PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
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PEOPLE
PRIVATE HEALTH SECTOR
QUALITY
IMPROVEMENT
PACKAGE
FOR MIDWIVES AND
SUPERVISORS
June 2007
This publication was produced for review by
the United States Agency for International
Development. It was prepared by the Private Sector
Partnerships-One project
A
PSP-Ozz^
PRIVATE SECTOR PARTNERSHIPS FOR BETTER HEALTH
7
PRIVATE HEALTH SECTOR
QUALITY IMPROVEMENT PACKAGE
DISCLAIMER:
The views expressed in this publication do not necessarily reflect the views of the United States Agency for
International Development or the United States government. This publication was produced for review by the
United States Agency for International Development. It was prepared by the Private Sector Partnerships-One
project.
FORWARD
We are pleased to present a package of materials designed for use by midwives practicing in the
private sector. This particular package was developed for midwives and their supervisors who are
members of the Uganda Private Midwives Association (UPMA). This association was formed in
1948 by 12 outstanding leaders of midwifery practice in Uganda to promote a high level of care
and service to women that they were serving. Overtime, UPMA has benefited from numerous
projects and efforts to help them grow their membership and to continue to improve the quality
of care provided to women and their families throughout Uganda.The purpose of this package is
to enable private practitioners to perform a self assessment of their practice, identify their perfor
mance gaps and consider ways of resolving the performance gaps.
The components of this Quality Improvement Package are as follows:
Section I: Implementation Guide for Midwives and Supervisors
Section 2: Self-Assessment Package for Midwives
Section 3: Action Plan for Midwives
Section 4: Supervisor's Guide
Section 5:Training Guide for Facilitators
The materials in this package were designed for use by midwives in Uganda; however; it has been
adapted for use by different cadres (physicians and pharmacists) and for different services (rural
primary health care centers and includes chronic conditions as well as MCH and FP), an expanded
version for all family planning methods, and three comprehensive modules concerning HIV/AIDS
andTB services. The different cadres have responded to the assumption that they are being em
powered to review their own practice, try to make improvements, and seek outside assistance for
resolving some of their issues. In one phrase, the users are discovering that “quality belongs to
everyone” and can be improved by their own initiatives. Currently, a research study is underway in
Uganda to determine if the tool improved quality of services provided by the midwives and under
what circumstance (with and without supervisory support). The results of the study are expected
in November 2007.
All the different modules and variations of this QI package can be found on the PSP-One project
website: www.psp-one.com. We welcome being contacted for guidance in adapting this tool and
approach to your country (mary_segall@abtassoc.com).
Ruth Berg, PhD
Project Director
Private Sector Partnerships-One
Mary E. Segall, PhD, RN
Director; Quality Improvement Program
Private Sector Partnership-One
ACKNOWLEDGEMENTS
The authors thank a number of people who were instrumental in developing this set of materials.
The performance improvement framework and tool that IntraHealth International in Armenia
developed with the FAPs (small health centers staffed typically with one provider) provided the initial
draft—thanks to Lauren Crigler and Rebecca Kohler The experience gained in developing a
performance improvement review process for primary health care centers in Jordan with Initiatives
Inc., under the direction of Joyce Lyons, was invaluable in learning the steps required to develop a
tool and process for improving quality. Thanks to the Private Sector Partnerships-One (PSP-One)
project director Ruth Berg, for reminding us that a simple and efficient tool designed for the private
sector would contribute to the care midwives provide and benefit their clients. Partners associated
with the PSP-One project who reviewed and commented on the document include Maureen Corbett
and Carol Stanley of IntraHealth International; Jeffrey Barnes, Denise Averbug, Neha Suchak, Susan
Scribner; Melinda Ojermark, Susan Mitchell, and Leanne Dougherty of Abt Associates; Carlos Huezo
and Barbara Janowitz of Family Health International; Meaghan Smith, Lisa Tarantino, and Bernard
Koissy of Banyan Global; Barbara O’Hanlon of O'Hanlon Consulting; and Sohail Agha of Tulane
University. Other individuals consulted included Barbara Kinzie Deller of JHPIEGO, Deborah
Armbruster of the Program for Appropriate Technology in Health, and Nester Moyo of the
International Confederation of Midwives.The materials benefited from the constructive comments
of external reviewers Betty Farrell, Patrice White, Martha Carlough, Catherine Murphy, and Thomas
Schwark, as well as Marguerite Farrell, Shyami de Silva, and Susan Wright of the United States Agency
for International Development. Finally, our sincere thanks and gratitude to the Uganda Private
Midwives Association Staff (Mary Namusisi,Theresa Nantale, Nina Shalita, and Michael Matsiko),the
executive committee, and the practicing midwives.
SECTION I: IMPLEMENTATION GUIDE FOR MIDWIVES
AND SUPERVISORS
Section 1:
Implementation Guide
PRIVATE HEALTH SECTOR
QUALITY IMPROVEMENT PACKAGE
CONTENTS
Section I: Implementation Guide for Midwives
and Supervisors
Acronyms............................................................................................................i
Introduction................................................................................................ 1-1
What Does the Package Contain?.................................................. 1-3
Step I: Review of Statistics Form...............................................I -3
Step 2: QI Self-assessment Tool..................................................1-4
Step 3:Action Plan for Midwives............................................... 1-6
Step 4: Supervisor’s Guide.......................................................... I -7
How do I use the package?...................... ........................................... 1-9
Getting Started...................................................... ................... I -10
Conclusions.............................................................................................. I-1 I
References................................................................................................. 1-12
SECTION I IMPLEMENTATION GUIDE FOR MIDWIVES
ACRONYMS
ANC
Antenatal care
COC
Combined oral contraceptive
EPl
Expanded program of immunization
FP
Family planning
HLD
High-level disinfection
IP
Infection protection
INFO
Information and Knowledge for Optimal Health
IUD
Intrauterine device
MCH
Maternal and Child Health
PMTCT
Preventing mother to child transmission
POP
Progestin-only pill
PPIC
Postpartum and infant care
PSP-One
Private Sector Partnerships-One
QA
Quality assurance
QI
Quality improvement
RH
Reproductive health
SMART
Specific, measurable, attainable, realistic, and time-bound
STI
Sexually transmitted infection
TBA
Traditional birth attendant
UPMA
Uganda Private Midwives Association
WHO
World Health Organization
SECTION I-.IMPLEMENTATION GUIDE FOR MIDWIVES
INTRODUCTION
WHY ADDRESS QUALITY IN THE PRIVATE SECTOR? WHY USETHIS PACKAGE?
Promoting and evaluating quality care is a priority for anyone delivering, organizing, or monitoring
clinical services. At the individual level, improved quality of care ensures clients receive respectful
treatment by technically competent providers. At the population or community level, greater
satisfaction with services should translate into better continuity of care and better utilization of
preventive services. From policy makers and managers at the country level to international donor
agencies, there is consensus that delivering quality services is important.
Initiatives to improve quality of care have a long history in the public sector throughout the world.
Little attention, however; has been paid to quality of care globally in the private sector Certainly the
same principles about the importance of quality in the public sector apply to the private sector:
better services and better continuity of care result in more repeat business and better health.
There are also more specific reasons to address quality in the private sector First, the public
sector is unable to keep up with the growing demand for certain services, including reproductive
health (RH) and family planning (FP). Second, the private sector is an important partner in HIV/
AIDS prevention, testing, and treatment.Third, health-sector reforms often call for segmentation
of services—some of which are most efficiently provided in the private sector And, finally, private
health expenditures already are substantial.
The last point warrants further explanation: by addressing the private sector we address significant
portions of the developing world’s population that pay for health services. According to recent
Demographic and Health Surveys and World Bank surveys, in many countries 60 to 80 percent
of health care services are delivered in the private sector In Vietnam, among the lowest income
quintile, 48 percent of ill respondents chose a private provider (Ha, Berman, and Larsen 2002). In
India private health services accounted for 56.5 percent of health services utilization in the most
deprived households (Srinivasan and Mohanty 2002). In Uganda's rural populations, the private
sector accounted for 44 percent of medical services used (Uganda Bureau of Statistics 2001).
The 60 to 80 percent of people who seek private sector services—-and pay significant amounts
out of pocket—do so with the assumption they receive better care than they would in the public
sectorThere are concerns, however; that private sector providers typically do not have a system to
monitor and evaluate their services. As such, the care provided in the private health sector may not
be any better than care delivered in the public sector In fact, private sector providers often are not
held to the same regulations and standards of service delivery as their public sector counterparts
are. In many instances the status of quality in the private sector is unknown because of the
individual and often unregulated nature of most private practices.
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
In March 2005 the Private Sector Partnerships-One project (PSP-One)1 conducted a quality
assurance (QA) panel that assembled a variety of experts to discuss current QA practices used in
the public health sector and how they can be applied to the private health sector (Segall 2005). A
major recommendation from this panel was that approaches and tools that improve the quality of
public-sector service provision be adapted for and tested in the private sector
PSP-One subsequently developed a quality improvement (QI) package for the provider and his or
her supervisor in the private sector2 This package is most effectively introduced through a formal
structure, such as a professional association, network, public/private partnership, or franchise that
can be strengthened to be a support to their members.
’PSP-One provides technical leadership to increase the private sectors interest, ability, and direct involvement in the delivery of quality
reproductive and other health products and services.To achieve this objective, PSP-One provides technical expertise in many areas, including
quality improvement
-This package was modeled after a QA package created for the USAID-funded Project Nova in Armenia (Crigler, Kohler, and Baghgdasarova
2005).
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SECTION I: IMPLEMENTATION GUIDE FOR MIDWIVES
WHAT DOESTHE PACKAGE CONTAIN?
PSP-One created a QI package for the private
effective operating procedures, and positive
sectorthat includes a review of service
health outcomes. It also will help the midwife
statistics, accompanying a QI self-assessment
market his or her services and attract new
tool for midwives to identify quality issues,
and repeat business. The statistics form
and a linked action plan for midwives and
collects simple data on 13 FP and MCH
supervisors to help solve issues the QI tool
indicators to ascertain if the midwives' quality
improvements result in changes in health
identifies.
outcomes and service use. If the practitioner
This package is aimed at practitioners (in
already is collecting these statistics, but in a
this case, midwives) in independent practice.
different form, then he or she can continue to
Midwives are a significant and growing
use his or her system, but still should review
segment of private providers of essential and
these indicators.
basic health services in the developing world.
The 13 indicators are
This group, along with other professional
providers (for example, general practitioners
I.
Births attended
2.
Live births attended
they provide. Furthermore, midwives are likely
3.
Antenatal visits
to be the only or one of a few staff members
4.
New antenatal visits in the first trimester
in a privately owned clinic.The government
5.
New antenatal visits
6.
Labor referrals
practice guidelines, subsidies for supplies,
7.
Pregnancy/fetal complications
or other inputs that affect the quality of
8.
Family planning (FP) counseling visits
9.
New FP users
10.
Return/repeat FP visits
or her services without relying on outside
II.
Infant Care Visits
monitoring. Descriptions of and purposes for
12.
Postpartum Visits
13.
Contraceptives Delivered and Type
and pharmacists), should have access to tools
to help them assess the quality of services
may officially license the facility, but it provides
little or no supervision, continuing education,
services.This QI package consists of steps
that a provider in independent private
practice can use to improve the quality of his
each of the package's elements are outlined
in the following section; they function with the
assumption that quality is a process.
Indicators I and 2 (Births attended
and Live births attended) will let
STEP I. REVIEW OF STATISTICS
FORM
practitioners know if they are seeing an
increase in the number of births attended and
Improving quality should result in quantitative
an increase in the number of births resulting
changes in service use, contraceptive use,
in a healthy baby.This data will help them
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PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
project how many pregnant women they
their supervisors with an indication on how
should be seeing (as a function of how many
effective their FP counseling skills are and
pregnant women there are in the catchment
also will allow them to project what types
area who choose not to birth at home or in a
of contraception they will need to keep on
public sector facility) in a given period of time
hand. Monitoring these indicators will help the
and will help them with revenue forecasting
practitioner avoid stock outs and potentially
and supply needs.These two indicators also
can add repeat customers.
will allow the practitioner to re-examine
causes of unfavorable birth outcomes or
Indicator I 1 (Infant care visits) will help
highlight and market positive outcomes.
determine if practitioners deliver essential
care to newborns that they attended.
Indicator 3 (Antenatal visits) is a
process indicator in which providers capture
Indicator 12 (Postpartum visits) helps
care given to a pregnant woman, even if not
providers monitor how many women they
related to her pregnancy.
see after discharge but within the first 6-
Indicators 4 and 5 (New antenatal
statistical indicators (step I) coupled with the
visits in the first trimester and New
QI self-assessment tool (step 2) will guide
antenatal visits) help providers monitor
practitioners toward identifying areas of
how many women they see early in the
improvement in their practice and guide and
woman’s pregnancy, as many women only
structure an action plan (step 3a) that moves
seek antenatal care in their last trimester if
users from problem identification to solutions.
8 weeks after birth. A quarterly review of
they seek it at all.
