throughout the pregnancy, childbirth and postnatal periods
ENAP-EPMM-Global Strategy-SDG-3
Universal Health Coverage
provide all mothers and newborns access to the health care system with good quality and financial protection

4. Basic needs for good quality care at the health facility
Point of Care Quality Improvement
WHO Collaborating Center for Training and Research in Newborn Care
Basic needs for good quality care at the health facility
Cost-efficiency
Infrastructure: Physical space, electricity, water, clean, safe surroundings
Health workers: appropriate number and competencies
Standard treatment guidelines are available and practiced
Equipment, medicines, supplies, lab
Case monitoring and actionable information
Patient communication, respect and satisfaction
Safety

5. Logical Framework Inputs – Process- Outcome
Policies
Physical infrastructure including basic amenities
Finances
Resources: People, Equipment, Supplies, Drugs
Information Technology for case records. monitoring
Support services and provisions for accompanying persons

6. Process Logical Framework Inputs – Process- Outcome
Content of Care
Process of Care
National Standards & Protocols
Flow of actions for patient care at HF
TRG in
Clinical competencies
QI capacity of HCP teams

7. Improving Quality of care
Quality Planning
Improving Quality of care
Quality Control
Inputs
Content of Care
Process of Care
Improved Outcomes
Policies Finances
Infrastructure
Resources: People
Equipment
Drugs
Information
Technology
Engage clients
No complications
Low case fatality rate
Decreased hospital stay
Patient satisfaction
National Standards & Protocols
Flow of actions for patient care at HF
TRG in
Clinical competencies
QI capacity of HCP teams

8. Health system GLOBAL FRAMEWORK FOR QUALITY OF CARE
Point of Care Quality Improvement
WHO Collaborating Center for Training and Research in Newborn Care
Structure
Health system
Quality of Care Framework
Process
PROVISION OF CARE
1- Evidence based practices for routine care and management of complications
2- Actionable information systems
3- Functional referral systems
EXPERIENCE OF CARE
4- Effective communication
5- Respect and dignity
6- Emotional support
GLOBAL FRAMEWORK FOR QUALITY OF CARE
7- Competent and motivated human resources 
Outcome
8- Essential physical resources available
Individual and facility-level outcomes
Coverage of key practices
People-centred outcomes
Health outcomes

9. Standards 1-3 (Provision of Care)
1- Evidence based practices for routine care and management of complications
2- Actionable information systems
3- Functional referral systems
Standards 4-6 (Experience of Care)
4- Effective communication
5- Respect and dignity
6- Emotional support
Standards 7-8 (Cross cutting)
7- Competent and motivated human resources 
8- Essential physical resources available
Global Standards for MNH

10. Regional Framework for QOC
Point of Care Quality Improvement
WHO Collaborating Center for Training and Research in Newborn Care
Regional Framework for QOC

11. Regional QI framework: Systematic process
Getting started: Preparation
Develop / adapt national standards of care and assessment tool
Assessment of current quality of care and identify gaps in quality
Improvement process:
Create improvement teams
Root cause analysis of the quality gap
Identify appropriate solution
Implement the selected solution: Collaborative approach
Reassessment: To find out if implementation of the solution has addressed the quality gap
Success:
Sustain: Supportive supervision, mentoring, continuous re-assessments
Celebrate: Recognition, award
Pick-up another quality gap and set in the improvement process
Disseminate for scaling-up
Failed: Apply another solution!
7. Scale up

12. Regional Plan and Country Actions: Two Tracks
Point of Care Quality Improvement
WHO Collaborating Center for Training and Research in Newborn Care
Regional Plan and Country Actions: Two Tracks
Track - 1
Country Actions
Strengthen leadership and governance: National and sub-national Units / Cells
Adopt Global standards for MNH care
Unified National Framework
Plan of action with budget
Situation analysis - Assessment of QOC
Adopt National Framework and Action Plan
Strengthen National and subnational support structures for QI
Actions at:
National level
State-District level
Health Facility level

13. Regional Plan: Track – 2 Build capacity for QI at Health Facility
Point of Care Quality Improvement
WHO Collaborating Center for Training and Research in Newborn Care
Regional Plan: Track – 2 Build capacity for QI at Health Facility
QI at Health Facilities:
Improvements can be achieved with local action, usually without additional resources
Main steps:
Identify the problem area in quality of care
Identify the causes of the problem
Make changes to improve the quality of care – implement and learn
Sustain the changed process (if successful)
Actions at:
National level
State-District level
Health Facility level

14. Regional Plan: Track – 2 Build capacity for QI at Health Facility
Point of Care Quality Improvement
WHO Collaborating Center for Training and Research in Newborn Care
Regional Plan: Track – 2 Build capacity for QI at Health Facility
Tools for building capacity for QI at Health Facilities:
In-service training / coaching
On the Job mentoring – Supportive Supervision
Pre-service education
E-Learning resources
Collaborative learning platform
Actions at:
National level
State-District level
Health Facility level

15. POCQI Point of Care Quality Improvement

16. QI at Point of Care in health facility POCQI-4 Steps model
STEP 1: IDENTIFY THE PROBLEM, FORM A TEAM AND WRITE AN AIM STATEMENT
STEP 2: ANALYZE THE PROBLEM AND MEASURE QUALITY OF CARE
STEP 3: DEVELOP AND TEST CHANGES
STEP 4: SUSTAIN CHANGES

17. THANKS Quality is never an accident…
It is always the result of intelligent efforts!