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Making changes in the health facility:

skills for improving the care of mothers and


babies
Nigel Livesley, MD, MPH
India Project Director
USAID ASSIST Project
South Asia Regional Director
University Research Co.
1

Three useful ideas

USAID Applying Science to Strengthen and Improve Systems

Degrees of implementation
(Fixsen DL et al 2005)
Paper implementation
The new idea remains in paper form

Process implementation
The superficial processes associated with a new idea are
put in place

Performance implementation
The new idea actually leads to improved benefit

USAID Applying Science to Strengthen and Improve Systems

Degrees of implementation
(Fixsen DL et al 2005)
Paper implementation
The new idea remains in paper form
Guidelines and standards

Process implementation
The superficial processes associated with a new idea are
put in place
People are trained
Monitoring of quality of care

Performance implementation
The new idea actually leads to improved benefit
Decreased mortality and morbidity
USAID Applying Science to Strengthen and Improve Systems

Degrees of implementation
(Fixsen DL et al 2005)
Paper implementation (90% of efforts)
The new idea remains in paper form

Process implementation
The superficial processes associated with a new idea are
put in place

Performance implementation
The new idea actually leads to improved benefit

USAID Applying Science to Strengthen and Improve Systems

Improving health service delivery organisational performance


in health systems.
Pallas et al. International Health 4 (2012) 2029

Leadership and management


(supervision)

Organisational structure
Standards and guidelines
(accreditation)

Knowledge and skills enhancement


Incentives
Process re-engineering
Organisational culture
USAID Applying Science to Strengthen and Improve Systems

People mean different things when they say


quality improvement
1. Management approach for front line workers to
improve processes (Juran)
2. Organizational development approach based
on systems and complexity theory (Deming)

USAID Applying Science to Strengthen and Improve Systems

People mean different things when they say


quality improvement
1. Management approach for front line workers to
improve processes (Juran)
2. Organizational development approach based
on systems and complexity theory (Deming)
3. Specific interventions that come out of
definition 1
4. Quality assurance=quality improvement
5. Anything that can improve quality of care

USAID Applying Science to Strengthen and Improve Systems

Implementation at a single facility


Focusing on what didnt work
Lessons for implementation

Implementation at large scale


ASSIST overview
Selected results

Integrating into existing government systems


Chamba district, India
General approach

USAID Applying Science to Strengthen and Improve Systems

Maternal mortality in a Delhi hospital in 2013


5854 deliveries
Pt.

Cause

1.

Age of the Time of death after


patient
delivery
22
96 hrs

2.

20

20 hrs

PPH

3.

21

6 hrs

PPH

4.

22

4 hrs

PIH

5.

21

24 hrs

PPH

PPH

USAID Applying Science to Strengthen and Improve Systems

Women assessed only twice in six hours


after delivery
9

# of times vitals taken

8
7
6
5
4
3
2
1
0

Jan-wk1

Jan-wk3

Feb-wk1

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

What changes could the team make?

USAID Applying Science to Strengthen and Improve Systems

How can higher levels support change?

USAID Applying Science to Strengthen and Improve Systems

First idea: management directive

9
8

Change idea: Letter from medical


superintendent instructing labour and
delivery room staff to assess women 6 times
in the first 6 hours. Week 4, January 2014

# of times vitals taken

6
5
4
3
2
1
0

Jan-wk1

Jan-wk3

Feb-wk1

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

Success!

9
8

# of times vitals taken

7
6
5
4
3

Letter from
superintendent
Week 4, January 2014

2
1
0

Jan-wk1

Jan-wk3

Feb-wk1

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

Success! Or is it?

Massive overcrowding
in labour room

# of times vitals taken

7
6
5
4

Tools:
Leadership
Standards
Incentives

3
2
1
0

Jan-wk1

Jan-wk3

Feb-wk1

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

What feedback should you give to the


team?

USAID Applying Science to Strengthen and Improve Systems

Success! Or is it?