STEP 2. QI SELF-ASSESSMENT
TOOL
Indicators 6 and 7 (Labor referrals
and Pregnancy/fetal complications)
The second tool in the package, the QI self
will allow practitioners to know that they
assessment tool, leads private providers
need to follow-up with the referred client
through a series of questions that indicate
and also market to their community that they
if they provide quality care.This tool helps
can care for a woman if complications arise.
providers measure quality, determine where
Also, by knowing the outcomes of referrals,
gaps in quality exist, and track improvements
providers can give better follow-up care when
in quality in individual practices.To achieve
patients seek care from the practitioner again.
desired results, quality must be viewed as
Providers also can seek out referred patients
a multi-dimensional concept in which the
to be sure follow-up care is administered.
dimensions can vary in composition and
importance depending on the context
Indicators 8 through 10 and 13 (Family
(Donabedian 1980).The dimensions that
planning counseling visits, New FP
experts working in developing countries
users, Return/repeat FP visits, and
most frequently agree upon are: technical
Contraceptives delivered and type)
competence, access to services, effectiveness,
monitor the practitioners' FP services.These
efficiency, continuity, interpersonal relations,
indicators will provide both midwives and
safety, and amenities (Brown, Fanco, and
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SECTION I:IMPLEMENTATION GUIDE FOR MIDWIVES
Rafeh 1998). PSP-One selected and adapted
This dimension also addresses the critical
the following dimensions for implementation
relationship private providers have with the
in the private sector because of their
community by understanding community
perceived relevancy:
needs (market analysis), marketing services
based on those needs, and eliciting client
• Physical environment refers
feedback. Community indicators are
to a facility's ability to provide a safe
included in the marketing dimension to
environment for health care and examines
reflect the priorities of the private sector.
equipment, supplies, and medicines in
facilities and the condition of the clinic’s
• Business practices examine the
infrastructure.
provider's goals, financial-management
practices (including record keeping and
• Technical competence examines the
pricing systems), resources for adequate
provider's performance and determines
financing, and allocation of resources.
if it meets acceptable standards. For
midwives, this tool examines performance
Within each dimension there are indicators
in the clinical areas of counseling, infection
and for each key indicator there are questions
prevention (IP), antenatal care (ANC), labor
for the provider to answer Each dimension
and delivery, family planning, postpartum
has a different number of questions. The
and infant cane (PPIC), sexually transmitted
number of questions does not necessarily
infections (STIs), and immunization.
reflect the dimension’s importance, but rather
the emphasis at the facility level. At a country
• Continuity of care examines functional
referral systems when care is needed
level, the midwives should agree upon what
outside of what providers can do in his/her
services they provide and, therefore, what
clinics. It includes knowing when to refer; if
services need to be assessed. For example,
there are proper and official procedures
if midwives in private practice in a particular
for referrals, the flow of client records or
country do not provide immunizations, then
information to and from a referral, client
questions relating to that indicator on the QI
follow-up, and ensuring repeat visits by the
self-assessment tool would be removed.The
pie chart on the following page represents
same provider.
the percentage each dimension contributed
• Management refers to the provider's
to the assessment. For example, there are
capacity to plan, organize, implement, and
30 questions in the physical environment
maintain effective health delivery services.
dimension out of a total of 266 questions in
Management includes utilizing data for
the entire tool; thus I I percent of the total is
decision-making and proper tracking of
concerned about the physical environment.
finances and supplies.
The question then becomes “how will
• Marketing refers to the providers’
knowledge of people in his/her community
providers know how well they are doing
and how effectively he/she markets services
under each dimension?" This tool shows
to maintain clients and attract new ones.
providers where they can improve by
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PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
reviewing questions that they answered “no”
If this tool is used quarterly, providers can
or “yes, but needs improvement" Review
see how they improved, what problems
of these answers is the simplest way for
were easy to fix, and what problems persist.
midwives to identify gaps in quality at their
The tool can be completed in parts over the
facilities. If there is a supervisor at the facility,
course of four or five days, if providers cannot
however; or through an association, network,
complete it in one day. After completing step
or franchise, a quality index score can be
two, providers will have an idea of the quality
of care that their facilities offer What this
calculated to measure trends.
tool does not do, however is guide providers
about how to improve in areas in which they
How do you calculate and use the
quality index score? Each question in
did not score well.That assistance occurs in
the dimension’s indicators can be answered
Step 3: Action Plan for Midwives and Step 4:
"Yes”; “Yes, but needs improvement”; "No”;
Supervisor's Guide.
or “Not Applicable." Each response is given
STEP 3. ACTION PLAN FOR
MIDWIVES
a numeric score: “Yes' — 2 points; “Yes, but
needs improvement’^ I point; "No”=0 points
(questions that receive a response of "Not
In tandem with the QI assessment tool,
Applicable" are dropped from the scoring). At
the action plan helps facilitate a simple
the end of each section, the poin ts are tallied
problem-solving process. A separate action
to give a score for that dimension. Specific
plan can be developed for each dimension
instructions on how to calculate the score are
so that providers can monitor progress and
in Step 4: Supervisor’s Guide.
add to the plans separately by each area.
PERCENTAGE OF EACH QUALITY DIMENSION’S CONTRIBUTION
TO ASSESSMENT
9%
11%
2%
[~~]
8%
\
3%
1 1 % Physical Environment
/
•
67%Technical Competence
\
Q] 3% Continuity of Care
/
IQ 8% Management
; . 2% Marketing
3 9% Business Practices
67%
1-6
SECTION I' IMPLEMENTATION GUIDE FOR MIDWIVES
Completing the action plan will help providers
or franchises with the potential availability
see where the most emphasis is needed and
of supervisors is a useful resource for the
how they are progressing. It prompts users
midwife.
to first revisit the statistics form to frame
STEP 4. SUPERVISOR’S GUIDE
interventions in terms of improved health
outcomes and then revisit low scores on the
If there are supervisors or other organizing
QI self-assessment tool.The action plan is
entities, such as networks or professional
laid out as a table.The data in column one
associations, they too can have a critical part
refer users back to the QI self-assessment
in ensuring the provider fully benefits from
tool—namely the question number, and
using the package.
questions to which they answered "no” or
“yes, but needs improvement.” Users are
Supervisors can discuss the causes, help with
then asked to state in column two what the
solutions, and mobilize external resources.
causes were (why) that led to a “no” or "yes,
Ideally, supervisors would visit quarterly to
but needs improvement" answer. Next, users
monitor progress toward completing action
are prompted in columns three and four to
plan items before the next self assessment
list possible solutions, actions, or next steps
is administered. In addition, professional
and then assign a responsible person with
associations, networks, or franchises also may
a deadline in columns five and six. Finally, in
use periodic, pre-set meetings to discuss
column seven, the user records the status of
or alleviate common problems and discuss
the action item (e.g. completed, pending) and
solutions as a group. For example, if multiple
whether external resources are required.
members of an association are unable to use
At this stage, an action plan is on paper. Will
will become aware of the problem by
it lead to change? Research shows that most
reviewing members’ actions plans and can use
quality issues a facility faces are solvable within
pre-set monthly meetings to educate them
that facility and do not require an outside
about how to use a pantograph.
a pantograph (question 2.34a), the association
intervention or resources (Bjerregaard 2004).
Often the problems are concerned with
Supervisors can use the package by scoring
management issues, communication among
the provider’s QI self-assessment responses
staff and with clients, listening to clients, and
to the questions.They also should record
updating records. Of course, other problems
the action plans of their supervisees in
do require additional resources or policy
their own records to monitor progress.The
changes to solve. Such problems often are
computerization of the tool and action plan is
more easily solved when a formal supervisor
being pilot-tested in Uganda with the Uganda
or professional association representative is
Private Midwives Association (UPMA) to
included in the quality improvement effort.
determine ways to track changes over time
While steps one through three are used with
using a computerized data base rather than
only an individual provider to improve quality,
manually.
the use of networks, professional associations,
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SECTION I: IMPLEMENTATION GUIDE FOR MIDWIVES
HOW DO I USE THE PACKAGE?
Implementation is a four-step process:
accompanying that step.This process is best
done with hands-on activities: coaching and
I.
Marketing the package and raising interest
2.
Training on how to use the materials in the
package
supervised practice. Finally, package materials
should be disseminated and a plan for
replacing instruments and forms should be in
3.
Dissemination of package materials
place and accessible to providers. Currently,
4.
Getting started
the QI self-assessment tool can record
answers on four occasions (ideally for four
I. MARKETING THE PACKAGE
AND RAISING INTEREST:
quarters). PSP-One has developed and field
tested a training guide that is included as
Projects, professional associations, networks,
part of this package. Please see the project
public/private partnerships, and governments
web site: www.psp-one.com for updates and
should market this package through local
examples of adap tations of these materials to
venues to promote and raise interest among
other types of provider groups and services,
relevant stakeholders. Such advocacy will
and future access to the training guide.
create demand for use in the private sector
3. DISSEMINATION OF PACKAGE
MATERIALS:
2.TRAINING ON HOWTO USE
THE PACKAGE:
Materials for the QI package and orientation
Providers and supervisors who use the
should be available at a number of different
tool need to be guided through its use.This
venues: networks, professional associations,
training or orientation can be short—even
government offices, and local health projects.
just a few hours or through self-paced
A plan also should be in place for duplicating
learning (no classroom required). Each
materials to ensure new and repeat users
provider should be given a short introduction
have access to the forms.The package has
to the package's purpose.The focus should
been designed so that users can use it for
be on why quality is important for the
one year before duplication is necessary.This
private provider. Next, the provider should
ensures that duplication is kept to a minimum
be introduced to each step and the tool
to ensure sustainability.
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PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
FLOWCHART FOR QUALITY IMPLEMENTATION ANDTRAINING
5. GETTING STARTED
Step 2:
N Assess Quality Using
z QI Self-Assessment Tool
Time: Quarterly
Purpose:
Measure quality,
determine gaps, and
track improvements
Step I:
Review Statistics
Time: Quarterly
Step 3:
Develop/Revise
Action Plan
Time: Quarterly
Purpose:
Collect data to determine
if improvements result in
changes in health status
and service utilization
Purpose:
Facilitate problem
solving process
Step 4:
Identify Resources
with Supervisors
Time: Monthly or
Quarterly
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SECTION I: IMPLEMENTATION GUIDE FOR MIDWIVES
CONCLUSIONS
Proper use and consistent implementation of
The self-assessment structure put
this package can improve quality in the private
responsibility on the provider to improve
sectocThis package also can be adapted for
services while engaging outsiders in a
other service providers, for example, general
collaborative and participatory mannen
practitioners and pharmacists.The package
instead of a punitive one.
hinges on the use of self assessment, which
is appropriate and feasible for small facilities
in the private sectorthat are operated by a
single service provider. Sustainability, however;
is always a challenge when introducing a new
process or concept—particularly if it involves
additional work for providers. Several options
for incentives exist and we will encourage
users of the tool to explore viable options.
• According to discussion groups PSPOne conducted with private providers
in Uganda in 2006, midwives stated that
providing quality services retains clients and
attracts new ones through word of mouth,
thus making their clinics more profitable.
• The same group said that the tool would
increase their efficiency by systematically
identifying problems as well as ways to
solve them.They also said the tool was easy
to use and did not require excessive time
commitments.
Research conducted by the PRIME II
Project in Kyrgyzstan (Levin, Luoma, and
Mason 2004) demonstrated that the public
posting of data could be a strong motivator
for providers. Data also may be able to be
used for marketing. Charts and graphs in
facilities and communities can be used to
show changes in data every month and can
be posted by providers or supervisors.
Although a formal accreditation system is
beyond this project's scope, approval for
formal recognition of quality that achieves
improvements in the data could be
explored through a professional association,
network, or franchise.
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
REFERENCES
Ha, N., R Berman, and U. Larsen. 2002. Household
Bjerregaard, D. 2004. Performance Improvement
Review: A Tool to Improve Performance at the
Health Center. Amman, Jordan: Primary Health
utilization and expenditures on private and
public health services in Vietnam. Health Policy
Planning 17 (I): 61-70.
Care Initiatives Project.
Segall, M. 2005. Quality assurance panel,
strengthening reproductive health services
quality in the private sector: approaches, tools,
and incentives. Panel held in Washington, DC,
Brown, L, LN. Franco, and N. Rafeh. 1998.
Quality Assurance of Health Care in Developing
Countries, Bethesda, MD: Quality Assurance
Project
March 3.
Crigler, L, R. Kohler and K. Baghgdasarova. 2005.
Reproductive Health and Maternal Health
Quality of Care. Project Nova. Yerevan, Armenia.
Srinivasan, K., and S.K. Mohanty. 2002. Health Care
Utilization by Source and Levels of Deprivation
in Major States of India: Findings from NFHS-2.
Mumbai: International Institute for Population
Sciences.
Donabedian, A. 1980. Explorations in Quality
Assessment and Monitoring. Ann Arbor Ml:
Health Administration Press.
