1. Sustaining Quality Improvement through Regional Capacity Building Paul Blumenthal, MD, MPH Global Medical Director- PSI Professor of Obstetrics and Gynecology Director, SPIRES Stanford University

2.  “Top Down” Perceived as potentially punitive M&M model Guilt and Blame Intermittent with little continuity Outside - In Traditional Approach to “Quality”

3. Often initiated with new services after an adverse event Needs to be built from the ground up Will need outside support during the building process Eventually, inside - out Realities of QA/QI Implementation

4. “Clinical” Services Offered

5. “STANDARDS” Training Evaluation Service Delivery

6. 1.Technical Competency 2.Client Safety 3.Informed Choice 4.Privacy and Confidentiality 5.Continuity of Care Five Components of PSI Service Delivery Standards

7.  Observations  Conclusions  Recommendations  Action Plan Audit “Matrix” O, C R AP

8.  Enhance local capacity for local supervision  Enhance local/regional expertise in QA/QI programs and philosophies  Enhance likelihood of “sustainable” network (and possible QA/QI programmes)  Enhance ability to put the audit recommendations to work Regionalization Strategy

9.  58 total External Audits.  26 regional Auditors trained – representing 14 countries. – Consistent with a “cascade” approach  Regional teams have carried out service quality audits in 14 countries.  Feedback from more senior auditors, programs, and the newly trained auditors: –regional auditors gaining the skills to lead future audits. –the use of regional staff has facilitated cross program learning – the training process itself has improved internal quality assurance systems in the trainee’s programs. Regionalization Progress: 2008-2015

10.  Regionally based staff –Audit training/experience –Leadership qualities Clinical AND Programmatic  Enhanced role: –Audit follow up (current) Development of Action Plans and follow through CME – Webinars, Clinical Updates –Audit Response (SIFPO-II) Increases Regional focus –Total Audit/QA Process (Goal) –Adverse event management, adjudication and drills Regionalization Evolved: Quality Assurance Regional Leaders (QARL)

11.  Combination of External and Internal Audits plus routine supportive supervision is an effective quality improvement strategy  Can be undertaken in non-threatening, constructive manner  The regionalization of auditor pool and instutionalization of both internal audits and routine supportive supervision has the potential to be “sustainable”  Sustainability will depend on –Level of internal commitment –Local commitment to fund QA/QI activities – Ability of “QA Regional Leads (QARLs) to provide continuing guidance and feedback, eventually eliminating the need for primary GMD oversight Conclusions

12. Thank you.