Integrating Best Practices for Performance Improvement, Quality Improvement, and Participatory Learning and Action to Improve Health Services

1
Integrating Best Practicesfor Performance
Improvement, Quality Improvement, and
Participatory Learning and Action to Improve
Health Services

• APPENDIX FSession A
• Facilitative Supervision for Quality Improvement
  Curriculum
• 2008

2
Resources Guidance for Program Staff

• Integrating Best Practices for
• Performance Improvement (PI),
• Quality Improvement (QI),
• and Participatory Learning and Action (PLA)
• to Improve Health Services

3
What Are These Approaches?

• Performance improvement (PI)
• Quality improvement (QI)
• Participatory learning and action (PLA)

4
Performance Improvement Process
Obtain and Maintain Stakeholder Agreement and
Participation in the PI Process
Consultant FactorsRole Assumed, Communication
Skills
PNA
Consider Institutional Context Mission Goals St
rategies Culture Client and Community Perspecti
ves
Define Desired Performance
Strengths to Build on and Performance Gaps
Find Root Causes Why does the
performance gap exist?
Select Interventions What can be doneto close
the performance gap?
ImplementIntervention
Describe Actual Performance
Monitor and Evaluate Performance
5
Performance Factors

• Job expectations
• Performance feedback
• Physical environment and tools
• Motivation
• Skills and knowledge to do the job

6
PI Tools and Interventions (1)

• PNA stakeholders meeting
• Typical tools to define actual performance
• Interviews with providers/staff/supervisors
• Observation of client-provider interaction
• Facility audit/assessment
• Review of service statistics
• Client interviews
• Group discussions in the community

7
PI Tools and Interventions (2)

• Interventions range widely in size and scale,
  based on the needs identified. The facilitator
  helps participants to diagnose gaps in
  performance and identify appropriate
  interventions. Interventions focus on
  strengthening the performance factors and may
  come from any source of knowledge, experience,
  and best practices.

8
PI Tools and Interventions (3)

• Intervention examples
• Training
• Supervision strengthening
• Marketing/communication
• Community mobilization

9
Quality Improvement Process
1. Information gathering and root cause analysis
2. Action planning and prioritization
Actual practice
4. Follow-up and evaluation
3. Implementation
10
Underlying Principles

• A customer mindset
• Staff involvement and ownership
• Focus on systems and processes
• Cost-consciousness and efficiency
• Continuous quality improvement
• Staff development and capacity building

11
Clients Rights and Staff Needs

• Rights of clients
• Information
• Access to services
• Informed choice
• Safe services
• Privacy and confidentiality
• Dignity, comfort, and expression of opinion
• Continuity of care

• Staff needs
• Facilitative supervision and management
• Information, training, and development
• Supplies, equipment, and infrastructure

12
EngenderHealths QI Package

• QI Approaches
• Facilitative supervision
• Whole-site training(including Inreach)

• QI Tools
• COPE
• Community COPE
• Quality Measuring Tool
• Cost Analysis Tool
• Medical Monitoring

13
Facilitative Supervision

• Facilitative supervision is a system of
  management whereby supervisors at all levels in
  an institution focus on the needs of the staff
  they oversee.
• The most important role of the facilitative
  supervisor is to enable staff to
• Manage the QI and PI process
• Meet the needs of clients
• Implement institutional goals

14
When Training Is the Answer Whole-Site Training
(WST)

• WST is an approach to training that
• Meets the learning needs of all staff at a
  service-delivery site
• Views a service-delivery site as a system and
  treats staff as members of the team that makes
  the system work
• Makes training more cost-efficient

15
Inreach

• Inreach involves orienting and informing staff
• within the facility about available services. It
  
• Reduces missed opportunities to provide needed
  services to clients
• Establishes linkages and referrals between
  departments
• Ensures that signs and information for clients
  are available throughout the facility

16
COPE A Continuous QI Process

• Client-
• Oriented,
• Provider-
• Efficient
• services

17
COPE Tools

• Self-assessment guides, including record-review
  checklist
• Client interviews
• Client-flow analysis (CFA)
• Action plan

18
The COPE Toolbox

• COPE Handbook
• COPE Toolbooks
• Family planning
• Reproductive health
• Child health
• Maternal health
• Community involvement

• Adolescent reproductive health
• Emergency obstetric care
• PMTCT services
• Cervical cancer
• HIV treatment and care
• HIV testing and counseling

19
Medical MonitoringWhat Is It?

• Medical monitoring
• Is an objective assessment of actual services, to
  identify and close gaps between actual and
  desired practices. The two main components to
  assess are readiness of the facility and
  processes of care
• Ensures that clinical standards, norms, and
  policies are implemented properly

20
Community COPE

• Based on experience in several countries
  (Bangladesh, Kenya, Nepal, and others)
• Some tools adapted from Participatory Learning
  and Action (PLA)
• Used after sites are experienced with COPE
• Helps establish links between site and community
• Uses combined strength to improve services

21
Cost-Analysis Tool

• Measures direct costs of providing services
• Cost of service providers time
• Cost of supplies used
• Can be used to
• Set user fees for different services
• Negotiate subsidies
• Compare costs of changes in type of procedure and
  provider (Decisions must be based on best
  medical practice, clients situation, etc.)