Uganda Bureau of Statistics. 2001. Uganda
National Household Survey 1999/2000. Entebbe,
Uganda: Uganda Bureau of Statistics with
World Bank Group.
Levin, L, M. Luoma, and R. Mason. 2004. Public
Posting in Kyrgyzstan. Chapel Hill, NC: PRIME II,
Project.
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PRIVATE HEALTH SECTOR
QUALITY IMPROVEMENT PACKAGE
Section 2:
Self-Assessment Package
SECTION 2: SELF-ASSESSMENT PACKAGE FOR MIDWIVES
CONTENTS
Section 2: Self-Assessment Package for Midwives
Introduction............................................................................................... 2-1
Monthly Statistics Form..................................................................... 2-3
Definitions of Service Statistics Indicators.............................. 2-3
Instructions................................................................................... 2-5
QI Self-Assessment Tool..................................................................... 2-7
Instructions................................................................................... 2-7
Dimension I-Physical Environment...........................................2-9
Dimension 2—Technical Competence.................................... 2-13
Dimension 3-Continuity of Care....................... ................... 2-31
Dimension 4-Management.... .......... ,...................................... 2-33
Dimension 5-Marketing........................................................... 2-37
Dimension 6-Business Practices...................... ...................... 2-39
References................................................................................................ 2-43
INTRODUCTION
Improving quality should result in quantitative changes in service use, contraceptive use, and
positive health outcomes.The following material is a quality improvement package that consists of
four steps:
Step I:
Statistics’ Form
Step 2:
Quality Improvement (QI) Self-Assessment Tool
Step 3:
Action Plan for Midwives
Step 4:
Supervisor’s Guide
The Statistics form is a place to record clinic data for 13 FP and MCH service indicators by month.
The QI self-assessment tool consists of six dimensions and indicators with questions for each
indicator. By having providers review their statistics and use the action plan to solve problems they
identify, the care they provide will improve and their clients will perceive the changes and spread
the word to others. This QI package has been developed specifically for use by midwives in the
private sector and relies on self-assessment of one's practice.
• Each month fill out the statistics form. Use the statistics in your clinic records to record the
data for each of the 13 service indicators explained on the first page of the statistics form.
• Each quarter complete the QI self-assessment tool and prepare your action plan to address
the quality dimensions that need strengthening according to your completed self-assessment
tool.
• During the quarter use your action plan to guide your QI activities, making adjustments as
needed.
• At the end of the quarter, review your action plan and refer to the statistics form from that
quarter to see whether there may be an association between your QI activities and improved
service statistics. Complete the QI self-assessment tool and update the action plan for the
next quarter For service statistics and QI indicators that still need improvement, keep them in
mind as you create your action plans for the next quarter and focus some of your activities on
addressing them.
’Statistics: the interpretation of large amounts of numbers, facts or data collected and arranged in an orderly way for study and analysis.
2-1
MONTHLY STATISTICS FORM
DEFINITIONS OF SERVICE STATISTICS INDICATORS
I.
Births attended: Total number of births you attended to completion (end point is the birth
of a newborn, alive or not).
2.
Live births attended: Of the number of births recorded in I, the number of newborns that
were born alive.
3.
Antenatal visits: Total number of pregnant women to whom you provided care or support per
month (i.e., pregnant women you saw for a new antenatal visit or a return antenatal visit).
4.
New antenatal visits in the first trimester: Number of pregnant women you saw for
their first antenatal visit who were in their first trimester (less than or equal to 12 weeks)
during the previous month. Record the first trimester separately from the other new antenatal
visits so that you can see if women are coming for care early in their pregnancies.
5.
New antenatal visits: Total number of pregnant women seen for their first antenatal visit
during the previous month. (Do not count as "new” women who come to you for the first
time, but who have been seen by another midwife during this pregnancy and have an ANC
card).
6.
Labor referrals: Number of women in labor who were referred to another facility or
provider during the previous month. It is important to keep a register/file of all women
referred and a brief statement of why they were referred.
7.
Pregnancy/fetal complications: Of the women you cared for; how many did you see
who had any of the following complications related to pregnancy, delivery, or after delivery:
suspected ectopic pregnancy, pre-eclampsia or any symptoms of pre-eclampsia, eclampsia,
premature rupture of membranes, malpresentation, prolonged/obstructed labor fetal distress
in labor; loss of fetal movement, prolapsed cord, excessive bleeding, postpartum hemorrhage,
tetanus, retained placenta, foul-smelling discharge with fever severe anemia, septic abortion,
fistula, or baby borne with weight less than 2.5 kgs?
8.
Family planning counseling visits: Number of people seen during the previous month
for counseling on FP methods. Include as a visit the person whom you counsel about a FP
method even if she does not choose a contraceptive product at that particular visit. Do not
count clients whose end treatment is for some reason other than FP (for example, a woman
who visits thinking that her vaginal discharge is a side effect of the FP method, but upon
examination, you conclude that she has a sexually transmitted infection). If the client is given or
accepts condoms as part of the STI management, then count the visit as a FP visit.
9.
New FP users: Of your number of FP visits during the previous month in number 8, how
many initiated, began using (or accepted) an FP method?
2-3
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
Return/repeat FP visits: Of your number of visits in number 8, the number of follow-up
10.
visits including counseling and re-supply of the product.
Infant care visits: Number of newborns and infants (up to I year old) seen for checkups
11.
(including height and weight monitoring), immunizations, and follow-up and/or referral for
malarial treatment?
Postpartum visits: Number of postpartum women seen after discharge but within the first
12.
6-8 weeks after birth.
13. Contraceptives delivered and type: Number of contraceptives given or sold to clients
by type (pill, condom, injectable, intrauterine device (IUD), and implants)? Please complete the
following table.
Number and type of contraceptives provided by month
Month
Number
of
condoms
Number of
pill cycles
coc
POC
Number of
injectable
doses
January
February
March
April
May
June
July
August
September
October
November
December
2-4
Number
of IUDs
inserted
Number of
implants
inserted
Number
of
referrals
Other
(specify, e.g.
counseling
about Moon
Beads)
INSTRUCTIONS
Each month complete the statistics form for the previous month (please specify the time
period). Use the statistics in your clinic records to record the data for each of the twelve service
indicators in the statistics form and the table on the preceding page to record statistics about
contraceptives provided and type (indicator 13).
Indicator Key:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Births attended
Live births attended
Antenatal visits
New antenatal visits in the first trimester
10.
II.
12.
13.
New antenatal visits
Labor referrals
Pregnancy/fetal complications
FP counseling visits
New FP client users
Return/repeat FP visits
Infant care visits
Postpartum visits
Contraceptives provided and type (refer
to table on previous page)
Number recorded for each indicator
Month
1
2
3
4
6
5
January
February
March
April
May
June
July
August
September
October
November
December
2-5
7
8
9
10
II
12
QI SELF-ASSESSMENTTOOL
The QI self-assessment tool consists of dimensions and indicators for ensuring quality health ser
vices. This tool will help you measure quality, determine where the gaps in quality exist, and track
improvements in quality in individual practices. Usually, there are six parts to this tool, one for each
dimension of quality being assessed:
• Physical Environment
• Technical Competence
• Continuity of Care
• Management
• Marketing
• Business Practices
The dimensions are subdivided into indicators and for each indicator there is a set of questions.
INSTRUCTIONS
I. Read through each question and record your answer in the column for the quarter you are
assessing. Record your answer in the following way:
a.
b.
If your answer is “Yes,” check or record the number “2" in the answer column.
If your answer is “Yes, but needs improvement,” check or record the number " I" in the
answer column.
c.
d.
If your answer is “No,” check or record the number "0" in the answer column.
If the question is not applicable to your clinic, record "N/A" (not applicable) in the answer
column. For example, in the Technical Competence dimension, indicator 10, question
2.74 "Do you store vaccines according to cold chain standards?” If you do not provide
immunizations that require a cold chain or you do not keep vaccines in your clinic that
require a cold chain, check the “N/A" box.
2. After completing this tool, refer to the action plan. For every question where you checked “No"
complete an entry in the plan (see instructions in the plan). You also should do so for questions
where you checked “Yes, but needs improvement" to help identify ways to improve your
practice. Give careful thought to underlying causes that may be influencing the response that
needs improvement or is not being performed.
2-7
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
It is suggested that you go through this tool four times a year (every quarter) so that you have a
chance to work on the indicators that need improvement and to evaluate your progress. This tool
allows you to assess your practice and record your answers for one year. After such time, you will
need to record you answers on a separate piece of paper or you can reproduce the tool.
In addition, if your schedule does not allow you to complete the tool in one day, you may com
plete it over the course of four or five days. As you gain practice with the tool, however, you will
find that you can complete it in less time.
2-8
Dimension I—Physical Environment:This dimension refers to a facility's ability to provide a safe environment for health care
and examines equipment, supplies, and medicines in facilities and the condition of the clinic's infrastructure.
Quarter 1
Physical Environment Dimension
Answer key: 2 =Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
1.
2
1
0
Facility is adequately equipped and supplied
Does your clinic have:
1.1
A waiting area with seating for clients?
1.2
An area for counseling that is private (i.e„ others cannot see
or hear) equipped with a table or desk and two chairs that is
private (that is, not in the waiting area)?
1.3
A locked storage cupboard for medicines?
1.4
An examination couch with plastic cover and sheet to cover
1.5
Vaginal specula of different sizes (small, medium, large)?
1.6
Three separate containers marked for decontamination, wash
ing, and rinsing equipment that come in contact with bodily
client?
fluids?
1,7
1.8
Bleach/Jik for mixing a 0.5 percent chlorine solution?
Liquid, powder; or bar soap? (If bar soap, is not sitting in soap
dish with accumulated water).
1.9
Boiler (covered saucepan), dry oven, or sterilizer?
1.10 Two clocks (one in reception and one in labor area)?
1.1 1
At least one bed with a plastic cover for adults?
1.12 A separate scale for babies and adults?
1,13 A tape measure?
1.14 A fetoscope?
1.15 A sphygmomanometer?
2-9
Quarter 2
NA
2
1
0
Quarter 3
NA
2
1
0
Quarter 4
NA
2
1
0
NA
Quarter 1
Physical Environment Dimension
Answer key: 2 = Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
2
1
1.16 Sterile syringes?
1.17 Tetanus vaccination supply?
1.18 Intrapartum medications and resuscitation equipment for
mothers and babies (in one easily accessible place, such as a
tray) including gloves, mucus extractor suction bulb, vitamin
K, 50 percent and 5 percent dextrose, normal saline, IV set,
oxytocics, scalp needle, needle and syringe, scissors, plaster;
diazepam or magnesium sulfate, torch, tongue depressor;
injectable antibiotics, and antihypertensives?
1.19 Bed nets for clients?______________________________________
2.
Facility infrastructure in adequate condition
1.20 Is there access to potable water (running water or a well near
your clinic)?
1.21
Is there electricity and/or a reliable alternative source of light
(for example, a lantern, torch, or generator)?
1.22 Do you have a toilet (indoor or outside latrine) that you
regularly clean for clients and staff?
1.23 Does your facility have the capacity for washing hands with
soap and water for staff and clients?
1.24 Does your facility have a ceiling?
1.25 Does your facility have a roof that does not leak?
1.26 Does your facility have windows or shutters that open and
close to ensure ventilation, warmth, and protection from rain?
2-10
0
Quarter 3
Quarter 2
NA
2
1
0
NA
2
1
0
Quarter 4
NA
2
1
0
NA
I
I
Quarter 1
Physical Environment Dimension
Answer key: 2 =Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
3.
2
1
Is a wall chart displayed indicating reproductive health services
provided and available by referral?
1.29 Are health educational materials on the wall in good condition
(not torn or dirty) and displayed where your clients can see
them?
4.
Professional appearance
1.30 Do you wear clean and neat appropriate clothing and/or a
uniform or lab coat during working hours?
2-11
Quarter 3
Quarter 2
NA
2
1
Facility has educational materials available for clients in graphic of local language?
1.27 Do you maintain a supply of educational materials on
different topics, including FR safe motherhood, infant care,
diarrhea, prevention and treatment of malaria, STIs, HIV, and
immunization for your clients?
1.28
0
0
NA
2
1
0
Quarter 4
NA
2
1
0
NA
Comments about Physical Environment: Use this space to record what you have done well in this section. Use the questions
where you answered "2" to guide you. After that, record where you could improve. Use the questions where you answered “I" or"0"
to guide you.
What you do well:
I.
2.
3.
Issues and areas where you need to improve:
I.
2.
3.
2-12
Dimension 2—Technical Competence: Examines provider’s performance and determine if it meets acceptable standards. For
midwives, this tool examines performance in counseling, infection prevention (IP), antenatal care (ANC), labor and delivery, family planning
(FP), postpartum and infant care (PPIC), sexually transmitted infections (STIs), and immunization.
Quarter 1
Technical Competence Dimension
Answer key: 2 =Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
2
1
0
Quarter 2
NA
2
1
0
i.
Facility has standards of care (service protocols) for providers to guide service provision
2.1
Do you have a copy of the most recent midwifery service
delivery guidelines that guides midwifery practice in your
country?
