Standards Based Management and Recognition Approach To Quality Improvement By Prof. Emmanuel Oladipo Otolorin, FMCOG, FWACS, FICS, FRCOG Country Director,

Standards Based Management and Standards Based Management and Recognition Approach To Quality Recognition Approach To Quality

ImprovementImprovement

ByProf. Emmanuel Oladipo Otolorin,

FMCOG, FWACS, FICS, FRCOGCountry Director, ACCESS/JHPIEGO

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Learning Objectives Define Quality of Care List a variety of quality improvement

approaches Describe the Standards Based

Management and Recognition (SBM-R) model

Describe lessons learnt so far in Nigeria

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What does “Quality of Care” mean?What does “Quality of Care” mean?

Illustrative definitions: “Doing the right things right” “Meeting minimal standards for adequate

care” “Offering the greatest health benefits, with

the least health risks, to the greatest number of people, given the available resources”

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World Health Organization’s World Health Organization’s Definition Of “Quality Of Care”Definition Of “Quality Of Care”

“The proper performance, according to standards, of interventions that are known to be safe, that are affordable to the society in question, and that have the ability to produce an impact on mortality, morbidity, disability and malnutrition”

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Different Perceptions of Quality

Client

Provider

State/USAID

CivilSociety

Social-cultural

Context

Q

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Criteria of good quality maternal health Criteria of good quality maternal health servicesservices

Accessible and available Acceptable to potential users/responsive to

local cultural and social norms (e.g. privacy, confidentiality, quick, care by female health workers

Adequacy of essential supplies and equipment

Provides comprehensive care and linkages to other RH services

Provides for continuity of care and follow-up

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Criteria of good quality maternal health Criteria of good quality maternal health services services continuedcontinued

Staffed by technically competent health care providers who rely of clear guidelines and protocols for treatment

Staffed by workers who provide respectful and non-judgmental care

Service site provides information and counseling for clients on their health and health needs

Involves clients in decision-making Offers economic and social support to health care

providers to motivate them to do the best job they can

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Why is Quality of Care important?Why is Quality of Care important?

Quality of care is important because good quality services: are cost-efficient are equitable are effective improve staff morale

save women’s lives

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Sample list of Quality Improvement Methods

Quality assurance Total Quality Management Continuous Quality Improvement Performance Improvement Supportive/Facilitative supervision Standard-Based Management and

Recognition (SBM-R) Approach

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What is SBM-R?

Practical management approach for improving performance and quality of health services

Based on use of operational, observable performance standards for on-site assessment

Must be tied to reward or incentive program

Consists of four basic steps

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The Four Steps of SBM-RThe Four Steps of SBM-R

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Step One: Step One: Set the Performance StandardsSet the Performance Standards

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Steps to Setting StandardsSteps to Setting Standards

Identify area of services to be improved Define core support and supply processes to

provide these services Develop performance standards based on

international guidelines, national policies or guidelines, and site-specific requirements

Consider providers’ input and clients’ preferences

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““Operationalization” of StandardsOperationalization” of Standards

National Guidelines

(“Reference” standards)

Assessment tool

(“Operational” standards plus indicators)

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Performance StandardsPerformance Standards

The standards tell providers not only what to do but also how to do it

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Sample Performance Sample Performance Assessment Tool (1)Assessment Tool (1)

Area: Pregnancy Care

Perf. Standard Verification Criteria Y, N, NA Comments

1. The facility conducts a routine rapid assessment of pregnant women

Observe in the reception area or waiting room if the person who receives the pregnant woman:

• Asks if she has or has had:

- Vaginal bleeding

- Headache or visual changes

- Breathing difficulty

- Severe abdominal pain

- Fever

• Immediately notifies the health provider if any of these conditions are present

See other examples in Nigerian Standards

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Assessment tool areas for EMNOC: Assessment tool areas for EMNOC: Nigerian HospitalsNigerian Hospitals

