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Benin

Enabling factors affecting the performance of skilled birth attendants
A wide variety of factors might affect the performance of skilled birth attendants, including provider competence and motivation, various patient characteristics, hospital leadership and supervision, availability of equipment, drugs and supplies, policies, time of day and week, and support team. This study examined the relationships between such factors and performance during labor, delivery and immediate postpartum maternal and newborn care. Data were obtained from 5 referral hospitals, 12 smaller hospitals, and 4 health centers in four countries (Benin, Ecuador, Jamaica, Rwanda). Performance was defined as compliance according to international standards and measured by direct observation of all births and retrospective record review of obstetric emergencies. The enabling factors were measured by a variety of instruments, measurements of the competency of birth attendants obtained from a related study.

Measuring competency of skilled birth attendants
This study developed instruments for measuring knowledge and skills of birth attendants. It was tested in four countries: Benin, Ecuador, Jamaica and Rwanda. The instruments measured competency during labor, delivery, postpartum maternal care, and postpartum newborn care. Knowledge was measured with a 55-item test derived from several well-known sources, such as the WHO IMPAC guidelines. The skills test included two partograph exercises and six skill stations using mannekins and attended by expert clinicians. Locally appropriate standards were added to the tests in each country.
Download report:
Comparison of Two Methods for Determining Provider Attendance during Normal Labor and Delivery: Benin, Ecuador, Jamaica, and Rwanda

Measuring in-facility delays during emergency obstetric care
This study developed and tested a method for measuring delays in the treatment of selected obstetrical emergencies within facilities in four countries: Benin, Ecuador, Jamaica, and Rwanda. Emergencies addressed included eclampsia/pre-eclampsia, sepsis, obstructed labor, postpartum hemorrhage, and post-abortion complications. The method included observing patient flow in the obstetrical ward and/or the emergency room, and record review of obstretrical emergencies. Patient flow data were obtained on 856 maternal cases, and 329 records of obstetrical cases were reviewed by a physician. The study found that patient flow observation is feasible and necessary to measure delays in initial evaluation. Record reviews by physicians also yielded usable information on delays in obstetrical emergencies.
Download report:
Safe Motherhood StudiesResults from Benin: Competency of Skilled Birth Attendants, The Enabling Environment for Skilled Attendance at Delivery, In-Hospital Delays in Obstetric Care (Documenting the Third Delay)

Chile

Evaluation of the Chile national quality assurance program
The Chile National Quality Assurance (QA) Program began in 1991, and working through a QA Unit in the Ministry of Health, developed standards, training modules, and communication strategies, eventually achieving country-wide coverage. This evaluation was undertaken in 1999 by a team of three senior staff from QAP and the director of the national program to develop and apply an evaluation methodology that would document the QA programs structure and management and its technical and support functions. The methodology included: (1) developing a logical framework of technical areas, (2) identifying questions for each technical area, and indicators, data sources, and data collection methods for each question, (3) setting the timing for data collection (before or during the evaluation team visit), and (4) analysis and write-up of the findings. The evaluation revealed a very successful program with many innovative characteristics. About 12,000 health professionals had been trained in QA methods, representing 25 % of the health workforce. The Chilean QA program is closely linked to primary care and public health, with QA more prevalent in health centers than larger facilities. Incentives have been in the form of professional awards and public acknowledgement. The team concluded that strong dedication to QA by health professionals throughout the country has developed close bonds at the local level that have been crucial to QAs success there.
Download report:

Evaluation of the Chile National Quality Assurance Program

Ecuador

Enabling factors affecting the performance of skilled birth attendants
A wide variety of factors might affect the performance of skilled birth attendants, including provider competence and motivation, various patient characteristics, hospital leadership and supervision, availability of equipment, drugs and supplies, policies, time of day and week, and support team. This study examined the relationships between such factors and performance during labor, delivery and immediate postpartum maternal and newborn care. Data were obtained from 5 referral hospitals, 12 smaller hospitals, and 4 health centers in four countries (Benin, Ecuador, Jamaica, Rwanda). Performance was defined as compliance according to international standards and measured by direct observation of all births and retrospective record review of obstetric emergencies. The enabling factors were measured by a variety of instruments, measurements of the competency of birth attendants obtained from a related study.