2.2
Do you consult the national guidelines/standards for clinical
issues of question in your daily work?
2.3
Do you have a summarized job aid to remind you of the core
steps of focused ANC, using a partograph, active management
of the third stage of labor, and management of postpartum
hemorrhage?
2.
Midwife follows basic counseling guidelines—protocols with clients
2.4
Do you and your support staff inform clients about the type of
reproductive health (RH) and other services available at your
facility?
2.5
Do you use the opportunity of a clinic visit with a woman to
discuss additional issues (for example, during a child health visit,
do you discuss her interest in FP and counsel about appropriate
methods)?
2.6
Do you inform your clients of their right to privacy
and confidentiality?
2.7
Do you provide your clients with the information to make
health-related decisions?
2.8
Do you individualize information you provide based on your
clients’ needs?
2-13
Quarter 3
NA
2
1
0
Quarter 4
NA
2
1
0
NA
Quarter 1
Technical Competence Dimension
Answer key: 2 =Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
2.9
Do you treat clients respectfully, including
a)
Asking clients questions about how they feel and listening
2
1
attentively?
b)
Ensuring that clients understand the information
provided by asking follow-up questions to clarify
information given?
3.
Midwife follows IP protocol
2.10 Do you wash your hands with soap and water before and
after each client?
2.11
Do you consistently clean your facility (for example, do you
wipe all surfaces (e.g.the delivery bed) that come in contact
with body fluids with a 0.5 percent Jik/bleach solution and then
wash with soap and water, and wash the floors of your facility
whenever they are soiled or contaminated and have you
removed all carpets from your clinic)?
2.12 Do you have buckets, containers, bleach, 0.5 percent bleach
solution, and water always available in the required quantities
for decontamination?
2.13
Do you have a boiler (covered saucepan), working stove, or
sterilizer and supplies for high-level disinfection or sterilization
available?
2.14 Is the equipment in working condition?
2.15
Do you follow the three steps for infection prevention for
equipment that has contact with bodily fluids? The steps are:
1) decontamination
2) washing and rinsing
3) high-level disinfection
2-14
0
2
1
0
NA
2
1
0
I
Quarter 4
Quarter 3
Quarter 2
NA
NA
2
1
0
NA
Quarter 1
Technical Competence Dimension
Answer key: 2 =Yes 1 =Yes, but needs improvement
0 - No NA = Not applicable
2
1
0
Quarter 2
NA
2.16 Do you have enough gloves, needles, syringes, antiseptic, and
decontamination solutions available to be able to always follow
the IP protocol?
2.17 Do you maintain single-use injection practice (that
is, only use the needle and syringe once)?
2.18 Do you dispose of needles using a sharp's container?
2.19 Do you burn, bury or dispose of contaminated materials and
other medical waste according to NOH standards?
2.20 Do you have a safe place to dispose of the placenta and other
tissue and blood products (such as a placenta pit)?
2.21
Do you wear protective garments for procedures, e.g., exam
gloves, utility gloves; plastic apron, face shield?
4.
ANC: Midwife counsels and prepares the pregnant women appropriately
2.22 Do you do the following during antenatal visits:
a)
Discuss with the client the need for at least the national
minimum standard of prenatal visits?
b)
Provide information about the due date?
c)
Provide information about any health problems you discover
and the appropriate treatment?
d)
Explain about the importance of personal hygiene; e.g. no
objection to bathing during pregnancy, wear a support bra,
clean external genitalia daily, wiping from front to back?
e)
Provide nutritional advice; e.g. eat a variety of nutritious foods,
take folic acid and iron supplementation, drink plenty of liquids,
no alcohol, gain an adequate amount of weight (between 1216 kilos)?
2-15
2
1
0
Quarter 3
NA
2
1
0
Quarter 4
NA
2
1
0
NA
Answer key: 2 = Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
f)
2
1
Discuss how to prevent malaria during pregnancy (through the
use of bed nets and integrated preventative treatment)?
g)
Discuss with the woman what to bring to the clinic when in
labor and for the delivery—plastic sheet, cover for mother and
wrap for the baby?
h)
Discuss with the woman the need to develop a birth plan
that includes complication readiness, such as early detection
of warning signs, emergency transportation and funds, a
designated decision maker, and a blood donor if necessary?
i)
Discuss the need and options for postpartum FP?
j)
Discuss with the client how to avoid exposure to STI and HIV
by being faithful and asking her partner to wear a condom?
k)
Discuss with the client how to ask her partner to wear a
condom?
2.23 Do you encourage the pregnant woman and her partner to
come for HIV counseling and testing?
2.24 Do you discuss what to do if she encounters any problems
during pregnancy or labor (including fever; heavy bleeding,
convulsions/fits. swelling, or labor pains for more than a day)?
2.25 Do you describe the signs and symptoms of labor what to
expect during labor and what to do when in labor?
2.26 Do you discuss local or traditional practices that might be
harmful to the mother or newborn?
2.27 If a woman wants to take her placenta home, discuss how to
safely store or dispose of it?
2.28 If the pregnant woman is HIV positive or her HIV status is
unknown, discuss the range of breastfeeding options using the
MOH criteria?
2-16
0
Quarter 3
Quarter 2
Quarter 1
Technical Competence Dimension
NA
2
1
0
NA
2
1
0
Quarter 4
NA
2
1
0
NA
2.29
2
1
Need to initiate or continue ARVs during pregnancy?
b)
Where she can obtain counseling and treatment to reduce
HIV transmission during pregnancy?
c)
Where her child can receive follow-up care, including Pneumoncystis carinii pneumonia (PCP) prophylaxis until HIV results
are known and confirmatory HIV testing has been conducted?
5.
ANC: Midwife performs obstetrical (physical) exam to standard
2.30 At the initial ANC visit, do you do the following:
Take and record the woman’s height, weight and blood
pressure?
b)
c)
NA
2
If the pregnant woman is HIV positive, do you share the following information:
a)
a)
0
Determine the expected date of delivery based on the last men
strual period or palpation or measurement of uterine/fundal size?
Perform or refer the client for laboratory tests according to
standards forVDRL, hemoglobin, typing and crossmatching,
HIV, and screening for tuberculosis?
d)
Listen for fetal heart tones and record results?
e)
Inspect and palpate breasts?
0
Prescribe or dispense iron, folic acid tablets,Vitamin A in
appropriate dose for pregnancy, other vitamins as indicated,
and any preventative medications that are appropriate, such
as for malaria, intestinal worms, or iodine deficiency according
to national standard?
g)
Determine tetanus toxoid status and vaccinate (or refer for
vaccination) according to national guidelines?
2-17
Quarter 3
Quarter 2
Quarter I
Technical Competence Dimension
Answer key: 2 =Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
1
0
NA
2
1
0
Quarter 4
NA
2
1
0
NA
2
1
2.31 During each ANC visit, do you do the following:
a)
Record the woman's weight and note changes?
b)
Record the fundal height/uterine size and note changes?
c)
Record the blood pressure and note changes?
d)
If the woman is greater than or equal to 18 weeks gestation
and/or the uterus is palpable near the umbilicus, listen for and
e)
Provide guidance for the common pregnancy-related
conditions (such as nausea, leg cramping)?
0
Develop an individual plan of management for the woman if
there are abnormalities in any of the aforementioned tests (i.e.
record the presence of fetal heartbeat?
refer for high blood pressure, severe anemia, inadequate or no
fundal growth, etc)?
g)
After 34 weeks, check the presentation and record; if the baby's head
is not down by 36 weeks refer to an appropriate provider midwife, or
facility?
_______________________________________________
2.32 During each ANC visit, do you check for warning/danger signs:
a)
Vaginal bleeding?
b)
Severe headache, visual changes, or epigastric pain?
c)
Swelling of the face or hands?
d)
Leaking amniotic fluid?
e)
Severe nausea or vomiting?
9
High temperature (greater than or equal to 38Q?
g)
Severe abdominal pain?
h)
Lack of fetal movement?
Quarter 2
Quarter 1
Technical Competence Dimension
Answer key: 2 = Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
2-18
0
NA
2
I
0
Quarter 4
Quarter 3
NA
2
1
0
NA
2
1
0
NA
1
2
0
2.33
If you identify any of the aforementioned warning signs during
the antenatal visit, do you refer the pregnant woman to place
where she can receive emergency obstetrical care?
6.
Safe labor and delivery—Midwife performs according to standard
Quarter 3
Quarter 2
Quarter 1
Technical Competence Dimension
Answer key: 2 = Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
NA
2
0
1
NA
2
Quarter 4
2
NA
0
1
0
1
NA
2.34 When a woman is in labor and during her delivery, do you:
a)
Use a pantograph during labor to chart progress?
1
1
1
I
1
1
1
r~
Ensure a safe and clean delivery by having:_______________________________________________________________________________________________________
b)
Clean hands?
c)
A clean surface for delivery?
d)
Clean gloves?
e)
Clean (HLD) instruments to cut cord: and
0
Encourage women to assume birthing positions of their choice that
also are safe for the mother and baby?
g)
Encourage woman to have support persons of her choice
present with her?
h)
Encourage woman to continue taking liquids and eating light
foods as she desires?
i)
Avoid doing an episiotomy (cutting the perineum) except
when indicated (fetal or maternal distress)?
Use active management of the third stage of labor including
j)
Give 10 units of oxytocin intramuscularly within the first
minute after birth?
k)
Controlled cord traction with abdominal hand support to the
uterus?
1)
Massage the uterus through the abdomen immediately after
delivery of the placenta?
2-19
Answer key: 2 =Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
2
1
2.35 Do you record details of birth, including:
a)
The date and time and sex?
b)
The birth weight?
c)
Apgar scores?
d)
The condition of perineum and description of any suturing?
e)
Estimated blood loss?
f)
Any changes from normal?
2.36
Do you continue to assess uterine tone, amount of vaginal
bleeding, and mother's vital signs (blood pressure and pulse
every 15 minutes) for at least two hours postpartum or until
stable?
2.37
Do you take steps to clear the airway and stimulate the infant
if s/he does not cry or breathe spontaneously?
2.38
Do you immediately dry the infant, place skin-to-skin with
mother covering the baby's head or wrap, and put to breast
within first 30 minutes following delivery?
2.39
Do you administer eye prophylaxis, according to national
standards?
2.40
If the mother has problems, do you assist her with
2.41
Within the first two hours of life, do you perform a complete
examination of the baby and inform the mother of results?
breastfeeding?
2.42
Do you refer newborn for further care if necessary based on
examination of the baby?
2-20
0
Quarter 2
NA
2
1
0
Quarter 4
Quarter 3
NA
2
1
0
NA
2
I
0
NA
PRIVATE HEALTH SECTORQUALITY IMPROVEMENT PACKAGE
Quarter 1
Technical Competence Dimension
Answer key: 2 =Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
Quarter 2
Quarter 1
Technical Competence Dimension
2
1
0
NA
2
7.
PP/Infant Care: provider conducts care to standard
2.43
Within the first week postpartum or before discharge from your facility do you:
a)
Take a history of the mother and baby and document your
findings?
b)
Check maternal and neonatal vital signs (including
temperature, pulse, respiration for both, and maternal blood
pressure) and document them?
c)
Conduct a physical exam of mother and baby (head to toe)
and record any abnormal changes?
d)
Inform the client of her and her newborn's conditions?
e)
Teach how to care for the umbilicus (that is, keep it clean and
dry)?
0
Assess mother's knowledge of and ability to breastfeed?
2.44
Discuss the following topics with the mother:
a)
Personal hygiene (wash breasts daily with a soft cloth and
wear a support bra, clean external genital gently daily, wiping
from front to back)?
b)
Nutrition and infant feeding?
c)
Family support?
d)
Family planning and how to avoid unwanted pregnancy?
e)
Benefits of exclusively breastfeeding for six months?
2-21
1
0
Quarter 4
Quarter 3
NA
2
1
0
NA
2
1
0
NA
2
1
0
NA
2
1
0
Quarter 4
Quarter 3
NA
2
1
0
NA
2
1
0
NA
2.45
Do you routinely teach the mother about postpartum danger signs and inform her to contact you if she has any of the following:
a)
Excessive vaginal bleeding or bleeding for more than two
weeks?
b)
Vaginal discharge with a foul/fishy odor?
c)
Severe abdominal pain?
d)
Worsening perineal pain from repaired laceration,
episiotomy?
e)
High temperature (greater than or equal to 38C)?
■f)
Redness, warmth, or pain in her breasts?
g)
Pain on urination, difficulty in voiding or defecating, or
incontinence of urine or stool?
2.46
Do you routinely teach the mother about the following signs of potentially serious problems with the infant and inform her to
contact you if the infant:
a)
Doesn't feed well?
b)
Sleeps all the time?
c)
Vomits or spits up a lot?
d)
Has watery, dark green stools?
e)
Breathes too fast (greater than or equal to 60 beats a
minute) or breathes with difficulty (indrawing)?
0
Has stiffness or convulsions?
g)
Has yellow skin and eyes?
h)
Has redness around or foul discharge from umbilicus or
discharge from eyes?