AREAS STANDARDS

1. Focused Antenatal Care 16

2. Pregnancy Complications 25

3. Labor, Delivery, Postpartum, and Newborn Care 27

4. Postnatal Care for Mother and Newborn 23

5. Support Services 24

6. Information, Education, and Communication 10

7. Human, Physical, and Material Resources 26

8. Management Systems 14

9. Infection Prevention 34

Total 199

See Page v of Nigerian Standards

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Assessment tool areas for EMNOC: Nigerian PHCs

AREAS STANDARDS

1. Focused Antenatal Care 16

2. Pregnancy Complications 20

3. Labor, Delivery, Postpartum, and Newborn Care 27

4. Postnatal Care for Mother and Newborn 23

5. Support Services 13

6. Information, Education, and Communication 10

7. Human, Physical, and Material Resources 25

8. Management Systems 14

9. Infection Prevention 25

Total 173

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Step Two: Step Two: Implement the StandardsImplement the Standards

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Steps to Implement Standards

Do baseline assessment Identify performance gaps Identify causes of gaps and interventions to

correct them Implement interventions Begin and support change process

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Implementation CycleImplementation Cycle

Model Adapted from the International Society for Performance Improvement

Desired performance

Actual performance

Gap Cause analysis

Intervention identification & implementation

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Baseline Assessment

Determines actual level of performance using the performance assessment tool

Helps to identify performance gaps Once gaps are identified, identifies their

causes

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Baseline SBM-R Scores in Kano and Zamfara Hospitals: Aug. 2007

0

5

10

15

20

25

30

Kano Hospitals Zamfara Hospitals

H1

H2

H3

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Baseline SBM-R Scores in Kano and Zamfara PHCs: Aug. 2007

0

5

10

15

20

25

30

Kano PHCs Zamfara PHCs

PHC1

PHC2

PHC3

PHC4

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Defining the performance gap: Defining the performance gap: Example Example

Define the performance gap for each task (in quantitative or

qualitative terms)

100% of pregnant women attending the ANC deliver with a skilled birth attendant

100% of pregnant women attending the ANC deliver with a skilled birth attendant

42% of pregnant women attending the ANC deliver with a skilled birth attendant

42% of pregnant women attending the ANC deliver with a skilled birth attendant

58% of pregnant women attending the ANC did NOT deliver with a SBA

Gap

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In order to perform, a performer needs to:In order to perform, a performer needs to:

Know how to do

Be enabled to do

Want to do

+

+

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Capability (Know how to do)

Opportunity (Be enabled to do)

Motivation (Want to do)

Knowledge, skills, information

Resources, tools, capacity

Inner drive, incentives

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Intervention Identification and Intervention Identification and ImplementationImplementation

Once gaps are identified, do root cause analysis to identify corrective interventions

Interventions should match the root cause of the gap

Implement selected interventions

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Pareto Graph for “Reasons for Not Delivering in the Hospital” (Uganda)A. Food not

culturally appropriate

B. Husband objects

C. Rude staff

D. Afraid

E. Language differences

F. Lack of privacy

G. Lack of knowledge

H. Hospital too far

I. Dirty hospital

J. Long waiting

K. Too crowded

160

140

120

100

80

60

40

20

0

42

2820

17 15 12 10 2 2 1 1

25%

50%

100%

28%

7047%

90

60%

107

71%

122

81%

134

89%

144 146 148 149 150

75%

C F H J D A E K G I B

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Intervention IdentificationIntervention Identification

MOTIVATION INCENTIVES

Resources, CapacityStrengthening of

Management Systems, Provision of Resources

Knowledge, Skills, Information

Training, Information

Type of problem Type of solution

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““If all you have is a HAMMER…If all you have is a HAMMER…everything looks like a NAIL.”everything looks like a NAIL.”

