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Using 5S-CQI-TQM Approach For Improving Quality of

Newborn Care In Bangladesh

Dr. Ziaul Matin


Health Specialist, UNICEF
8 April 2015

Outline
Background of Quality Improvement Initiative
Different QI approaches for MNCH services
5S-CQI-TQM Approach for QI
Applying 5S-CQI-TQM approach for Quality
Improvement of Newborn Care
Findings from 11 hospitals under 5S-CQI-TQM
Challenges and Way forward

Context and Background


Substantial efforts have been taken so far to
improve MNH services
There are still concerns regarding the quality
and safety of services
Poor quality leads to medical errors, waste
Currently the quality of services in the
hospitals is unsatisfactory and lead to
client/consumer dis-satisfaction and mistrust
3

Context and Background


The basic characteristics of service delivery in our
hospitals are characterized by:

Long waiting time


Overcrowding
Unhygienic and disorganized work environment
Wastage

Many of our hospitals ignore the non-healtrh


expectations of the people:

Dignity
Basic human needs
Prompt attention for care and treatment
Communication
Confidentiality
4

Lot of problems in The Hospital

Current Efforts of the MoHFW for QI


MoHFW has incorporated Quality Improvement programme in the Health
Sector Programme 2011-16
5S-CQI-TQM approach scaled up in 97 facilities
BFHI/WFHI (21 hospitals) accredited
Development of National Strategic Framework for QI
Development of National Health Care Standards and guidelines for 5S-CQITQM
Regulatory framework for the private sector/ NGO hospitals/
clinics/laboratories
Introduction of standard waste management system
Development of guidelines and national standards of clinical care following
WHO guidelines/protocols
Regional quality assurance system for family planning services etc.
Other agencies/NGOs adopted different approaches for QI- SBMR, ISO,
COPE etc.
6

Partnership and collaboration in QI


MoHFW: Implementation through DGHS, DGFP and HEU (QIS)
Partner Agencies: WHO, UNICEF, JICA, GIZ, USAID, MCHIP, SC, FHI

Policy advocacy
QI Strategic Planning
Resources
Knowledge management on QI
Technical assistance on 5S-CQI-TQM
Capacity building
South-South collaboration

icddr,b; CIPRB: Assessment, monitoring and mentoring, HMIS, MPDR


Professional bodies and Academia: SOP development, Strategic
planning, mentoring/monitoring
Technical agency: Supply Chain Mangement, equipment maintenance,
NGOs: BRAC, Engender Health, others
7

MaMoni HSS Projects Integrated QI Approaches


Improved Outcome of
MNCH/FP/N Services

Competency
Based
Training

SBM-R

Regional
Roaming QI
Teams

Step 1: 5 S
Step 2: KAIZEN
Step 3: TQM

MPDR

Joint
Supervisory
Visits
(Supportive
Supervision)

MNCH/FP/N
Clinical services at
facility & community

Work environment
Problem solving
Quality services &
customer satisfaction

TQM Approach

What is 5S?
Sort

Remove un-necessary items from your


work place and reduce clutter

Set

Organize everything needed in proper


order for easy operation

Shine
Standardize
Sustain

Maintain high standard of cleanliness


Set up the above 3 Ss as norms in every
section of your work place
Train and maintain discipline of the
personnel engaged

11

Quality Improvement Process

12

Trunk

KAIZEN

Water

LEADERSHIP

Root

14

Implementation Steps of 5S-CQI-TQM

Formation
of QIT/WITs
Assess situation/
baseline

Develop WIT
Action Plans
and
monitoring
framework

Implement
WIT Action
Plans; track
progress;
Monitoring
by QIT

5S-CQI-TQM

Advocacy and sensitization


workshop at facility

15

5S Activities: Implementation

Taking leadership &


support for 5S activities.
Learn and practice 5S
principles by him/herself

Train the hospital staff

Support implementation
of 5S activities

Monitor & assess


achievements of WITs

Coaching the WITs

Work Improvement
Team
[3 - 5 persons]

Top
management
Implement 5S in respective
work units/dept.
Develop WIT Action Plans
Conduct periodical
monitoring
Reporting to QIT

Quality
Improvement
Team
[5 - 15 persons]

Work Improvement
Team
[3 - 5 persons]

Work Improvement
Team
[3 - 5 persons]

16

Improving Newborn Care in UICEF


Supported 11 Hospitals with 5SCQI-TQM
Medical
College
Hospital
Chittagong
and
Mymensing

District
Hospital
Bandarban,
Coxsbazar,
Kishorganj,
Netrokona
Moulavibazar,
Narail
Tangail

Upazila
Health
complex

Funding

GoJ

Kalia,
Barolekha

DFATD
(MNHI)
UNICEF/
KOICA

Introducing the 5S-CQI-TQM approach


Strategic planning and orientation
workshops organised in the targeted
hospitals. QIT and WITs formed and QI
plan was developed and has been
implemented.
Training on Hospital Change
Management through 5S-CQI-TQM
approach was organised jointly with JICA
in Sri Lanka during 2013.
Various QI activities such as clinical case
review and continuous medical education
sessions were supported.
Bi-annual and annual QI review workshop
were organised by DGHS with joint
support from UNICEF and JICA.