2-22
private health sector quality improvement package
Quarter 2
Quarter 1
Technical Competence Dimension
Answer key: 2 =Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
Quarter 1
Technical Competence Dimension
Answer key: 2 = Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
2
1
0
Quarter 2
NA
2
1
0
Quarter 3
NA
2.47
During the six-week exam do you perform the following tasks when examining the newborn:
a)
Weigh the baby?
b)
Measure the length of baby?
c)
Plot weight and length on growth chart?
d)
Assess if growth pattern meets national standards?
e)
Explain about the importance of having the infant fully
immunized, give a schedule of immunizations, and tell the
mother where to get her baby immunized?
f)
Weigh the mother and assess her blood pressure?
g)
Examine breasts, perineum and uterine size?
b)
Ask the woman if she has any physical, social or emotional
concerns?
i)
If anemic when pregnant or had postpartum hemorrhage,
recheck or refer for assessment of hematocrit or hemoglobin
and continue iron therapy if indicated?
J)
If HIV status unknown, encourage VCT?
k)
If HIV+, encourage to initiate or continue ARVs?
8.
FP: Midwife counsels and provides FP according to standard
2.48
Do you discuss with your clients how their reproductive
system works?
2.49
Do you use every opportunity to discuss the benefits of family
planning according to the client's situation?
2.50
Do you introduce the client to the family planning methods
that are available at your facility?
2-23
2
1
0
Quarter 4
NA
2
1
0
NA
Answer key: 2 =Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
2.51
Quarter 2
Quarter 1
Technical Competence Dimension
2
1
0
NA
2
1
0
Quarter 3
NA
2
1
0
Quarter 4
NA
2
1
0
NA
Do you discuss with your client why she came to you for
family planning services, what she knows and wants?
2.52
Do you counsel each patient based on her unique FP needs
(for example, single and does not want to become pregnant,
breastfeeding and wants to space her pregnancies, is not
breastfeeding and wants to space her pregnancies, or she does
not want any more pregnancies) and provide information
that will help her select a method or methods suitable for her
personal situation and reproductive intentions?
2.53
Do you explain benefits, risks, contraindications, side effects, or
other consequences of their chosen contraceptive method?
2.54
Do you try to ensure that you are able to provide three
contraceptive methods to your clients (for example, progestinonly (mini) pills and combined oral contraceptives, condoms,
injectable, lactational amenorrhea, or standard days method)?
2.55
Do you discuss with the client how the methods work and
how to use the contraceptive method that she wants?
2.56
Do you provide information about the side effects of the
method provided and what to do if the signs or side effects
occur?
2.57
Do you explain how and when to obtain resupply of the
selected contraceptive method?
2.58
Do you discuss the option of changing methods if your client's
current method is not working for her or her partner?
2.59
Do you explain about where, when, and why your clients
need to return for follow-up as part of effective use of a
contraceptive method?
■■
■*
■■
■»
■■■
Ml
M
■■
Quarter 1
Technical Competence Dimension
Answer key: 2 =Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
2.60
Do you describe to the client how, why, and when to use a
condom, (dual protection and dual method use) i.e. explaining
use of condom with another contraceptive method for
women at risk for exposure to HIV or others STIs?
2.61
Do you encourage the client to ask her partner to come
for counseling and involve the partner in decision-making
regarding FP?
2.62
Do you provide information about where to obtain the
desired contraceptive method if you are not able to provide
it?
2
1
0
Quarter 2
NA
2
1
0
2.63
If a client wants to discontinue using a contraceptive method, do you do the following:
a)
Discuss with the client the reasons for wanting to discontinue
and address any side effects she may be experiencing that
affect the choice to discontinue?
b)
Offer appropriate alternatives?
c)
Provide support and information if the client wishes to
d)
Treat the client’s wishes with respect?
e)
Do you ask your clients whether they understand the
information that they have received and whether they have
questions?
g)
Do you ask your clients to repeat key information to be sure
that the clients understand what you have said or they key
messages that need to be understood?
become pregnant?
2-25
Quarter 3
NA
2
1
0
Quarter 4
NA
2
1
0
NA
2
2.64
Do you provide information on FP to the following clients?
a)
Adolescents and young adults, both female and male?
b)
Women of all ages, regardless of their marital or reproductive
1
0
2
1
0
Quarter 4
Quarter 3
Quarter 2
NA
NA
2
1
0
NA
2
1
0
NA
status?
c)
Men of all ages, regardless of their marital or reproductive
status?
d)
Disabled clients?
e)
Different social and ethnic groups?
2.65
Do you feel comfortable counseling your client about the following skills? (If you do not provide this method because you do not
know how, please score as “0”).
a)
Progestin-only (mini) pills?
b)
Combined oral contraceptives?
c)
Injectables?
d)
IUDs?
e)
Implants?
f)
Condoms?
g)
Moon Beads?
2.66
Do you feel comfortable in performing the following contraceptive methods to your clients?
a)
Inserting an IUD?
________________________________________
b)
Removing an IUD?
c)
Inserting an implant?
d)
Removing an implant?
e)
Giving an injectable maintaining single-use injection practice?
2-26
PRIVATE HEALTHSECTORQUALITY IMPROVEMENT PACKAGE
Quarter 1
Technical Competence Dimension
Answer key: 2 =Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
Quarter 1
Technical Competence Dimension
Answer key: 2 =Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
9.
2
1
STI—Patient counseling and education according to standard
2.67 Do you counsel and discuss with all clients:
a)
How transmission of HIV or STI occurs?
b)
How to avoid getting infected?
c)
What to do if client thinks he or she may have become infected?
d)
When and where to go for STI screening and treatment if you
are unable to provide those services?
2.68
For those who have STIs do you discuss:
a)
The importance of treating the partner(s)?
b)
Where to go for testing and treatment (if you can not provide it)?
<)
Treatment instructions?
d)
Importance of compliance with treatment?
e)
How to prevent reinfection (including information about
practice of abstinence, monogamy and safe sex)?
_9___ How having an STI can increase the risk of acquiring HIV?
J___ The value of using dual protection?
h)
The option of emergency contraception?
2.69
Do you record the treatment given in the client's chart?
2-27
0
Quarter 2
NA
2
1
0
Quarter 3
NA
2
1
0
Quarter 4
NA
2
1
0
NA
2
1
0
Quarter 2
NA
10.
Immunization: Provider manages immunizations according to standard
2.70
Do provide immunizations to your clients?
2.71
Do you have vaccine supplies to immunize clients when they
need immunizations (Le. vaccine, needles, syringes, cotton, alcohol)?
2.72
Are you able to keep an adequate supply of vaccines and avoid
stock outs?
2.73
Do you have an easily available job aid to guide the schedule
of immunizations?
2.74
Do you store vaccines according to cold chain standards?
2.75
Do you record the immunizations and date given in client's
chart or register?
2-28
2
1
0
Quarter 3
NA
2
1
0
Quarter 4
NA
2
1
0
NA
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PA
Quarter 1
Technical Competence Dimension
Answer key: 2 = Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
Comments about Technical Competence: Use this space to record what you have done well in this section. Use the questions
where you answered "2” to guide you. After that, record where you could improve. Use the questions where you answered " I" or "0”
to guide you.
What you do well:
I.
2.
3.
Issues and areas where you need to improve:
I.
2.
3.
2-29
Dimension 3—Continuity of Care: Examines functional referral systems when care is needed outside of what you can do in your
clinic. It includes knowing when to refer; if there are official procedures for referral, the flow of client records or information to and from a
referral, client follow-up, and ensuring repeat visits by the same provider
2-31
Comments about Continuity of Care: Use this space to record what you have done well in this section. Use the questions
where you answered “2" to guide you. After that, record where you could improve. Use the questions where you answered " I ” or
"0"to guide you.
What you do well:
I.
2.
3.
Issues and areas where you need to improve:
I.
2.
3.
2-32
Dimension 4—Management: Refers to the provider's capacity to plan, organize, implement, and maintain effective health delivery
services. Management includes utilizing data for decision-making and proper tracking of finances and supplies.
Quarter 1
Management Dimension
Answer key: 2 = Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
2
1
0
Quarter 2
NA
2
1
>.
Facility/staff has adequate review of practice provided including review of action plan
4.1
Do you use this self-assessment QI tool quarterly? (Note: this
question is only applicable after the first time that you have
used the tool. These first three questions are only applicable
after the first time that you have used the tool—so omit it for
the first quarter that you are conducting a self-assessment of
your practice.)
4.2
Do you prepare an updated action plan to improve quality
using the information this tool provided?
4.3
Has any action been taken in the last month to address items in
the plan?
0
Quarter 3
NA
2.
Facility/practice has accurate and current client records including confidentiality of records
4.4
Do you have a written procedure or job aid for guiding
infection prevention at your facility?
4.5
Do you maintain client records/registers to record client visits
for every client?
4.6
Are the records complete (shows reason for visit, treatment
given, outcome, and note for follow up visit or referral, if
necessary)?
4.7
Are your client records kept where others cannot see them?
4.8
Do you maintain strict confidentiality concerning all personal
information collected during a client's visit to protect her/his
privacy?
2-33
2
1
0
Quarter 4
NA
2
1
0
NA
3.
4.9
2
1
Quarter 2
NA
2
1
0
Quarter 3
NA
2
1
0
Quarter 4
NA
2
1
Medical equipment, furniture, consumable drugs and supplies are properly inventoried and procured to prevent stock-outs
Do you keep an inventory list/stock cards of consumable
supplies in your facility?
4.10 Has your consumable inventory list been updated within the
last three months?
4.11 Does the list include expiration dates on drugs and supplies?
4.12 Do you have a reliable supplier of drugs and other supplies?
If you do not, do you work with some organization (such as
UPMA, ministry of health, or nongovernmental organization) to
try to correct this problem?
4.13 Do you order drugs and supplies based on a reliable estimate
of your pharmaceutical needs?
4.14 Do you keep records about cold-chain conditions for vaccines
(for example, check and record the temperature and specified
by EPI guidelines)?
4.15 Have you been able to avoid running out of drugs,
contraceptives, or other commodities in the last three months?
4.
0
Supplies and equipment are in working condition
4.16 Do you keep an inventory list of medical equipment and furni
ture that includes date of purchase, projected date of repair; and
replacement?
4.17 Are the facility's medical equipment and furniture in working
condition?
2-34
0
NA
PRIVATE HEALTH SECTORQUALITY IMPROVEMENT PACKAGE
Quarter 1
Management Dimension
Answer key: 2 = Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
Quarter 1
Management Dimension
Answer key: 2 =Yes 1 = Yes, but needs improvement
0 = No NA = Not applicable
5.
2
1
0
Quarter 2
NA
2
1
Information on clinic operating hours and billing procedures are available to patients
4.18 Do you have a midwife to cover your facility when you are
away from your clinic?
4.19 Are there instructions posted about what to do in an
emergency if the clinic is closed?
4.20 Are the prices of your services explained or available for clients
to read before services are provided?
2-35
0
Quarter 3
NA
2
1
0
Quarter 4
NA
2
1
0
NA
What you do well:
I.
2.
3.
Issues and areas where you need to improve:
I.
2
3.
2-36
PRIVATE HEALTH SECTORQUAUTY IMPROVEMENT PACKAGE
Comments about Management Use this space to record what you have done well in this section. Use the questions where you
answered "2" to guide you. After that, record where you could improve. Use the questions where you answered “I" or"0”to guide
you.
Dimension 5—Marketing: Refers to midwife's knowledge of the people in their communities and how effectively they market their services to
maintain their clients and attract new ones.
Quarter I
Marketing Dimension
Answer key: 2 =Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
2
1
0
Quarter 2
NA
2
i.
Midwife solicits and uses client feedback for marketing quality health services
5.1
Do you regularly ask clients what they think about the services
provided by you?
5.2
Do you have a way to determine the satisfaction of your clients
(such as a suggestion box or conducting small group discussions
with the community)?
5.3
Do you act on feedback received from clients and the
community?
5.4
Do you encourage clients to ask questions during visits?
2.
Midwife advertises quality service to the community to increase client base
5.5
Do you market your services to the community that you serve
(for example, presentations to the community, and participates
in community meetings related to health)?
5.6
Do you use other acceptable modes of marketing your services
to clients in your community?
5.7
Do you list all services that you provide on a signpost near your
clinic?
2-37
1
0
Quarter 4
Quarter 3
NA
2
1
0
NA
2
1
0
NA
you.
What you do well:
I.
2.
3.
Issues and areas where you need to improve:
2.
3.
2-38
PRIVATE HEALTHSECTORQUALITY IMPROVEMENT PACKAGE
Comments about Marketing: Use this space to record what you have done well in this section. Use the questions where you
answered "2" to guide you. After that, record where you could improve. Use the questions where you answered “ I" or"0" to guide
Dimension 6—Business Practices: Examines midwife's goals, financial-management practices (including record keeping and pricing
systems), resources for adequate financing, and allocation of resources.