# of times vitals taken

9
8

Massive overcrowding

No action to address
crowding for 1 week

6
5
4
3
2
1
0

Jan-wk1

Jan-wk3

Feb-wk1

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

9
8

A Letter from the Boss doesnt affect


systemic issues

# of times vitals taken

7
6
5
4
3
2
1
0

Jan-wk1

Jan-wk3

Feb-wk1

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

9
8

A Letter from the Boss doesnt affect


systemic issues

# of times vitals taken

Not testing the letter led to a week of


problems

6
5
4
3
2
1
0

Jan-wk1

Jan-wk3

Feb-wk1

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

Addressing overcrowding

9
8

# of times vitals taken

7
6

Clarified that women should be


discharged to ward

Made some changes in efficiency


of assessment

4
3
2
1
0

Jan-wk1

Jan-wk3

Feb-wk1

Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1

Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

Sustained improvement!

9
8

# of times vitals taken

7
6
5
4
3
2
1
0

Jan-wk1

Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

What feedback should you give to the


team?

USAID Applying Science to Strengthen and Improve Systems

Sustained improvement! Or is it?

9
8

# of times vitals taken

7
6
5

What are we trying to accomplish?

Doing assessments or identifying and


managing women in danger?

3
2
1
0

Jan-wk1

Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Average number of times vitals recorded within first 6 hrs of birth


USAID Applying Science to Strengthen and Improve Systems

0.16% of women identified with


complications
9
8

# of times vitals taken

7
6
5
4
3
2
1
0

Jan-wk1

Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3

Ju-wk1

Ju-wk3

Number of women with danger signs identified in PNC ward


Average number of times vitals recorded within first 6 hrs of birth
USAID Applying Science to Strengthen and Improve Systems

0.16% of women identified with


complications
9
8

# of times vitals taken

7
6
5
4
3
2

Lots of change in assessment;


not much improvement in care

1
0

Jan-wk1 Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3 Ju-wk1

Ju-wk3

Number of women with danger signs identified in PNC ward


Average number of times vitals recorded within first 6 hrs of birth
USAID Applying Science to Strengthen and Improve Systems

What feedback should you give to the


team?

USAID Applying Science to Strengthen and Improve Systems

What changes could the team make?

USAID Applying Science to Strengthen and Improve Systems

How can higher levels support change?

USAID Applying Science to Strengthen and Improve Systems

Improving ability to identify and


management women with complications
9
8

# of times vitals taken

7
6
5

What the team did differently:

4
3
2
1
0

Jan-wk1 Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3 Ju-wk1

Ju-wk3

Number of women with danger signs identified in PNC ward


Average number of times vitals recorded within first 6 hrs of birth
USAID Applying Science to Strengthen and Improve Systems

Improving ability to identify and


management women with complications
9
8

# of times vitals taken

7
6
5
4
3

What the team did differently:


Identified the root cause of
poor assessment

2
1
0

Jan-wk1 Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3 Ju-wk1

Ju-wk3

Number of women with danger signs identified in PNC ward


Average number of times vitals recorded within first 6 hrs of birth
USAID Applying Science to Strengthen and Improve Systems

Improving ability to identify and


management women with complications
9
8

# of times vitals taken

7
6
5
4
3
2

What the team did differently:


Identified the root cause of
poor assessment
Used small scale tests to
learn what works

1
0

Jan-wk1 Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3 Ju-wk1

Ju-wk3

Number of women with danger signs identified in PNC ward


Average number of times vitals recorded within first 6 hrs of birth
USAID Applying Science to Strengthen and Improve Systems

Improving ability to identify and


management women with complications
9
8

# of times vitals taken

7
6
5
4
3
2
1

What the team did differently:


Identified the root cause of
poor assessment
Used small scale tests to
learn what works
Focused on the aim

Jan-wk1 Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3 Ju-wk1

Ju-wk3

Number of women with danger signs identified in PNC ward


Average number of times vitals recorded within first 6 hrs of birth
USAID Applying Science to Strengthen and Improve Systems