Measuring competency of skilled birth attendants
This study developed instruments for measuring knowledge and skills of birth attendants. It was tested in four countries: Benin, Ecuador, Jamaica and Rwanda. The instruments measured competency during labor, delivery, postpartum maternal care, and postpartum newborn care. Knowledge was measured with a 55-item test derived from several well-known sources, such as the WHO IMPAC guidelines. The skills test included two partograph exercises and six skill stations using mannekins and attended by expert clinicians. Locally appropriate standards were added to the tests in each country.

Measuring in-facility delays during emergency obstetric care
This study developed and tested a method for measuring delays in the treatment of selected obstetrical emergencies within facilities in four countries: Benin, Ecuador, Jamaica, and Rwanda. Emergencies addressed included eclampsia/pre-eclampsia, sepsis, obstructed labor, postpartum hemorrhage, and post-abortion complications. The method included observing patient flow in the obstetrical ward and/or the emergency room, and record review of obstretrical emergencies. Patient flow data were obtained on 856 maternal cases, and 329 records of obstetrical cases were reviewed by a physician. The study found that patient flow observation is feasible and necessary to measure delays in initial evaluation. Record reviews by physicians also yielded usable information on delays in obstetrical emergencies.

Measuring the cost of inefficiency in hospital labs in Ecuador
This study developed a method for identifying inefficiencies in hospital laboratories and measuring their cost, and tested it in three hospitals in Ecuador. Seven types of inefficiency are included: (1) ordering unneeded tests, (2) test results never picked up, (3) inefficient use of lab resources, (4) low productivity of laboratory staff, (5) expiration of lab reagents, (6) lack of quality and cost control practices, and (7) inefficient procurement of lab reagents and other resources. Theft and long-term costs of poor quality were not addressed. It was necessary for the hospitals to develop explicit standards before the cost of unneeded tests could be measured. Data collection methods included review of existing lab records, financial records, hospital utilization records, and a sample of medical records; observation of high frequency tracer tests to estimate time used; and key informant interviews. The study found that staff time was the largest cost factor and that under-utilization of staff is a potentially large component of inefficiency. Expired reagents were a significant contributor to inefficiency in all three hospitals. High costs of resources due to poor procurement practices were a major source of inefficiency in at least one hospital. Unneeded tests comprised about 7% of all costs due to inefficiency, while three types of inefficiency were not important (tests not picked up, inefficient use of lab resources, lack of practices).

Redesign of obstetric records
This study redesigned the obstetric patient record process in four Ecuadorian hospitals using a standard QA redesign approach. As part of this process, eight key indicators of patient record quality were defined: (1) complete set of forms, (2) correct chart headers, (3) complete discharge form, (4) complete delivery record, (5) signed patient consent and release forms, (6) identification on admit and discharge forms, (7) legible, (8) coherent and consistent. A random sample of about 200 records from each hospital (about 100 before the redesign and 100 after) were audited. The percentage of indicators meeting the standard in the sample improved significantly in all four hospitals. Overall, quality increased by an average of 27 percentage points, from 41% compliant with quality standards before redesign to 69% compliant afterwards. The biggest gains were in legibility, coherency and consistency, complete set of forms, discharge form, and delivery record. Further work is required to assess whether the increase in quality reduced medical errors, and whether the records are now of sufficient quality to use as a data source for monitoring quality assurance activities.
Download report:
Redesigning Hospital Documentation Systems to Improve the Quality of Obstetric Patient Records in Ecuador

Jamaica

Enabling factors affecting the performance of skilled birth attendants
A wide variety of factors might affect the performance of skilled birth attendants, including provider competence and motivation, various patient characteristics, hospital leadership and supervision, availability of equipment, drugs and supplies, policies, time of day and week, and support team. This study examined the relationships between such factors and performance during labor, delivery and immediate postpartum maternal and newborn care. Data were obtained from 5 referral hospitals, 12 smaller hospitals, and 4 health centers in four countries (Benin, Ecuador, Jamaica, Rwanda). Performance was defined as compliance according to international standards and measured by direct observation of all births and retrospective record review of obstetric emergencies. The enabling factors were measured by a variety of instruments, measurements of the competency of birth attendants obtained from a related study.