Quarter 2
Quarter 1
Business Practices Dimension
Answer key: 2 - Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
2
1
0
NA
2
1
0
Quarter 3
NA
Facility/practice has specific, measurable, attainable, realistic and time-bound (SMART) g<sals
6.1
Do you have financial and other goals for your business for:
a)
Next month?
b)
3 months?
c)
6 months?
d)
Next 1 year?
6.2
Do you have a plan to achieve these goals?
2.
Facility/practice has efficient financial practices and records
6.3
Do you keep track of your monthly costs/expenditures?
6.4
Do you keep track of how much you earn each month?
6.5
Do you have a plan/budget for how much money you need in
order to cover your operating expenses?
6.6
6.7
Do you review your clinic’s budget at least quarterly?
Do you know how much it costs you to operate your clinic
each month?
6.8
Do you know how much it costs you to provide the different
services that you provide?
6.9
Do you prepare your own financial records?
2-39
2
1
0
Quarter 4
NA
2
1
0
NA
2
1
6.10 If yes, do you prepare or analyze:
a)
Balance sheet?
b)
Income statement?
c)
Cash Flow statement?
6.1 1 If yes, do you use these records to:
a)
Make management decisions?
b)
Analyze cash flow?
Facility/practice has functioning pricing and collection isystems
6.12
6.13
Do you keep track of how much people owe you?
Do you have a plan to collect payment from clients that owe
you payment for services?
4.
Facility/practice is profitable
6.14
Did you make a profit in the last 3 months?
5.
Facility/clinic has adequate financing
6.15
If you need a loan, do you know where to go and how to get
one?
6.16
Do you know where to access outside financing to grow your
business (for example, equity, lease, loans, and supplier credit)?
2-40
0
Quarter 3
Quarter 2
NA
2
1
0
NA
2
1
0
Quarter 4
NA
2
1
0
NA
PRIVATE HEALTH SECTORQUALITY IMPROVEMENT PACKAGE
Quarter 1
Business Practices Dimension
Answer key: 2 = Yes 1 =Yes, but needs improvement
0 = No NA = Not applicable
Comments about Business Practices: Use this space to record what you have done well in this section. Use the questions
where you answered “2" to guide you. After that, record where you could improve. Use the questions where you answered "I” or“0”
to guide you.
What you do well:
I.
2.
3.
Issues and areas where you need to improve:
I.
2.
3.
2-41
REFERENCES
ACDI/VOCA Business and Finance Training Unit.
Business Plan Handbook for Midwives.
Klein, S., S. Miller; and EThompson. 2004. A Book
for Midwives: Care for Pregnancy, Birth and
Women's Health. Palo Alto, CAThe Hesperian
Foundation.
Banking on Health. 2006. Financial Planning and
Business Practices Training Needs Assessment Tool.
Prime II Project. 2003. Performance Improvement
Stages, Steps andTools.www.prime2.org/sst
(accessed May 23,2006).
Bjerregaard, Donna. 2004. Jordan: Building Quality in
Primary Health Care. Jordan: Primary Health Care
Initiatives Project.
EngenderHeafth. 2002. COPE Self-Assessment Guides
for Reproductive Health Services. New York:
Engender Health
EngenderHeafth. 2000. Infection Prevention
(multimedia package). New York: EngenderHeafth.
Franco, Lynne Miller; Diana R. Silimperi.Tisna
Veldhuyzen van Zanten, Catherine MacAulay,
Karen Askov, Bruno Bouchet, and Lani Marquez.
2002. Sustaining Quality of Healthcare:
Institutionalization of Quality Assurance. Bethesda,
MD:The Quality Assurance Project.
Program for Appropriate Technology in
Health (PATH). 2004. Preventing Postpartum
Hemorrhage:Toolkit for Providers. Library
reference Version. Washington, DC: PATH.
Sibley, L„ and C. Quimby. 1997. Module 4: Providing
Basic Maternal and Newborn Care Services.
Reproductive Health Training for Primary Providers:
A SourceBook for Curriculum Development
Chapel Hill, NG PRIME I Project.
Tietjen, Linda, Debora Bossemeyer; and Noel
McIntosh. 2003. Infection Prevention: Guidelines
for Healthcare Facilities with Limited Resources.
Baltimore, MD:JHPIEGO.
Fraser, Diane, and Maggie Cooper, eds. 2003. Myles
Textbook for Midwives. 14th ed. New York:
Churchill Livingstone.
Hatcher; R.A..W Rinehart, R. Blackburn, J.S.
Geller; and J.D. Shelton. 1997. The Essentials of
Contraceptive Technology. Baltimore: Johns Hopkins
Bloomberg School of Public Health, Population
Information Program.
Initiatives Inc. 2004. Performance Improvement Review:
Resources &Tools for NGOs & CBOs. Boston,
MA. Initiatives Inc.
International Confederation of Midwives and
International Federation of Gynaecology and
Obstetricians. Joint Statement: Management
of the Third Stage of Labour to Prevent
Post-partum Haemorrhage. http://www.
intemationalmidwives.org/Statements/Joint
Statement Haemorrhage eng.htm (accessed June
2004).
2-43
World Health Organization (WHO). 2000.
Integrated Management of Pregnancy and
Childbirth: Managing Complications in Pregnancy
and Childbirth: A guide for midwives and
doctors. Geneva, Switzerland. World Health
Organization, Department of Reproductive
Health and Research.
World Health Organization (WHO) and
Johns Hopkins Bloomberg School of Public
Health, Center for Communication Programs,
Information and Knowledge for Optimal Health
(INFO). 2005. Decision-making tool for family
planning clients and providers. Baltimore, MD:
INFO and Geneva: WHO Family Planning
Cornerstone.
SECTiOl J 2. SELF ASSESSMENT PACKAGE FOP. MIDWIVES
NOTES:
2-45
|
PRIVATE HEALTH SECTOR
QUALITY IMPROVEMENT PACKAGE
SECTION 3: ACTION PLAN FOR MIDWIVES
I
Section 3:
Action Plan
CONTENTS
Section 3: Action Plan for Midwives
Action Plan for Midwives.................................................................... 3-1
Instructions................................................................................................ 3-1
Sample Entry................................................................................. 3-2
Action Plans for Different Dimensions...................................... 3-3
Physical Environment Action Plan............................................. 3-3
Technical Competence Action Plan...........................................3-5
Continuity of Care Action Plan................................................. 3-7
Management Action Plan............................................................. 3-9
Marketing Action Plan............................................................... 3-1 I
Business Practices Action Plan................................................ 3-13
Notes........................................................................................... 3-15
10^
SECTION 3: ACTION PLAN FOR MIDWIVES
ACTION PLAN FOR MIDWIVES
INSTRUCTIONS
This action plan helps facilitate a simple problem-solving process. Please follow the steps to use the
instrument to improve the quality of your services.
If this is your first time using this action plan, please skip ahead to step 4.
I.
Review your statistics form. Have things changed since the last time you updated
the indicators?
a.
If they have changed for the better; congratulations! Please review your notes on the statistics
form and reflect on what actions helped facilitate that change.
b.
If you still feel like your indicators could improve, keep these goals in mind as you continue to
use the action plan instrument.
2.
Review previous entries recorded in the action plan instrument.
a. If you have successfully resolved an issue, put a check or tick mark (✓) in the status column
(column 7).
b. For the issues that remain, think about why they have not been resolved. If you need external
support, put an "E” in the status column and in the actions/next steps column forthat issue,
record whom you will contact, how you will contact him or her; and what you will ask him or
her to do.
3.
Now go back through your QI self-assessment tool.
a. Note the questions where you answered "0" or" I.”
b. Refer to these questions as you develop your action plan.
4. Now develop your action plan. Step-by-step instructions and a sample action plan follow.
The following pages contain a series of blank tables for you to create your plans. Create a
separate plan for each dimension to help prioritize your interventions. Indicate the date of the
assessment at the top of the action plan.
a. Put a mark (* or X) in the QI tool next to the questions you answered "0” or" I". Then
record the question number in column I and rewrite the question so that you know what
the issue is.
b. In column 2 determine why you have this issue.You can use a simple "Why? Why?" exercise.
For example, the issue might be that you do not have adequate space for privacy.Then ask
yourself "Why?” Answer: My clinic is small. Again ask why? Why is my clinic small? "Because
real estate is expensive and at the time I built my clinic I could not afford a larger space.'
3-1
3-2
until door
installed
5. me
4. April 10
3. April 7
renovation
expensive
2. Property and
1. Clinic small
D o not have a
separate area for
counseling w ith a
table o r desk and
tw o chairs that is
private.
Column 2
resolve issues you cannot resolve by yourself.
1
issues. Your supervisor may be able to help
you mobilize the resources you need to
Causes (Why)
familiar with this instrument and review any
Question
Column
6. Encourage your supervisor to become
Q# and Restated
tool (it should be reviewed four times
annually).
5. Ongoing
complete o r
when you
review the
next quarter).
room that can be
shut
time you use the QI self-assessment
build another
room o r build a
door on exam
5. Review this action plan after each
Save money to
mark it with a check.
Column 3
Solutions
will ask. If the task has been completed,
hear is w hat said.
in column 7 identify who you will ask for
help, what you will request and how you
5. In the interim, offer clients to meet outside
behind clinic where other clients can not see o r
If it has not been resolved, write an "E" if
you will require external assistance and
monthly and the cost o f the door and carpenter
Finally, in column 7 (the status column),
indicate if the problem has been resolved
4. me
steps.
f.
4. Develop a budget to save fo r purchase and
installation o f a door (i.e, calculate how long
it will take you to save the total needed given
the amount o f money you can save weekly o r
a deadline (by when) to accomplish those
(accountant)
In columns 5 and 6 assign a responsible
person (by whom) for each next step and
Column 4
Actions/Next Steps
e.
1. Analyze monthly costs and revenue.
identified in column 3. Make sure these
are speciflc.There can be many next steps.
in when
(W ill fill this
1. March 31
In column 4, list your next steps for the
short-, medium-, and long-term solutions
3. Mr. Michael
padlock for your medication cupboard.
d.
3. Price doors and costs o f carpenter
where you may just need to purchase a
1. Midwife
By W hom
(as the example above) while other plans
will have a simple, short term solution
Column S
short-, medium-, and long-term solutions
2. March 31
By When
In column 3 record possible solutions.
For some plans, you may need to include
Column 6
exhausted all influencing factors.
c.
2. Maria (me)
renovation is also costly." Continue to ask
yourself why until you feel like you have
2. Determine a realistic amount that you can save
weekly o r monthly.
Status
Once again, ask yourself why? "Because
Column 7
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
Physical Environment Action Plan
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Dates of Assessment
Actions/Next
Steps
Column 4
3-3
By Whom
By When
Status
Column 5
Column 6
Column 7
Technical Competence Action Plan
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Dates of Assessment,,,
Actions/Next
Steps
Column 4
3-5
By Whom
ByWhen
Status
Column 5
Column 6
Column 7
Continuity of Care Action Plan
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Dates of Assessment
Actions/Next
Steps
Column 4
ByWhom
By When
Status
Column 5
Column 6
Column 7
Management Action Plan
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Dates of Assessment
Actions/Next
Steps
Column 4
3-9
,,,
By Whom
ByWhen
Status
Column 5
Column 6
Column 7
Marketing Action Plan
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Dates of Assessment,,,
Actions/Next
Steps
Column 4
3-11
By Whom
By When
Status
Column 5
Column 6
Column 7
Business Practices Action Plan
Dates of Assessment,,,
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Actions/Next
Steps
Column 4
3-13
By Whom
ByWhen
Status
Column 5
Column 6
Column 7
SECTION FACTION PLAN FOR MIDWIVES
NOTES:
3-15
PRIVATE HEALTH SECTOR
QUALITY IMPROVEMENT PACKAGE
SECTION 4: SUPERVISOR’S GUIDE
Section 4:
Supervisor's Guide
CONTENTS
Section 4: Supervisor’s Guide
Introduction................................................................................................. 4-1
Scoring the Midwives’ Performance and Reviewing
Their Action Plans................................................................................... 4-3
Instructions for Scoring............................................................... 4-3
QI Self-Assessment Score Sheet
4-7
Summary Chart of Self-Assessment Scores........................4-1 I
Instructions for Reviewing and Supporting the
Midwives’Action Plan............................................................... 4-13
Instructions for Action Plan for Midwives.............................. 4-15
Sample Entry............................................................................... 4-16
Action Plans for Different Dimensions................................... 4-17
Physical Environment Action Plan........................................... 4-17
Technical Competence Action Plan........................................ 4-19
Continuity of Care Action Plan............................................... 4-21
Management Action Plan.......................................................... 4-23
Marketing Action Plan............................................................... 4-25
Business Practices Action Plan................................................. 4-27
Notes
4-29
)S<U3
SECTION 4: SUPERVISOR'S GUIDE
INTRODUCTION
Used with the QI self-assessment tool, the Action Plan for Midwives helps facilitate a simple
problem-solving process. Midwives that you supervise should develop a separate action plan for
each dimension of quality so you can monitor progress along with them.This process will help you
both see where emphasis is needed and how your supervisee is progressing.