Women with complications are now 12


times more likely to be identified early
New system
of care

9
8

# of times vitals taken

Observation
room

6
5

Partnering
with patients

4
3
2
1
0

Jan-wk1 Jan-wk3 Feb-wk1 Feb-wk3 Mar-wk1 Mar-wk3 Apr-wk1 Apr-wk3 May-wk1 May-wk3 Ju-wk1

Ju-wk3

Number of women with danger signs identified in PNC ward


Average number of times vitals recorded within first 6 hrs of birth
USAID Applying Science to Strengthen and Improve Systems

Sustained improvement and NO MATERNAL


DEATHS in post partum ward

3.0%

number of times women were assessed


in first 6 hours
2.5%

2.0%

5
1.5%
4

% of women identified with


complications and managed
appropriately

1.0%

2
0.5%
1

0.0%
Jan

Feb

March

April

May

June

July

Aug

Sept

Oct

USAID Applying Science to Strengthen and Improve Systems

Sustained improvement and NO MATERNAL


DEATHS in post partum ward
Tools:

Leadership
Standards
Incentives
9

3.0%

Process redesign
Organizational culture
2.5%

number of times women were assessed


in first 6 hours

2.0%

5
1.5%
4

% of women identified with


complications and managed
appropriately

1.0%

2
0.5%
1

0.0%
Jan

Feb

March

April

May

June

July

Aug

Sept

Oct

USAID Applying Science to Strengthen and Improve Systems

Lessons learned
1. Standards and instructions from management
dont fix all problems
2. Small scale testing is necessary for solving some
problems
3. Focus on the right aim
1. so what?

USAID Applying Science to Strengthen and Improve Systems

General principles for problem solving

Subject
knowledge

Context
knowledge

Change
method

USAID Applying Science to Strengthen and Improve Systems

ASSIST overview

USAID Applying Science to Strengthen and Improve


Systems (ASSIST) is a five-year project of the Office
of Health Systems of the USAID Global Health Bureau
designed to:
Improve health and social services at scale
Strengthen host country capacity to improve care
Learn and share knowledge about improvement
globally

USAID Applying Science to Strengthen and Improve Systems

ASSIST has worked in 24 countries

USAID Applying Science to Strengthen and Improve Systems

Scale of USAID ASSIST Activities, FY13-FY14

222 government and


implementing partners

4,339 facility based


improvement teams

994 community based improvement


teams

124 million catchment population

USAID Applying Science to Strengthen and Improve Systems

ASSIST India

349 improvement teams

12-17,000 deliveries
per month
30% of deliveries in
27 High Priority
Districts

USAID Applying Science to Strengthen and Improve Systems

Births per country in 2010


(1000s of births)
Tajikistan

194
193
184
181
180
179

Eritrea
Azerbaijan
Netherlands
India supportedsites
sites
ASSIST ASSIST
India supported
Tunisia
Paraguay
Liberia
Israel
Central African Republic
Jordan
Congo
Libya
Lao People's Democratic Republic
Nicaragua
State of Palestine
Kyrgyzstan
El Salvador
Belgium
Mauritania
Greece
Czech Republic
Sweden
Serbia
Cuba
Turkmenistan

158
157
156
156
154
145
144
140
138
137
131
126
123
118
117
116
113
110
110
109

If ASSIST-supported
sites in India were their
own country, they
would rank 88th out of
180 countries in the
world in total deliveries,
just behind Azerbaijan
and the Netherlands

USAID Applying Science to Strengthen and Improve Systems

What we do

Support team-based problem solving at facility and


community level
Support peer-to-peer learning between networks of
teams
Support government to incorporate these
approaches into their systems

USAID Applying Science to Strengthen and Improve Systems

Seven steps to support team-based


problem solving

Decide what problem you want to fix


Get a team together to fix it
Identify the causes of the problem
Develop a simple measurement system
Come up with some possible solutions
Test the solutions on a small scale
Implement the effective solutions

