1. Improving the quality of maternal & newborn health in Makueni county using small test of change (STOCs): the case of Kanzokea community unit Oruko Happiness 1, Gitimu Anne 1, Karijo Evalin 1 1 AMREF Kenya 1

2. Outline Background Rationale Methods Results Conclusions & Recommendations 2

3. Background Quality Improvement was initiated in the manufacturing industry STOCs is a process used in quality improvement It tests change on small scale, see how it works and refine as necessary before implementing on broader scale Applied by Institute of health care improvement, University of Maryland –HIV programs 3

4. Rationale Testing or adopting change Implementing an improvement To minimize resistance upon implementation Spreading the improvements to the rest of the organization 4

5. 5 Map of Makueni County

6. Background Kanzokea CU and link facility selected as first site for implementing Small Test of Change (February 2013- January 2014) 6 Problems Identified Inadequate MNCH skills among health workers – Low quality of care Inaccurate, incomplete & untimely reports by CHWs Low skilled birth attendance37.5% Low ANC attendance (timely four visits)49.5%

7. 7 PDSA Model The Model for Improvement was developed by Associates in Process Improvement

8. Methods Trained: Two nurses from Kanzokea Health Centre on BEmONC, and standards of quality care Two CHEWs on management of community health units and data quality 50 CHWs on basic packages of health and data management (MOH 513 & MOH 514) 8

9. Methods Used Partnership Defined Quality (PDQ) model to improve the quality and accessibility of services PDQ- Involved the community in defining, implementing, and monitoring the Quality Improvement (QI) process Facilitated formation and institutionalization of a QI Team (Quality improvement team) of 11 - comprising of SCHMT, facility and community members 9

10. Methods Agreed to Monitor two Quality of Service Indicators a)Use of partograph in the management of labour (correct plotting & Interpretation) b)Community level data accuracy, timeliness and completeness Developed work plans to track progress over a period of twelve months 10

11. Methods Together with the SCHMT conducted support supervision and mentorship: (i)To health workers on correct plotting and interpretation of partograph (i)To CHWs on community level data quality control (Spot checks, accompanied interviews, and retraining CHWs during data collection) 11

12. Results Indicator 1: Quality of Care by health workers 12 All health workers use partograph to monitor pregnant women during delivery Shows progress of labour, and when HWs should conduct deliveries and referrals if need be HWs fill partographs appropriately

13. 13 Timely referral to higher level facilities “When the health workers from Kanzokea Health centre refer pregnant women, they refer them with the client records as well as partographs. This assists the nurses from Makueni County Hospital to track the progress of labour and also take appropriate actions based on information on the partographs’’ (Angela* Not her real name) Kanzokea health centre utilizes the CU data other than population estimates for planning (Annual Work plan) Results

14. 14 CHWs track pregnant women, malnourished children CHWs collect accurate, timely & complete reports Skilled attended delivery improved from 37.5 % to 44.2 % Four ANC visits improved from 49.5 % to 54.8 %. Indicator 2: Community level data from CHWs

15. Conclusions The outcome of STOCs was positive and was scaled up to 10 sites It’s a rigorous process, but once the QI team learns it becomes part of their work County Leadership is needed for continuous support 15

16. Recommendations Need for stakeholders to use STOCs to improve service delivery/quality Need to dialogue on impediments towards provision of quality services at the health facilities (Use of PDQ model) Institutionalize the process of quality improvement since it enables to achieve results faster. 16

17. 17 QIT members in meeting

18. Acknowledgements Donor-Comic Relief Amref Health Africa- UK Kanzokea Community Unit Kanzokea Health Centre Ministry of Health- Makueni County Makueni Sub County Health Management Team Project team members - Mama na Mtoto wa Afrika 18