The Action Plan for Midwives prompts the midwife to first complete the statistics form to frame
interventions in terms of improved health outcomes and then revisit low scores on the QI self
assessment tool.The action plan is in a table format.
• In column I ,the midwife then records the question number and rewrites the question so that
she knows what the issue is.
• In column 2, the midwife is asked to determine why she has this issue. She (or with your
assistance) can use a simple "Why? Why?” exercise. For example, the issue might be that the
midwife does not have adequate space for privacy. Then the midwife asks herselfwhy?”
Answer:“My clinic is small." Again ask“why?”Why is my clinic small? "Because real estate is
expensive and at the time I built my clinic, I could not afford a larger space.” Once again, the
midwife asks herselfwhy?" "Because renovation is also costly." She should continue to ask
herself "why" until she feels like she has exhausted all influencing factors.
• In columns 3 and 4 the midwives are prompted to list possible solutions, actions, or next steps. In
column 5, assign a responsible person with a deadline in column 6. Finally, column 7 indicates the
status of the action item and whether external resources are required.
As a supervisor; you can discuss the causes, help with solutions, and mobilize external resources.
Ideally, you would visit quarterly to monitor progress toward completing action plan items before
the next self-assessment is conducted by the midwife. In addition, a professional association,
network, or franchise also may use periodic, pre-set meetings to discuss or alleviate common
problems and discuss solutions as a group. For example, if multiple members of an association are
unable to use a pantograph (question 2.34a), the association will become aware of the problem by
reviewing members' actions plans and can use pre-set monthly meetings to conduct educate them
about how to use it.
A quality index score can be calculated to measure trends in the midwives’ QI self-assessment
responses. Supervisors should record the action plans of their supervisees in their own records to
monitor the midwives' progress in improving quality. Detailed instructions in howto calculate the
score and use the action plan are outlined in the next sections of this document.
4-1
SECTION 4: SUPERVISOR'S GUIDE
SCORINGTHE MIDWIVES’ PERFORMANCE
AND REVIEWING THEIR ACTION PLANS
Improving quality should result in increased service use, contraceptive use, effective operating
procedures, and positive health outcomes. By summarizing the midwives' scores on each of the
dimensions and indicators, it will help you to see how to best help the midwife improve the
quality of services she offers. Along with the action plan, these scores will guide you in helping the
midwives resolve quality gaps they identify.
INSTRUCTIONS FOR SCORING
I. Review the midwife's completed self-assessment tool answers for the current quarter
2. Use the QI self-assessment score sheet on pages 4-6,4-7, and 4-8 of this booklet to record the
scores of the answers for each question.
For example, the physical environment section of the score sheet looks like this:
Table I: Example of physical environment
1. Physical Environment Dimension
Indicator 1
Indicator 3
Indicator 2
l.ll___
1.12___
1.3___
1.13___
1.4___
1.14___
1.5___
1.15___
1.6___
1.16___
LZj
1.7___
1.17___
so
O
l.l___
1.2___
1.8___
1.18___
1.9____
1.19___
Indicator 4
1.30___
1.27___
_____ 160
£| m £
Illi!!
1.28___
1.29___
1.10___
5
3
Score:___ /38
Total
Score
Score:___ 16
4-3
Score:___ 12
Comments
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
Indicator I in table I has 19 questions, I. I -1.19.Table 2 is an example of what the score sheet
could look like if the midwife answered the first 19 questions.
Table 2: Example of Indicator I
1. Physical Environment Dimension
Indicator 1
Indicator 2
Indicator 3
l.l
2
l.ll
0
1.20___
1.27___
1.2
1
1.12 2
1.21___
1.28___
1.3
1
2
1.13 2
1.22___
1.29___
1.14 2
1.5 2
1.15 1
1.23___
1.24
0
1.7 0
1.16 1
1
1.18 1
1.9 2
1.100
1.19 1
1.4
1.6
1.8
1.17 NA
Score:_____ 136
Indicator 4
Total
Score
Comments
1.30___
_____ /
1.25___
1.26___
Score:___ ./14
Score:____ 16
Score:___ 12
CALCULATION OF MIDWIFE’S SCORE
a.
Add up the numbers the midwife gave for each question.This sum will give the top number
(numerator) for that indicator In table 3 the numerator for indicator I is 21.
b.
If the midwife has no NA in that indicator then the bottom number (denominator) remains
the same. In table I it would be 38. In table 2, however the midwife has one NA answer For
dimensions that have NA answers, there are two ways to calculate the denominator
1. Count each NA answer Multiply the number of NA answers times 2 and subtract this
number from the bottom number (denominator). In this example, the midwife has one NA
answer So you would subtract 2 points (I NA answer x 2 points = 2 points to subtract).The
bottom number (denominator) in this example is 36 (38 — 2 = 36). So the score for indicator
I in this exampleis 21/36 (refer to Table 3).
2. If you subtracted 2 points for each NA answer along the way, you can just add/sum up the
bottom numbers (denominators) of each indicator.
c.
To calculate the final score for that dimension, sum up the numerators for each indicator. In
the complete example in table 3, the total (numerators) is 41 (21 + 13 + 5 + 2).To calculate
the bottom numbers (denominator), add the total number of NA answers. In this example
there is only I NA.Then multiply the total number of NA answers by 2 (I x 2 = 2). Finally, take
the original denominator total, in this example it is 60, and subtract 2 to obtain the final score
denominator of 58 (60 - 2 = 58). Or; if you properly calculated the denominators for each
indicator along the way you can simply add the denominators: 36 + 14 + 6 + 2 = 58.
4-4
SECTION 4: SUPERVISOR'S GUIDE
Table 3: Example of calculating numerator and denominator
1. Physical Environment Dimension
Indicator 1
l.l
1.2
1.3
1.4
15
1.6
1.7
1.8
1.9
2
1
1
2
2
0
0
1
2
0
1.12 2
1.13 2
1.14 2
1.15 1
1.16 1
1.17 2
1.18 1
l.l 1
Indicator 2
1.20 1
Indicator 3
1.27 2
1.21 2
1.28 2
1.22 2
1.29
Indicator 4
Total Score
1.30 2
1
1.23 2
1.24 2
1.25 2
1.26 2
1.19 1
1.100
Score: 20/34
Score: 13/14
Score: 5/6
Score: 2/2
4-5
41/58
Comments
SECTION 4: SUPERVISOR'S GUIDE
QI SELF-ASSESSMENT SCORE SHEET
1. Physical Environment Dimension
l.l___
l.ii___
1.2___
1.12___
1.3___
1.4___
1.13___
1.14___
1.5
1.15___
1.6___
1.16___
1.7___
1.17___
1.8___
1.18___
1.9____
1.19___
Indicator 2
Indicator 3
1111111
° NNRNSS
Indicator 1
1.27___
Total
Score
Indicator 4
Comments
1.30___
1.28___
1.29___
1.10
g
1
Score:___ 133*
Score:___ 16*
Score:___ 12*
_____ 160*
2.Technical Competence Dimension
Indicator 1
Standards of Care
Indicator 2
Basic counseling
Indicator 3
IP
Indicator 4
ANC-Counseling
2.1___
2.4___
2.10___
2.22a ___
2.2___
2.5___
2.1 1___
2.22b ___
2.24___
2.3___
2.6___
2.7___
2.12___
2.22c.___
2.25___
2.8___
2.13___
2.14___
2.22d ___
2.22e.___
2.26___
2.27.__
2.9a___
2.15___
2.9b___
2.16___
2.17___
2.22f___
2.22g.___
2.22h ___
2.29a___
2.29b___
2.18___
2.22i __
2.29c___
2.19___
2.22j_
2.20___
2.21___
2.22k.
Score:___ /24*
Score:.__ /40*
Score:___ 16*
Score:___ ./14*
Comments
2.23___
2.28___
The denominator for each indicator is decreased by two for any items scored as not applicable
"NA.”
4-7
2.Technical Competence Dimension
Indicator 6
2.32f___
2.34e___
2.35f___
2.30g___
2.32g___
2.34f___
2.36___
2.31 a___
2.32h___
2.33___
2.34g___
2.37___
2.34h___
2.38____
2.34i___
2.39____
2.34j___
2.40____
2.31 c___
2.3ld___
2.3le___
2.3 If___
2.41____
2.341 ___
2.42 _ ___
1
Score:____ 746*
p?
2.35a___
II
2.3lg_
2.34k___
M 00
2.30f___
0
2.35e___
n
2.34d___
"*> C
D CL
2.35d___
2.32e___
Ox Qx Qx Ox Ox CT' Ox Ox Ln
2.34c___
2.32d___
2.30e___
0" CO ZT0-Q
2.32c___
2.30d___
2.45f
CL CT
2.30c___
Score:___ .762*
Score:___ J 50*
Indicator 8
Indicator 9
Indicator 10
FP
STI
Immunization
2.48___
2.63f___
2.67a___
2.70___
2.49
2.50___
2.63g___
2.64a___
2.67b___
2.67c___
2.71 ___
2.72___
2.51___
2.64b___
2.64c___
2.67d___
2.73___
2.52___
2.74___
2.53___
2.64d___
2.68a___
2.68b___
2.54___
2.65a
2.68c
2.55___
2.65b___
2.68d___
2.56____
2.65c___
2.68e___
2.57____
2.65d___
2.68f____
2.58____
2.68g____
2.59____
2.65e___
2.65f___
2.60____
2.65g___
2.69 ____
2.61____
2.66a___
2.62____
2.66b___
Total
Score
2.75___
2.68h ____
2.66d___
2.66e___
C
D
*
cl
11111
CT
2.66c___
_/76*
Score:
Comments
2.45e____
2.43a___
2.43b
■\l —J ■'■•J '-'J
2.35c___
111
2.35b___
2.34b
II1111II
2.34a___
2.32b___
pp
2.32a___
2.30b___
u 3? 3?
2.30a___
2.31b
Indicator 7
PPIC
Labor and delivery
C
D
Indicator 5
ANC—Conducting
ob/physical exam
.................................................................................
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
Score:____ 712
126*
4-8
____ 73 5 6*
Comments
SECTION 4: SUPERVISOR’S GUIDE
3. Continuity of Care Dimension
Comments
Total Score
3.1___
3.2___
3.3___
3.4___
3.5___
3.6___
3.7___
3.8___
3.9___
3.10___
3.11___
______ /22*
4. Management Dimension
Indicator 3
Indicator 2
Indicator 1
4.9___
4.10___
4.1 1___
4.12___
4.13___
4.14___
4.15___
4.1___
4.2___
4.3___
4.4___
4.5___
4.6___
4.7.__
4.8___
Score:___ 16*
Score:___ /10* Score:__/I4*
Indicator 4
4.16___
4.17___
Indicator 5
Total
Score
Comments
4.18___
4.19___
4.20___
Score:___ 14* Score:___ 16*
___/40*
5. Marketing Dimension
Total Score
Indicator 2
Indicator 1
Comments
rrrr
5.5___
00
5.6___
__ /12*
*
Score:___ 14*
6. Business Practices Dimension
Indicator 1
6.1a___
6.1b___
6.1c___
6.ld___
6.2___
Indicator 2
6.3___
6.4___
6.5___
6.6___
6.7___
6.8___
6.9___
6.10a___
6.10b___
6.10c___
6.1 la___
6.1 lb___
Score:___ /I0* Score__ _/24*
Indicator 4
Indicator 3
6.12___
6.14 ___
6.13___
Indicator 5
Total
Score
6.15___
6.16___
Score:___ 14* Score:___ 12* Score:___ 14* ___ 144*
4-9
Comments
SECTION 4: SUPERVISOR'S GUIDE
SUMMARY CHART OF SELF-ASSESSMENT
SCORES
Instructions: This form allows you to chart the changes in the indicators scores for each of
the dimensions.The unshaded boxes for each dimension are for you to write the score for that
indicator. The shaded boxes are left alone (there are no more indicators for those numbers in that
dimension).Two pages have been included here to allow for charting the scores for four quarters.
Dimension
1st Quarter
1. Physical
Environment
Scores for each indicator by dimension
1
2
3
4
/38
/I4
16
12
16
/14
124
140
5
6
7
8
9
10
Total
160
2. Technical
Competence
3. Continuity of
Care
146
ISO
162
176
126
/12
/I8
I3S6
l\8
4. Management
16
/IO
18
14
/IO
124
14
12
14
1
2
3
4
5
138
/I4
16
12
16
/14
124
140
114
14
16
140
5. Marketing
6. Business
Practices
2nd Quarter
112
144
6
7
8
9
10
Total
1. Physical
Environment
160
2. Technical
Competence
146
3. Continuity of
Care
ISO
162
176
126
ZI2
I3S6
l\8
118
4. Management
16
/IO
18
14
/IO
124
l\4
14
16
140
5. Marketing
/12
6. Business
Practices
14
12
14
144
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
Dimension
Scores for each indicator by dimension
3rd Quarter
1
2
3
4
1. Physical
Environment
/38
/I4
16
12
/6
/14
124
140
5
6
7
8
9
10
Total
160
2. Technical
Competence
3. Continuity of
Care
146
ISO
162
176
126
/12
/18
1356
118
4. Management
16
/IO
114
14
140
16
5. Marketing
18
14
6. Business
Practices
/IO
124
14
12
14
4th Quarter
1
2
3
4
5
/38
/I4
16
12
16
/I4
124
140
112
144
6
7
8
9
10
Total
1. Physical
Environment
160
2. Technical
Competence
146
ISO
162
176
126
/I2
1356
3. Continuity of
Care
l\8
l\8
4. Management
16
/IO
18
14
/IO
124
/14
14
16
140
5. Marketing
112
6. Business
Practices
14
12
14
4-12
144
SECTION 4: SUPERVISOR'S GUIDE
INSTRUCTIONS FOR REVIEWING AND SUPPORTING THE MIDWIVES’
ACTION PLANS
I.