USAID Applying Science to Strengthen and Improve Systems

Support networks between teams based on


peer-to-peer learning
Multiple sites simultaneously
testing changes, common
indicators, peer learning
about how to improve that
area of care

Learning
Session
Collaborative-level sharing
and synthesis of best
practices
Site-level summary

QI team
representative

QI team
QI team

site
site

QI team
site

QI team
QI team

site

site
QI team

QI team

site

site

QI team
site

QI team
site

QI team
site

Site-level testing of changes


and analysis of results

USAID Applying Science to Strengthen and Improve Systems

Continuum of care
Aims

District Hospital
Community
Health Centre
Primary Health
Centre
Sub-centre
Community

Routine care
- Active management of
3rd stage of labor
- Essential newborn care
- Improving ANC
- Improving PNC

Complication
care
- Management of anemia
- Neonatal resuscitation
- PPH management
- Management of pre/ -eclampsia
- Prevention and control
of infection
- Other

- Improving ANC (BP, Hb, weight, counseling)


- Early registration
- Identification of danger signs
- Identification of severe anemia
- Promotion of institutional delivery

USAID Applying Science to Strengthen and Improve Systems

Improving routine care for over 15 000


pregnancies and deliveries per month
100%

Newborns breastfed in first hour


90%
80%
70%

Hb checked

60%
50%
40%

Vitamin K

30%
20%
10%

Oxytocin
0%
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14

USAID Applying Science to Strengthen and Improve Systems

Improving routine care for over 15 000


pregnancies and deliveries per month
100%

Newborns breastfed in first hour


90%
80%
70%

Hb checked

60%
50%
40%

Vitamin K

30%

Tools used:
- Standards
- Process re-engineering
- Culture change

20%
10%

Oxytocin
0%
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14

USAID Applying Science to Strengthen and Improve Systems

Improvement in recording and drug


management
Refrigerator

Oxytocine

Room temp

50 USAID Applying Science to Strengthen and Improve Systems

Improved organization and cleanliness

51 USAID Applying Science to Strengthen and Improve Systems

After building improvement


skills on routine care, teams
move on to complications care

52

Practice of ENC in 11 facilities in Delhi

Delivering baby on mothers


abdomen
1,9
Kangaroo Mother Care
0,0

Immediate drying
11,11

Inj. Vit K to all newborns


10,10

Delayed cord clamping


0,9

Breast feeding within 1 hour


of birth
9,11

Sterile cord clamping


11,11
Avoid prelacteals
11,11

No. of Facilities practising before training

USAID Applying Science to Strengthen and Improve Systems

Improvement after mentorship/process


improvement support
Delivering baby on mothers
abdomen
1,9
Kangaroo Mother Care
0,0

Immediate drying
11,11

Inj. Vit K to all newborns


10,10

Delayed cord clamping


0,9

Breast feeding within 1 hour


of birth
9,11

Sterile cord clamping


11,11
Avoid prelacteals
11,11

No. of Facilities practising before training


No. of facilities practising after 1 month

USAID Applying Science to Strengthen and Improve Systems

Tools for improvement

Delivering baby on mothers


abdomen
1,9
Kangaroo Mother Care
0,0

Immediate drying
11,11

Inj. Vit K to all newborns


10,10

Delayed cord clamping


0,9

Breast feeding within 1 hour


of birth
9,11
Avoid prelacteals
11,11

No. of Facilities practising before training


No. of facilities practising after 1 month

Sterile cord clamping


11,11
Tools used:
- Skills building
- Process reengineering
- Culture change

USAID Applying Science to Strengthen and Improve Systems

NR equipment readiness
Availability of mucous suckers
6.9
Practice of cleaning/disinfecting
Availability of masks & bag
after every use
11,11
1,9
Practice of checking before
every delivery
0,4