Follow-up of HIV+ mother and child pairs in Jamaica
This study examined the practices of women in Jamaica who had been found HIV-positive during antenatal visits and who had participated in a pilot program to prevent mother-to-child transmission of HIV/AIDS. The study measured the womens knowledge, attitudes, and practices relating to the prevention of transmission, stigma, and related issues; tested infants of consenting mothers for HIV status; and observed providers in selected clinics to identify program areas needing improvement. Although the small sample size did not show any statistical difference in disease transmission for women who did or did not take nevirapine, the study did find that women who did not breast feed were less likely to transmit the virus to their infants
(p< 0.001).
Download report
The Impact of a Programme to Prevent Mother-to-Child Transmission of HIV: Disease Transmission and Health-Seeking Behaviour among HIV-Positive Mother-Child Pairs in Jamaica

Measuring competency of skilled birth attendants
This study developed instruments for measuring knowledge and skills of birth attendants. It was tested in four countries: Benin, Ecuador, Jamaica and Rwanda. The instruments measured competency during labor, delivery, postpartum maternal care, and postpartum newborn care. Knowledge was measured with a 55-item test derived from several well-known sources, such as the WHO IMPAC guidelines. The skills test included two partograph exercises and six skill stations using mannekins and attended by expert clinicians. Locally appropriate standards were added to the tests in each country.

Measuring in-facility delays during emergency obstetric care
This study developed and tested a method for measuring delays in the treatment of selected obstetrical emergencies within facilities in four countries: Benin, Ecuador, Jamaica, and Rwanda. Emergencies addressed included eclampsia/pre-eclampsia, sepsis, obstructed labor, postpartum hemorrhage, and post-abortion complications. The method included observing patient flow in the obstetrical ward and/or the emergency room, and record review of obstretrical emergencies. Patient flow data were obtained on 856 maternal cases, and 329 records of obstetrical cases were reviewed by a physician. The study found that patient flow observation is feasible and necessary to measure delays in initial evaluation. Record reviews by physicians also yielded usable information on delays in obstetrical emergencies.
Download report
Safe Motherhood StudiesResults from Jamaica: Competency of Skilled Birth Attendants; The Enabling Environment for Skilled Attendance at Delivery; In-Hospital Delays in Obstetric Care (Documenting the Third Delay)

Indonesia

Improving family planning counseling with self-assessment and peer review in Indonesia
The quality of client-provider communication during a counseling session was measured by the number of facilitative communications and number of informative communications by the provider during the session. Three interventions were tested: a one week training for the providers in inter-personal communication, a low cost self-assessment protocol, and weekly peer review meetings. The self-assessment and peer review aimed primarily at reinforcing facilitative communication. A sample of 203 family planning counselors was randomly assigned to one of three groups. Group 1 received the training only; group 2 received the training and implemented the self-assessment for 16 weeks following the training; and group 3 received the training and implemented both the self-assessment and peer review for 16 weeks. Approximately two counseling sessions per counselor were audio-taped and analyzed at three different times: just before the training, just after the training, and 16 weeks after the training. The average number of facilitative and informative communications increased by 2-3 times between the first two measurements for all three groups, indicating that the training had a strong short-term impact. However, after 16 weeks, the training-only group lost about half of its gain in both facilitative and informative communication, while the other two groups maintained their gain in facilitative communication although they lost about half the gain in informative communication. These results suggest that self-assessment and peer review interventions are effective strategies for reinforcing training in facilitative communication.
Download report:
Improving Provider-Client Communication: Reinforcing IPC/C Training in Indonesia with Self-Assessment and Peer Review