18

5S Activities (SORT)
in Coxs Bazar District Hospital

19

5S Activities (SET) activities


Nurses station in Newborn Care Unit

BEFORE 2011

AFTER 2014

20

3S: Shining

21

3S: Shining

22

4S: Standardize

23

Various QI activities (5S: Sustain)

24

CQI in SCANU
Before

After

25

Renovation Works of SCANU in Mymensing Medical


College Hospital

26

Strengthen Service Delivery


Capacity Development of Human Resource
237 medical officers and around 580
nurses were trained in the
Emergency Triage and Treatment for
sick newborns (ETAT) at BSMMU
and other institutes in 2013-2014
A visual learning tool explaining
Standard Operating Procedures for
use and maintenance of selected
essential newborn equipment was
developed with technical support
from BSMMU.
27

Strengthen Service Delivery


SCANU Establishment
Renovation works of SCANU by the Public Works Department and Health
Engineering Department under MoHFW
Quality assurance of the renovation works by Technical agency
Procurement of Essential newborn care equipment
Technical agency for installation, commissioning, user training and
maintenance of the equipment

28

Small CQI/KIZEN

29

Example of CQI/KIZEN Activity

Waste disposal at the Bandarban District


Hospital, before 5S implementation - first
monitoring visit in August 2013

CQI/KIZEN activity at Bandarban District


Hospital, after 5S implementation (and after
building waste disposal system0, fourth monitoring
visit in April 2014
30

CQI In HMIS of Newborn Care


2013

2012
2011

31

Policy Advocacy Through Demonstrating Impact of


Innovations For Improved Quality of Newborn Care in
SCANU
Quality Improvement of
services adopting TQM
approach

Competency based
training and use of audiovisual tools for skill
development
Paper-based record
keeping and reporting to
Dashboard and individual
case-tracking through
web-based MIS

32

Radar diagram showing overall quality of management of MNH and


support services at selected hospitals during baseline assessment
(2011)
Overall outlook
QA Activities

Record Keeping

100%
90%
80%
70%

Provision of Responsive Health


Services
Infection Control and Waste
management

60%
50%
40%

Maintenace of Equipments

30%

Bandarban DH
Out-patient Department:
Maternal

10%
0%

Chittagoong MCH
Cox's Bazar DH

20%
Human Resource Management
and Leadership

Barlekha UHC

Out-patient Department:
Neonatal

Kalia UHC
Kishoregonj DH
MoulviBazar DH
Mynenshigh MCH

Diet and Kitchen Mangement

Pharmacy Management

Narail DH
Netrokona DH
Tangail DH

Store Management

Emergency Management

Pathology Management

Indoor Management: Maternal


Indoor Management: Neonatal

33

Radar diagram showing overall quality of management of MNH and


support services at selected hospitals during end line assessment
(2014)

Record Keeping
Maintenace of Equipments

Human Resource Management


and Leadership

Overall outlook
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

Diet and Kitchen Mangement

Provision of Responsive Health


Services
Infection Control and Waste
management

Bandarban DH
Barlekha UHC

Out-patient Department:
Maternal

Chittagoong MCH
Cox's Bazar DH
Kalia UHC
Kishoregonj DH

Out-patient Department:
Neonatal

MoulviBazar DH
Mynenshigh MCH
Narail DH

Store Management

Pathology Management
Indoor Management: Neonatal

Pharmacy Management

Netrokona DH
Tangail DH

Emergency Management
Indoor Management: Maternal

34

Sick Newborn Admission during 2013-2014


12000
9960

10000

8000

8007
7178

7560

6000
3785

4000

2947
1541

2000
99

0
MMCH

CMCH

KDH
2013

2140

138
BDH

CDH

2014

35

Measuring KIZEN/CQI
SCANU total admission in 2013 and 2014

SCANU Case fatality rate in 2013 and


2014

30000
30.0

27996

25000

25.0
20000
19772

20.0

15000
15.0

17.2
14.4

10000

10.0

5000
3405

0
Total Admission

4041

Total mortality
2013

5.0
0.0
2013

2014

2014

36

Window for Policy Support of Strengthening National


Capacity Building for QI
QI Secretariat at HEU, MoHFW

Divisional QI
Committee
QI Assessor team

District/Upazila QI
Committee
QIT/WIT

Lessons Learned
This initiative has demonstrated evidence of changes resulting from the
QI interventions in a small unit of targeted hospitals and documented
those changes and processes for knowledge and evidence generation.
This has facilitated the programme managers to adopt the 5S-CQI-TQM as
a feasible and doable approach for improving the quality of maternal and
newborn care services at Primary/Secondary/Tertiary level hospitals within
the HSS framework..
This has led to useful learnings and strategic directions to the policy
makers and programme managers to further scale-up any Quality
Improvement Initiatives/ in Bangladesh.

Challenges
Poor institutional mechanism and organogram for QI
Inadequate institutional capacity at national and subnational level for QI programme management
Lack of effective coordination, harmonization and
integration among different programmes and
agencies for Quality Improvement (QI)
Operationalize the national strategic framework and
comprehensive Action Plan for QI
Shortage of human resources in number and skills
Inadequate monitoring & supervision system
Poor motivation of service providers for compliance
of clinical standards and protocols

Way Forward
Capacity building of Quality secretariat and Qi committees both at
national and Sub-national levels
Develop a realistic implementation plan with costing based on the
national strategic framework for QI
Bring synergy, harmonisation and effective partnership under
different QI programmes
Scale-up 5S-CQI-TQM sequentially from MNCH to cover whole
hospital services leading to TQM
Develop assessors team at divisional level and conduct periodic
assessment of facilities
Integrate core sets of quality indicators in the DHIS 2 (web-based
HMIS)to monitor the quality of care
Institute comprehensive QI/QA system at all levels of health
facilities leading to formal accreditation and reporting mechanism

Systematic Approach For Total Quality Management (5S-CQI-TQM)


Introduced in 11 Hospitals

After