Ready to use masks & bag


5,9

Use of NB care unit


10,9

Tubing for Oxygen


10,11

Functional NB care unit


11,11

Oxygen source
8,11

No. of facilities having before training

USAID Applying Science to Strengthen and Improve Systems

Improvement after mentorship/process improvement


support
Availability of mucous suckers
6.9
Practice of cleaning/disinfecting
Availability of masks & bag
after every use
11,11
1,9
Practice of checking before
every delivery
0,4

Ready to use masks & bag


5,9

Use of NB care unit


10,9

Tubing for Oxygen


10,11

Functional NB care unit


11,11

No. of facilities having before training

Oxygen source
8,11

No. of facilities having 1 month after training

Tools used:
- Skills building
- Process reengineering
- Culture change

USAID Applying Science to Strengthen and Improve Systems

Perinatal mortality all ASSIST supported sites


10 000 15 000 deliveries per month
3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%

Jul-13

Sep-13

Nov-13

Jan-14

Baseline mortality 2.35%

Mar-14 May-14

Jul-14

Sep-14

Nov-14

Jan-15

Current mortality 2.07%

USAID Applying Science to Strengthen and Improve Systems

Transfer of improvement
skills into government
systems

59

India: Timeline of activities in Chamba District


Nov
2013

Dec
2013

Jan
2014

Feb
2014

Mar
2014

In December 2013,
ASSIST supported 5
facilities in Chamba
to set up QI teams

Apr
2014

May
2014
In May 2014, the
District Chief Medical
Officer requested
ASSIST support the
rest of the district

They began to
achieve some
impressive results

Impressive!

USAID Applying Science to Strengthen and Improve Systems

Timeline of activities in Chamba District


May 2014

Jun 2014

Jul 2014

Aug 2014

In July and August 2014,


ASSIST worked with the district
to plan scale up of activities.

ASSIST

MOHFW

Sep 2014

Oct 2014

Nov 2014

In September 2014,
ASSIST trained 38
new facilities and 10
government coaches

Going forward
Coaches will provide on-site
coaching support to facilities
These 43
facilities cover
35% of the
births in this
district of
540,000 people

2 Block Medical Officers will oversee


the work
Improvement reports will be included
in monthly district meetings
District will organize quarterly
peer-to-peer learning sessions
USAID Applying Science to Strengthen and Improve Systems

37 of 38 facilities supported by government


coaches collecting and reporting data and
showing initial signs of improvement
100%

80%

Iron
supplementation

60%
Oxytocin at
delivery
40%

>2gm inc in Hb

20%
ANC Hx and Px

0%
Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

USAID Applying Science to Strengthen and Improve Systems

General principles of setting up a system


for quality improvement
Facility and community-based improvement
teams
Team support system
Leadership component

USAID Applying Science to Strengthen and Improve Systems

General principles of setting up a system


for quality improvement
Facility and community-based improvement
teams
Team-based QI
ID problems that need to be solved at other levels

Team support system


Leadership component

USAID Applying Science to Strengthen and Improve Systems

General principles of setting up a system


for quality improvement
Facility and community-based improvement
teams
Team-based QI
ID problems that need to be solved at other levels

Team support system


Support QI skills development
Spread good ideas between teams
Support multi-level problem solving

Leadership component

USAID Applying Science to Strengthen and Improve Systems

General principles of setting up a system


for quality improvement
Facility and community-based improvement
teams
Team-based QI
ID problems that need to be solved at other levels

Team support system


Support QI skills development
Spread good ideas between teams
Support multi-level problem solving

Leadership component

Set goals
Encourage problem identification and solving
Fix problems at their level
Encourage learning
USAID Applying Science to Strengthen and Improve Systems