Client communication behaviors with healthcare providers
This study used the data obtained in the Indonesia counseling, self-assessment, and peer review study to analyze what causes clients to participate actively during family planning counseling. Culturally acceptable ways for Indonesian clients to participate in consultations include asking questions, requesting clarification, stating opinions, and expressing concerns. Based on a multi-variate analysis of 1,200 counseling sessions, factors significantly associated with client active communication were, in order of importance: providers information giving, providers facilitative communication, providers expressing negative emotion, client educational level, and province. The studys findings reinforce the importance of achieving good provider counseling performance.
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Client Communication Behaviors with Healthcare Providers in Indonesia

Kenya

QA teams and IMCI compliance in Kenya
This study tested whether facility-based QA teams, trained and coached to develop and implement solutions to IMCI problems, could improve IMCI case management after one year. The study looked at 21 QA teams that implemented a variety of improvements: procure more IMCI drugs, clocking-in register, on-the-job IMCI training, patient IMCI education, workload sharing by staff, reduce waiting time, and monthly meetings. Approximately 70 providers were observed attending about 10 IMCI cases each before the team interventions, and again after the interventions, in the 21 facilities with QA teams and in 14 facilities without QA teams. Case management was scored against a set of indicators for IMCI assessment, classification, treatment, and counseling, and change in performance was analyzed for the 59 providers observed both before and after. Quality of case management improved by 57 percentage points in the facilities with QA teams, compared to only 14 percentage point improvement in the control facilities.
Download report:
Using Problem-Solving Teams to Improve Compliance with IMCI Guidelines in Kenya

Vendor-to-vendor education to improve malaria treatment by private drug outlets
Although many patients obtain anti-malarial drugs from small private drug outlets in Kenya, earlier studies indicated that 87% of shopkeepers had never received training in appropriate use of anti-malarial drugs and that 60% gave instructions or dosages to customers. This study tested whether a low-cost education strategy in one district of Kenya would increase private drug outlet knowledge of and compliance with national malaria guidelines. Local wholesalers (mobile vendors and counter attendants at wholesale outlets) were given a one-day training in malaria drug standards and equipped with customized job aids (posters) to give to the retail drug outlets that were their customers. Mystery shoppers visited 101 intervention outlets that received the job aids from wholesalers and 151 control outlets that did not receive the job aids, asking for treatment for their child under two distinct scenarios that required decision-making by the shopkeeper. In response, the mystery shoppers were sold over 70 different anti-malarials (only 5 are government approved), and over 30 anti-pyretics. In the intervention outlets, the shoppers came away with an approved anti-malarial and were told the correct dosage 17% (27/157) of the time compared to 1.5% (3/202) in the control outlets. In the intervention outlets, 35% of shopkeepers answered all 10 knowledge questions correctly compared to only 4% in the controls. The intervention cost was about $17 per outlet reached, or about $0.10 per additional case correctly treated.
Download report:
Vendor to Vendor Education to Improve Malaria Treatment by Drug Outlets in Kenya

Neighbor-to-neighbor education to improve malaria treatment by private drug outlets
This study tested interventions to increase the compliance of private drug outlets in selling anti-malarial drugs for children beyond what was achieved in the Vendor-to-Vendor study summarized above. The intervention tested was a public education campaign that included recruiting and training one advocate in each village who spread information and brochures via a reach-one-teach-five diffusion strategy and a radio campaign. An evaluation of a sample of households seeking to purchase anti-malarials for a child from private drug outlets found that 57 percent of households exposed to the education campaign obtained acceptable medicines and doses, compared to only 31 percent of households not exposed. Another interesting finding was the messiness of the marketplace for anti-malarials. Over 100 different substances were offered for sale by the drug outlets studied, only a few of which were appropriate. Many inappropriate substances mimicked the packaging of approved drugs, thus increasing confusion and inappropriate treatment.

 

 

 
 

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development (USAID) under Contract Number GPH-C-00-02-00004-00.