Transcript Title of Presentation - The ACQUIRE Project : EngenderHealth

Integrating Best Practices
for Performance Improvement,
Quality Improvement, and
Participatory Learning and
Action to Improve Health
Services
APPENDIX F
Session A
Facilitative Supervision for
Quality Improvement Curriculum
2008
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
What Are These Approaches?

Performance improvement (PI)

Quality improvement (QI)

Participatory learning and action (PLA)
Performance Improvement Process
Consultant Factors—Role Assumed, Communication Skills
Obtain and Maintain Stakeholder Agreement and Participation in the PI Process
PNA
Consider
Institutional
Context
Define Desired
Performance
Find Root
Causes
Mission
Goals
Why does the
performance
gap exist?
Strategies
Select
Interventions
What can be done
to close the
performance gap?
Culture
Client and
Community
Perspectives
Describe Actual
Performance
Monitor and Evaluate Performance
Implement
Intervention
Performance Factors

Job expectations

Performance feedback

Physical environment and tools

Motivation

Skills and knowledge to do the job
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
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.
PI Tools and Interventions (3)

Intervention examples:
– Training
– Supervision strengthening
– Marketing/communication
– Community mobilization
Quality Improvement Process
1. Information gathering
and root cause analysis
2. Action planning
and prioritization
Best
practice
Actual
practice
4. Follow-up and
evaluation
3. Implementation
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
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
EngenderHealth’s QI Package
QI Approaches
QI Tools

Facilitative supervision

COPE®

Whole-site training
(including Inreach)

Community COPE

Quality Measuring Tool

Cost Analysis Tool

Medical Monitoring
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
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 servicedelivery 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
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
COPE: A Continuous QI Process

Client-

Oriented,

Provider-

Efficient
services
COPE Tools

Self-assessment guides, including
record-review checklist

Client interviews

Client-flow analysis (CFA)

Action plan
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
Medical Monitoring—What 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
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
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, client’s situation, etc.)
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
Quality of Care at a Site (1996-1998)
Clients' Rights and Staff's Needs
Information and Training
Supplies and Equipment
Management and Supervision
Continuity
Dignity
Privacy and Confidentiality
Safety
Choice
Access
Information
0
20
40
60
Percent Score
Dec-96
Dec-97
Sep-98
80
100
Information Gathering
CFA
Client
interview
Observation
of services
Data
review
Record/
case review
Staff
interview
Facility
audit
INFO
COPE®
Quality
Measuring
Tool
Community
assessment
PNA
INFO
Cost analysis
Identify gap between
actual practice and best
practice
PLA Process
2. Build support:
1. Explore issues:
• Gather information
• Analyze and prioritize problems
• Orientation to project objective
and process
• Identify community participants
• Create linkages w/other
stakeholders
Apply relevant PLA tools in all steps
• Were actions completed?
3. Develop
community action plans:
• Were results satisfactory?
• Are there new issues
to address?
Solutions may be implemented
by community members and
health workers
4. Monitor progress:
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
PLA Tools for RH Issues

Social mapping

Picture stories/
cartooning

FP or sex census mapping

Transect walks

Drama and role plays

Venn diagrams


Matrix ranking
Flexi-flans as creative
materials

Trend analysis (RH lifeline)

Unserialized posters

Ranking and scoring

Carts and rocks

Causal-impact analysis

Critical incident analysis

Pocket chart

Two circles exercise

Three-pile sorting

Semi-structured interviews

Focus-group discussions

Case studies, stories, portraits
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.
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., USAID’s MAQ Initiative,
WHO’s Implementing Best Practices Initiative, Advance
Africa’s Compendium of Best Practices)
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
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.
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
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
What Do We Recommend? (1)

PI is most appropriate at national, regional, and
district levels, but can be applied to specific
cadres of providers.

EngenderHealth’s 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
What Do We Recommend? (2)

Use PIA to identify needs at higher program levels.

When implementing any of the approaches, at the datagathering 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.
Complementary Use of PI, QI, and PLA Beginning at a National Programming Level
1. MOH wants to
explore
performance
problems
3. PNA
conducted in
regions
2. National
Stakeholder
Agreement
Meeting
Stakeholders analyze gaps,
select interventions
DESIGN, IMPLEMENT, MONITOR, EVALUATE
Whole-site training:
Develop, disseminate job
expectations, standards
Ex: Orient all staff on IP, CTU
COPE® at facility
PLA
Facilitative supervision for QI
training
For regional and district supervisors
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:
1. Numerous improvements in participating facilities
2. Continuous QI in participating facilities
3. Increased IUD utilization (Expected Result)