For more information and resources please visit:

www.usaidassist.org
Or contact
nlivesley@urc-chs.com

USAID Applying Science to Strengthen and Improve Systems

Baseline perinatal mortality in Jama CHC


Dumka District, Jharkhand

4.0%

3.5%

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%
May.14

Jun.14

Jul.14

Aug. 14

Sep.14

Oct.14

Nov.14

Dec.14

Jan.15

Feb.15

USAID Applying Science to Strengthen and Improve Systems

Changes in perinatal mortality in Jama CHC,


Dumka District, Jharkhand

4.0%

3.5%

Improvement team working on


neonatal resuscitation and
partograms

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%
May.14

Jun.14

Jul.14

Aug. 14

Sep.14

Oct.14

Nov.14

Dec.14

Jan.15

USAID Applying Science to Strengthen and Improve Systems

Changes in perinatal mortality in Jama CHC,


Dumka District, Jharkhand

4.0%

3.5%

Improvement team working on


neonatal resuscitation and
partograms

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%
May.14

Jun.14

Jul.14

Aug. 14

Sep.14

Oct.14

Nov.14

Dec.14

Jan.15

USAID Applying Science to Strengthen and Improve Systems

Perinatal mortality including when mothers


and babies are referred to other facilities
9
8

Improvement team working


on neonatal resuscitation and
partograms

7
6
5
4
3
2
1
0
May.14

Jun.14

Jul.14

Aug. 14

Sep.14

deaths in hosp

Baseline
2.4% babies died in hospital
2.4% babies died after referral

Oct.14

Nov.14

Dec.14

Jan.15

deaths in ref

After improvement work


1.7% babies died in hospital
1.0% babies died after referral

USAID Applying Science to Strengthen and Improve Systems

Improved management and decreased


referrals of moribund babies
0.08

0.07

Improvement team working on


neonatal resuscitation and
partograms

0.06

0.05

0.04

0.03

0.02

0.01

0
Jun.14

Jul.14

Aug. 14

Baseline mortality 4.8%

Sep.14

Oct.14

Nov.14

Dec.14

Jan.15

Feb.15

Intervention mortality 2.7%


USAID Applying Science to Strengthen and Improve Systems

How does performance compare between facilities with


improvement aims and those without improvement
aims?
100%
90%

Teams NOT TRYING to


improve Hb measurement

80%
70%
60%
50%
40%
30%
20%
10%
0%
Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

USAID Applying Science to Strengthen and Improve Systems

Women attending clinics which are aiming to improve


Hb measurement are now more likely to get their Hb
measured
100%
90%

Teams NOT TRYING to


improve Hb measurement

80%
70%
60%
50%
40%
30%

Teams TRYING to improve


Hb measurement

20%
10%
0%
Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

USAID Applying Science to Strengthen and Improve Systems

Antenatal care in Mandi, Himachal Pradesh

Denominator: Number of ANCs conducted per week in Mandi, Himachel Pradesh (average = 45.6)

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

W-2

W-1

W-3

W-2

W-1

W-5

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-5

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

100
80
60
40
20
0
Mar-14

USAID Applying Science to Strengthen and Improve Systems

Antenatal care in Mandi, Himachal Pradesh


Percentage of ANCs during which BP and Hb were measured
in Mandi, Himachal Pradesh, July 2013-March 2014
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

% BP measured

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

W-2

W-1

W-3

W-2

W-1

W-5

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-5

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

% Hb measured

Mar-14

Denominator: Number of ANCs conducted per week in Mandi, Himachel Pradesh (average = 45.6)

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

W-2

W-1

W-3

W-2

W-1

W-5

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-5

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

100
80
60
40
20
0
Mar-14

USAID Applying Science to Strengthen and Improve Systems

Mandi, Himachal Pradesh case study


Number of high-risk pregnancies identified and percentage of ANCs during which
BP and Hb were measured in Mandi, Himachel Pradesh
# high-risk identified

% BP measured

% Hb measured
12

100%
90%

10

80%
70%

60%

50%
40%

30%
20%

10%
0%
Jul-13

Aug-13

Sep-13

Oct-13

18 high-risk
pregnancies
identified (1.4%)

Nov-13

Dec-13

Jan-14

Feb-14

W-2

W-1

W-3

W-2

W-1

W-5

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-5

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

W-4

W-3

W-2

W-1

0
Mar-14

39 high-risk
pregnancies
identified (12.3%)

USAID Applying Science to Strengthen and Improve Systems