Lack of data and information

Lack of motivation and incentives

Lack of tools and equipment

Lack of knowledge and skills

Training

Lack of financial transparency

There is an epidemic of “workshopitis” in Nigeria

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Effort = PerformanceEffort = Performance

Effort is NOT the same thing as Performance

//

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Change Management StrategyChange Management Strategy

Implementation of change can be difficult (business as usual mentality is rampant)

Performance standards are a tool for initiating and sustaining change

Important to focus on actions and achievement of early results to help ease the change process

Individuals can be powerful agents for or against change

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Change Management StrategyChange Management Strategy

The standards in the tools represent easy and hard challenges

Changes start with the “low-hanging fruit” Managers and providers should start with the

easiest tasks and then move to more difficult tasks, as they develop and increase their change management skills

Observe change process to identify new developments, initiatives and behaviors

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““Multidimensional” Multidimensional” Supervision and SupportSupervision and Support

SBM-R process uses a variety of ways to supervise and support change process: Self/internal assessment Peer/benchmarking Supportive supervision (on demand), external

assessment Client involvement and community participation

(e.g. HFDC with community membership) Bottom-up approach: based on local control,

empowerment, motivation, advocacy, resource mobilization

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Step Three: Measure ProgressStep Three: Measure Progress

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Steps to Measure ProgressSteps to Measure Progress

Encourage providers to self-assess

Measure progress (internal monitoring)

Bring facilities together to share challenges and successes

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Example: Total Results by Hospital, Example: Total Results by Hospital, HondurasHonduras

0

10

20

30

40

50

60

70

80

HRO HJMG HSMO

Baseline

1st internal

2nd internal

3rd internal

2001-2004

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Results from Seven Hospitals in MalawiResults from Seven Hospitals in Malawi

0

10

20

30

40

50

60

70

80

90

100

CDH SJH LCH MCH QECH ZCH LH

2002 2002 2003 Ext 03-04 Ext 04

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PROQUALI, BrazilPROQUALI, BrazilCompliance with standards of reproductive

health care

13th Health Center-Bahia

0

20

40

60

80

100

Total InfectionPrevention

Infra-structure

Baseline

12 Months

15 Months

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PROQUALI Brazil:PROQUALI Brazil: Results from Five Pilot Clinics Results from Five Pilot Clinics

0102030405060708090

100

Baseline 9 months 12 months 24 months

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Qualitative resultsQualitative results

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47

48

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Step Four: Recognize Step Four: Recognize and Reward Achievementsand Reward Achievements

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Steps to Recognize AchievementsSteps to Recognize Achievements

Address motivational issues Decide upon incentives Implement incentive programs

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Ways to Enhance MotivationWays to Enhance Motivation

Empowerment: Giving the tools to self-assess and implement

Challenges: Establishing a clear goal Achievements: Easy to show results Healthy competition: Grouping facilities

encourages sharing of experiences and some competition to succeed

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Recognition methods (as an Incentive)Recognition methods (as an Incentive)

Feedback (verbal, written)

Social recognition

Material recognition

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____________________________Secretary for Health

Conferred by the Ministry of Health to

Mzuzu Central Hospitalin recognition of the

achievement of standardsof excellence in

Infection Preventionpractices

Year 2004

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More sample awards

Health care quality improvement award for Texas State, USA

Uganda’s Yellow Star

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Defining LeadershipDefining Leadership

Leadership: Enabling groups to make progress in complex conditions

Leadership is an activity that takes place at all levels, not a position of authority

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We need Leaders and Change Agents!We need Leaders and Change Agents!

Leaders must be: Visionary Committed Courageous Proactive Determined to make a

difference Humble Role model Persistent Kind Understanding

Mahatma Ghandi

Mathew Luther-King

Nelson Mandela

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Managers should think of LEGACY after office!Managers should think of LEGACY after office!

Tune off the W.I.I.F.M radio station.

Think LEGACY

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SummarySummary

The Standard Based Management and Recognition Approach has been used in different parts of the world to improve the quality of health care services

It can be applied to a variety of technical areas including integrated RH, IMCI, EPI, Malaria, HIV/AIDS, Trauma, and Management of Chronic diseases etc.

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SummarySummary

SBM-R is: A four-step process Not as complicated as it may sound Puts the power in the hands of local

providers and managers Requires multiple sources of

supervision and support

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Thank You from