1. Improving health care Nigel Livesley MD, MPH
Regional Director, South Asia
USAID ASSIST Project
University Research Co., LLC (URC)

2. 50% of women attending an ANC clinic did not get their BP and Hb measured

3. Implementation interventions (Tuncalp et al) http://www
Leadership and governance of quality
System re-design for implementation and scale up
Financial strategies to support improvement
Assessment and provision of resources
Engaging women, families, communities in their care
Education, training and supportive supervision for clinical and system activities
Data to support improvement
Learning communities for accelerating improvement
Theory, Evidence, Experience

4. 50% reduction in maternal
and newborn death

5. 50% reduction in maternal and newborn death
Provider-patient interaction

6. 50% reduction in maternal and newborn death
Provider-patient interaction
Appropriate resources
Appropriately skilled and motivated healthcare workers
Appropriate processes to deliver care

7. 50% reduction in maternal and newborn death
Provider-patient interaction
Appropriate resources
Appropriately skilled and motivated healthcare workers
Appropriate processes to deliver care
Leadership and governance

8. 50% reduction in maternal and newborn death
Provider-patient interaction
Appropriate resources
Appropriately skilled and motivated healthcare workers
Appropriate processes to deliver care
Provide resources
Financial strategies $$
Education and support
Learning communities
Data to support improvement
System redesign
Leadership and governance

9. 50% reduction in maternal and newborn death
Provider-patient interaction
Engaging women, families, and
communities in their care
Appropriate resources
Appropriately skilled and motivated healthcare workers
Appropriate processes to deliver care
Provide resources
Financial strategies $$
Education and support
Learning communities
Data to support improvement
System redesign
Leadership and governance

10. What approach should we use to improve this problem?

11. Poll 1: What strategy would you suggest we use to improve care at this hospital?
Leadership and governance of quality
System re-design for implementation and scale up
Financial strategies to support improvement
Assessment and provision of resources
Engaging women, families, communities in their care
Education, training and supportive supervision for clinical and system activities
Data to support improvement
Learning communities for accelerating improvement
I don’t know

12. 50% reduction in maternal and newborn death
Provider-patient interaction
Appropriate resources
Appropriately skilled and motivated healthcare workers
Appropriate processes to deliver care

13. The approach to fix this depends on the cause of the problem
Resource problem
Individual performance problem
Process problem

14. The approach to fix this depends on the cause of the problem
Resource problem
Individual performance problem
Process problem
Nurses lack equipment or supplies

15. The approach to fix this depends on the cause of the problem
Resource problem
Individual performance problem
Process problem
Nurses lack equipment or supplies
Approaches
Provide resources
Financing

16. The approach to fix this depends on the cause of the problem
Resource problem
Individual performance problem
Process problem
Nurses lack equipment or supplies
Nurses aren’t doing their job
Lack knowledge
Lack skills
Lack respect/empathy
Lack motivation
Approaches
Provide resources
Financing

17. The approach to fix this depends on the cause of the problem
Resource problem
Individual performance problem
Process problem
Nurses lack equipment or supplies
Nurses aren’t doing their job
Lack knowledge
Lack skills
Lack respect/empathy
Lack motivation
Approaches
Provide resources
Financing
Approaches
Training
Involve women
Supervision
Financing
Leadership

18. The approach to fix this depends on the cause of the problem
Resource problem
Individual performance problem
Process problem
Nurses lack equipment or supplies
Nurses aren’t doing their job
Lack knowledge
Lack skills
Lack respect/empathy
Lack motivation
The way service delivery is organized makes it hard for nurses to do their job
Approaches
Provide resources
Financing
Approaches
Training
Involve women
Supervision
Financing
Leadership

19. The approach to fix this depends on the cause of the problem
Resource problem
Individual performance problem
Process problem
Nurses lack equipment or supplies
Nurses aren’t doing their job
Lack knowledge
Lack skills
Lack respect/empathy
Lack motivation
The way service delivery is organized makes it hard for nurses to do their job
Approaches
Provide resources
Financing
Approaches
Training
Involve women
Supervision
Financing
Leadership
Approaches
System redesign
Use data

20. What approach should we use to improve this problem?

21. Huge variation from patient to patient and week to week

22. Poll 2: The cause of this variation is most likely to be:
Due to resource constraints
Due to staff with poor knowledge and skills
Due to staff with poor motivation
Due to inappropriate processes

23. THIS IS A PROCESS PROBLEM

24. Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station

25. Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station

26. Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station

27. Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station

28. Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station
Nurse’s station

29. What will be the effects of this new process?
It will make things worse
It will not change anything
It will make a minor improvement
It will make a major improvement
I don’t know

30. Improving processes of care…

31. …led to a nine fold increase in the number of women identified with risk factors
18 high-risk pregnancies identified (1.4%)
39 high-risk pregnancies identified (12.3%)

32. 50% reduction in maternal and newborn death
Provider-patient interaction
Engaging women, families, and
communities in their care
Appropriate resources
Appropriately skilled and motivated healthcare workers
Appropriate processes to deliver care
Provide resources
Financial strategies $$
Education and support
Learning communities
Data to support improvement
System redesign
Leadership and governance

33. Four steps to improve care
STEP 1: IDENTIFY THE PROBLEM, FORM A TEAM AND WRITE AN AIM STATEMENT STEP 2: ANALYZE AND MEASURE QUALITY OF CARE STEP 3: DEVELOP AND TEST CHANGES STEP 4: SUSTAIN CHANGES

34. Point of Care Quality Improvement Authored by AIIMS, WHO-SEARO, USAID ASSIST

35. Start with small problems and progressively solve and move on

36. Ingredients for success
Structures
QI Team and leadership
Attitudes
Curiosity
Skills
Humility
Optimism
Collaboration

37. Perinatal deaths/1000 births Jul-Nov 2013-2015

38. How a carpenter builds a chair

39. How a carpenter builds a chair

40. How a carpenter builds a chair

41. How should health services care for humans?

42. How should health services care for humans?