22
Quality Measuring Tool (QMT)

• The QMT
• Is based on COPE
• Measures progress in improving quality over time
• Quantifies the results of efforts to improve
  quality
• Encourages staff participation in monitoring

23
Quality of Care at a Site (1996-1998)
Clients' Rights and Staff's Needs
24
Information Gathering
Record/ case review
Data review
CFA
Observation of services
Client interview
Staff interview
COPE
Facility audit
INFO
Quality Measuring Tool
Community assessment
Cost analysis
Identify gap between actual practice and best
practice
INFO
PNA
25
PLA Process

• 1. Explore issues
• Gather information
• Analyze and prioritize problems

• 2. Build support
• Orientation to project objective and process
• Identify community participants
• Create linkages w/other stakeholders

Apply relevant PLA tools in all steps
3. Develop community action plans Solutions
may be implemented by community members
and health workers

• 4. Monitor progress
• Were actions completed?
• Were results satisfactory?
• Are there new issues
• to address?

26
PLA vs. PRA

• Participatory learning and action (PLA)
• Aims to empower communities to undertake ongoing
  self-development
• Participatory methods used in assessment, project
  design, implementation, monitoring, and
  evaluation
• Requires ongoing commitment over many months or
  years
• Participatory Rural Appraisal (PRA)
• Aims to extract information from communities for
  assessments, usually to inform project design
• Can be done in only a few days per community

27
PLA Tools for RH Issues

• Social mapping
• FP or sex census mapping
• Transect walks
• Venn diagrams
• Matrix ranking
• Trend analysis (RH lifeline)
• Ranking and scoring
• Causal-impact analysis
• Pocket chart
• Three-pile sorting

• Picture stories/cartooning
• Drama and role plays
• Flexi-flans as creative materials
• Unserialized posters
• Carts and rocks
• Critical incident analysis
• Two circles exercise
• Semi-structured interviews
• Focus-group discussions
• Case studies, stories, portraits

28
Interventions Based on PLA

• PLA-based interventions range widely, depending
  on the issues addressed, the resources available,
  the level of participation, and who participates.
• Some are implemented by community members
• Some are implemented by health workers or outside
  agency
• At the highest level of participation,
  communities set their own agenda and mobilize to
  carry it out in the absence of outsiders,
  initiators, and facilitators. They may identify
  issues beyond health.

29
What Makes All of These Approaches Best
Practices?

• They are
• Evidence-based
• Replicable
• Transferable
• Sustainable
• Widely recognized and applied in the field of
  international health (e.g., USAIDs MAQ
  Initiative, WHOs Implementing Best Practices
  Initiative, Advance Africas Compendium of Best
  Practices)

30
Why Integrate These Approaches?

• ACQUIRE partners bring proven, effective
  approaches to improve provider performance and
  quality of services.
• The approaches are mutually reinforcing.
• Together, they promote the ACQUIRE Project
  results
• Access
• Quality
• Use of RH services

31
What Are the Similarities in These Approaches?

• All are participatory.
• All rely on a step-by-step process to identify
  gaps and solutions.
• All include root-cause analysis of gaps.
• All include stakeholder involvement and
  empowerment.

32
What Are the Differences in These Approaches? (1)

• PI focuses on provider performance and provider
  perspective
• QI focuses on clients rights and staff needs and
  the client perspective

33
What Are the Differences in These Approaches? (2)

• Both PLA and Community COPE emphasize the
  community perspective, but
• Community COPE focuses on involving communities
  in improving facility-based health care
• PLA includes more tools and addresses community
  empowerment more broadly around health and/or
  other issues
• Under ACQUIRE, PLA methods have also been applied
  to tailor information and marketing materials and
  referral systems based on community perceptions
  of underutilized methods

34
What Do We Recommend? (1)

• PI is most appropriate at national, regional, and
  district levels, but can be applied to specific
  cadres of providers.
• EngenderHealths QI tools address multiple
  levels, with a focus on the facility level.
• Community COPE and PLA are complementary.
• e.g., use any of the PLA tools when doing
  Community COPE

35
What Do We Recommend? (2)

• Use PIA to identify needs at higher program
  levels.
• When implementing any of the approaches, at the
  data-gathering stage, consider adapting tools
  from any of the other approaches.
• In a PNA, consider using QMT, the COPE client
  interview guide, or any PLA tool.
• Within PLA, consider using Community COPE tools.
• Apply QI and PLA as ongoing processes to improve
  quality and address the needs identified.

36
Complementary Use of PI, QI, and PLA Beginning
at a National Programming Level

2. National Stakeholder Agreement Meeting
1. MOH wants to explore performance problems
3. PNA conducted in regions
Stakeholders analyze gaps, select interventions
DESIGN, IMPLEMENT, MONITOR, EVALUATE
Develop, disseminate job expectations, standards
Whole-site training Ex Orient all staff on IP,
CTU
Facilitative supervision for QI training For
regional and district supervisors
COPE at facility
PLA
37

Complementary Use of PI, QI, and PLA Beginning
at the Community Level  
Ongoing community health and development actions,
based on PLA activities
Facilitative supervision implemented at the
community health facilities
COPE implemented in facilities
Plan To do a PNA to agree on and develop
appropriate interventions to strengthen and
improve access to IUD services

• Results
• Numerous improvements in participating facilities
• Continuous QI in participating facilities
• Increased IUD utilization (Expected Result)