1. Improving QoC in deliveries in public sector hospitals Approaches to Measuring Quality in Bihar

2. Context CARE’s Bihar TSU: multidimensional support to Health and ICDS programs: Started with 8 districts, now covers all 38 Includes all OUTREACH and FACILITY level interventions aimed at reducing MMR, NMR, U5MR, TFR, malnutrition (and elimination of Visceral Leishmaniasis) Focus on making the most effective and feasible interventions a reality Large program team: Technical support / guidance at State level Catalytic technical, operational support at district and block levels Independent measurement team Large pilots for testing specific approaches / interventions

3. Context of public sector hospitals High case loads in block PHCs – JSY driven Poor infrastructure, supplies, hygiene Deliveries conducted by dais (Mamta) Near-absence of clinical records Near-absence of clinical rounds / reviews No difference in care provided at block / district levels CEmONC available only in 6 medical college hospitals, a few private nursing homes in district towns: CS rates in public sector < 2%

4. Quality parameters Basic infrastructure, equipment, supplies Basic hygiene, sanitation GNM/ANM to conduct ‘normal’ deliveries Protocolized care: triage, monitoring of labor, AMTSL, management of neonate, postnatal care, identification-stabilization-referral of complications Clinical records to include critical information on patient’s condition, care provided and outcomes Emergency CS rates to improve

5. Interventions QI process, through non-clinical project staff Infrastructure, supplies etc Goal setting for specific processes, outcomes Nurse mentoring at BEmONC level facilities Bedside + practicals + ‘theory’ Simulations for complications management Nurse+Doctor mentoring at CEmONC level facilities Clinical reviews: All maternal/neonatal complications 10% of ‘normal’ deliveries

6. Approaches to measuring quality: ‘Monitoring’ Clinical events and outcomes data maintained by nurse mentors Log of progress of individual nurse mentees, maintained by nurse mentors Check-ins by Block Managers 2-3 times / week: Numerical summary of delivery cases, and outcomes Telephonic or physical tracking postpartum of all complications and sample of normal deliveries Documentation of gaps identified during clinical reviews Improved clinical records

7. Approaches to measuring quality: ‘Evaluation’ Direct observation of Deliveries Periodic independent assessments by trained observers Limited to ‘normal’ deliveries (labor monitoring, AMTSL, postnatal care, delays in care provision) Exit interviews, including patient perceptions of care provided Difficult to standardize and randomize Assessment of complications management in CEmONC facilities Evaluating videos of simulation exercises Household surveys: Specific practices during hospital stay Advice and guidance provided during hospital stay Overall outcomes, procedures, etc

8. Sample DoD data Indicators Before Mentoring (%) After Mentoring (%) Blood Pressure measured at least once in labour room 14.925.3 Foetal Heart Rate checked at least once after admission 3.815.4 Correct Hand Washing procedures followed14.036.8 Sterile delivery instruments or kits used13.043.5 Attendant wore gloves76.090.4 Oxytocin correctly administered for AMTSL8.658.5 Warm temperature maintained in labour room 11.346.8 Skin to skin care initiated30.962.5 Breast feeding initiated in labour room49.171.5

9. What next? Challenges: Scale Broken traditions of clinical / hospital care Information systems not geared to measure what matters Monitoring data must come from (long term solution): improved clinical records, reviewed regularly Population level reviews based on ‘HMIS’ Evaluations – continue to experiment with combination of direct observation and household level assessments