After completing the scoring, refer to the Action Plan for Midwives (Section 3). If your time is
limited, you may want to concentrate on entries where his or her scores are lowest. For every
question where the midwife answered "0” or" I ” make sure he or she has made an entry for it
in the action plan booklet
2.
In your action plan tables on pages 4-17 to 4-27, record the items that the midwife has entered.
If time is limited, only copy those that need your assistance, but do note in brief the items he
or she was able to solve.This booklet is for you to record the plans the midwives that you are
responsible for have developed. If you want to develop your own plan for your own practice,
please use a separate booklet.
3.
As you copy a midwife's issue(s) please note the name of the midwife, so when you go back for
other visits, you can turn directly to that midwife’s plan.
4.
Please refer to the beginning instructions of for the action plan for midwife tables on page 4-1
and 4-3 for further guidance instructions.
5.
After reviewing the scores and helping the midwife develop her action plan, consider ways that
you as the supervisor can help resolve the identified problems. For example, if the problem is
due to a knowledge or skill deficit, consider how you can facilitate a learning session on the topic
or to have this midwife included in a training session on that topic. For example, at a monthly
branch meeting, you might organize a session on a topic that several midwives need updating
and invite a speaker from the community or local hospital with that expertise. If the problem
is due to a lack of equipment, explore with the district nursing officer at the Ministry of Health
if there is any equipment available from their stores that might be signed out to the midwife
or if many midwives in your area are lacking the same equipment, you could contact a local
vendor and see if you can negotiate a discount to buy equipment in bulk. If midwives are lacking
health educational materials, frequently, the Ministry of Health has a supply of health educational
brochures, posters, and booklets, that are available if someone will come and collect them.
4-13
SECTION 4: SUPERVISOR'S GUIDE
INSTRUCTIONS FORACTION PLAN
FOR MIDWIVES
Instructions for Scoring:
This action plan helps facilitate a simple problem-solving process. Please follow the steps to use the
action plan to improve the quality of your services.
If this is your first time using this action plan, please skip ahead to step 4.
I.
Review your statistics form. Have things changed since the last time you updated
the indicators?
a.
If they have changed for the better; congratulations! Please review your notes on the statistics
form and reflect on what actions helped facilitate that change.
b.
If you still feel like your indicators could improve, keep these goals in mind as you continue to
use the action-plan instrument.
2.
Review previous entries recorded in the action plan.
a. If you have successfully resolved an issue, put a checkmark/tick in the status column,
b. For the issues that remain, think about why they have not been resolved. If you need external
support, put an "E" in the status column and in the actions/next steps column for that issue,
record whom you will engage, how you will engage him or her; and what you will ask him or
her for.
3.
Now go back through your QI self-assessment tool.
a. Note the questions where you answered "0” or” I."
b. Refer to these questions as you develop your action plan.
4. Now develop your action plan. Step-by-step instructions and a sample action plan follow.
Subsequent pages contain a series of blank tables for you to create your plan.This document is
your action plan. If you choose, create a separate plan for each dimension to help prioritize your
interventions.
a. Write a star or X (* or X) in the QI tool next to the questions you answered "0” or" I ."Then
record the question number in columns I and rewrite the question so that you know what the
issue is.
b. In column 2 determine why you have this issue.You can use a simple "Why? Why?" exercise.
For example, the issue might be that you do not have adequate space for privacy.Then ask
yourself “why?" Answer: My clinic is small. Again ask"why?"Why is my clinic small? “Because
real estate is expensive and at the time I built my clinic I could not afford a larger space."
Once again, ask yourself why? “Because renovation is also costly." Continue to ask yourself
why after until you feel like you have exhausted all influencing factors.
4-15
until door
installed
hear is what said.
5. Ongoing
5. me
3. A p ril 7
5. In the interim, offer clients to meet outside
behind clinic where other clients can not see o r
4. April 10
4. me
4. Develop a budget to save for purchase and
installation o f a door (i.e., calculate how long
it will take you to save the total needed given
the amount o f money you can save weekly o r
monthly and the cost o f the door and carpenter.
Finally, in column 7 (the status column),
assistance.Then identify in column 7
who you will ask for help, what you will
request and how you will ask. If the task
has been completed, mark it with a tick/
check.
Column 4
Actions/Next Steos
resolved. If it has not been resolved,
write an “E” if you will require external
1. Analyze
5. Review this action plan after
monthly costs and revenue.
indicate if the problem has been
each time you use the QI self
assessment tool (it should be
mobilize the resources you need to resolve
issues you cannot do by yourself
1
1
3
4-16
Question
Column
u.
Do not have a
“O
OJ
shut.
renovation
expensive
Causes (Why)
professional association or network).
Your supervisor may be able to help you
Column 2
a supervisor who is part of a
2. Property and
Column 3
assessment of your practice and
to review any issues (if you have
1. Clinic small
Solutions
Encourage your supervisor to
become familiar with your self
Save money to
i
reviewed four times annually).
6.
2. March 31
Column 7
(W ill fill
this column
in when
complete
o r when
supervisor
reviews the
status the
next quarter.)
!
those steps.
f.
3. me
tn
and a deadline (by when) to accomplish
Column 5
person (by whom) for each next step
1. Midwife Mary
Zaki
E
In columns 5 and 6 assign a responsible
build another
room o r build a
door on exam
room that can be
e.
2. Mr. Adenekan
co
steps.
3. Price doors and costs o f carpenter
identified in column 3. Make sure these
are specific.There can be many next
2. Determine a realistic amount that you can
save weekly o r monthly.
c
1
March 31
In column 4 list your next steps for the
short-, medium-, and long-term solutions
Column 6
long-term solutions.
d.
1.
In column 3 record possible solutions.
Try to include short-, medium-, and
separate area for
counseling w ith a
table o r desk and
tw o chairs that is
private.
c.
Status
1
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
Physical Environment Action Plan
Dates of Assessment,,,
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Actions/Next
Steps
Column 4
4-17
By Whom
ByWhen
Status
Column 5
Column 6
Column 7
Technical Competence Action Plan
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Dates of Assessment,,,
Actions/Next
Steps
Column 4
4-19
By Whom
ByWhen
Status
Column S
Column 6
Column 7
Continuity of Care Action Plan
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Dates of Assessment,,,
Actions/Next
Steps
Column 4
4-21
By Whom
ByWhen
Status
Column 5
Column 6
Column 7
Management Action Plan
Dates of Assessment,,,
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Actions/Next
Steps
Column 4
4-23
By Whom
By When
Status
Column 5
Column 6
Column 7
Marketing Action Plan
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Dates of Assessment,,,
Actions/Next
Steps
Column 4
4-25
ByWhom
ByWhen
Status
Column 5
Column 6
Column 7
Business Practices Action Plan
Midwife’s Name:Location of Clinic:
Q# and Restated
Question
Column 1
Causes (Why)
Solutions
Column 2
Column 3
Dates of Assessment,,,
Actions/Next
Steps
Column 4
4-27
By Whom
By When
Status
Column 5
Column 6
Column 7
SECTION 4: SUPERVISOR'S GUIDE
NOTES:
4-29
PRIVATE HEALTH SECTOR
QUALITY IMPROVEMENT PACKAGE
SECTION 5: TRAINING GUIDE FOR FACILITATORS
CONTENTS
Section 5:Training Guide for Facilitators
Acronyms........................................................................................................... i
Overview of the Quality Improvement
Approach and Tools............................................................................... 5-1
Improving Quality in the Private Health Sector..................... 5-1
Quality Improvement Model.......................................................5-1
Purpose and Objectives.............................................................. 5-2
Flowchart for Quality Implementation and Training...............5-3
How to Use This Guide........................................................................ 5-5
Approach to Training and Learning............................................ 5-5
Training Methods.......................................................................... 5-5
Evaluation....................................................................................... 5-5
In Each Training Session............................................................... 5-6
Sample Schedule for Training in How to Use
the QI Package.............................................................................. 5-8
Day I
Session I: Creating a Learning Environment........................... 5-9
Session 2: Why Address Quality in the Private Sector?...... 5-11
Session 3:The Statistics Form and Review of Data............. 5-15
Session 4: QI Self-AssessmentTool........................................ 5-17
Session 5: Problem Solving Process: Root Cause Analysis ..5-19
Session 6:Action Plan for Midwives....................................... 5-23
Session 7: Closing Circle.......................................................... 5-27
Day 2
Session 8: Opening Circle...................... ................................. 5-29
Session 9: Reviewing the Five Whys....................................... 5-31
Session 10: Problem-Solving Process: Fishbone Diagram.... 5-33
Day 3
Session 12: Opening Circle/Reviewing the Visits to Clinics 5-37
Session 13: Scoring the QI Self Assessment......................... 5-39
Session 14: Working Together to Improve Quality and
Practice Conducting the Supervision Meeting..... 5-41
Session 15: Evaluation and Final Closing Circle....................5-43
Appendices
I.
Adult Learning Cycle and Training Methods........ 5-45
References................................................................................................ 5-49
Handouts
I.
QI Package Workshop Learning Objectives......... 5-51
2.
Scenarios.................................................................... 5-53
3.
Quality Improvement for Midwives
Workshop Evaluation............................................... 5-55
4.
Blank QI Self-Assessment Scores............................5-57
5.
Blank Summary Chart of Self-Assessment
Scores..........................................................................5-61
6.
Sample Summary Chart for Self-Assessment
Scores..........................................................................5-63
SECTION STRAINING GUIDE FOR FACIUTATORS
ACRONYMS
COPE
Client Oriented Provider Efficient
FP
Family planning
IUD
Intrauterine device
PSP-One
Private Sector Partnerships-One project
QI
Quality improvement
SECTION ^TRAINING GUIDE FOR FACIUTATORS
OVERVIEW OFTHE QUALITY
IMPROVEMENT APPROACH AND TOOLS
are receiving better care than that found in
the public sector (Ha, Berman and Larsen
2002, Uganda National Household Survey
1999/2000). In reality, however the status of
quality in the private sector is variable, and
what is known is anecdotal. (Brugha and Zwa
1998). Frequently, the status of quality in the
private sector is unknown because, by nature,
private practice is individual and often unregu
lated. PSP-One developed a quality improve
ment (QI) package for both the midwife and
his/her supervisor when available.The package
effectively helps the midwife identify quality
gaps, develop short-, medium- and long-term
action plans, and monitor improvement over
Organizations seeking to solve quality and
performance problems frequently implement
training and other interventions without fully
understanding the nature of the performance
gaps and whether the chosen interventions
are appropriate for closing the gaps.This
problem is further compounded when work
ing with providers in the private sector given
the lack of a built-in supervisory system and
frequent lack of access to organized continu
ous education.Therefore, when trainings and
other interventions are organized for the
private sector, it is especially important that
these interventions be directed to identified
gaps in quality.
time.
The Private Sector Partnerships-One project’s
overall goal is to increase access to and the
quality of services provided by the private
sector, in particular the services provided by
general practitioners, midwives, nurses, phar
macists and drug shop vendors.
QUALITY IMPROVEMENT
MODEL
PSP-One developed and refined the QI pack
age in collaboration with developing country
institutions that are focused on working with
private providers.The initial conceptualization
was derived from IntraHealth International’s
assessment tool developed in Armenia for use
by small health centers primarily staffed by
one professional provider PSP-One selected
dimensions of quality from the IntraHealth
self-assessment tool that were relevant for
the private sector and added two new di
mensions: marketing and business practices.
The QI package applies tools that meet the
criteria of simplicity and practicality with
emphasis on root-cause analysis and problem
solving. It is used on site by the midwife and
reviewed with the supervisor at regular sup
port meetings, including professional associa
tion meetings.The QI methodology was also
influenced by the experience of the perfor
mance improvement review approach of
Initiatives Inc. in Jordan's primary health care
IMPROVING QUALITY INTHE
PRIVATE HEALTH SECTOR
Promotion and evaluation of high-quality care
is a priority for anyone delivering, organizing
or monitoring clinical services. Initiatives to
improve quality of care have a long history
in public sectors around the world. However
little has been done globally in the private
sector due to the individual and often un
regulated nature of most private practices. In
addition to the known reasons why quality
is important (better services, better continu
ity of care, better repeat business and better
health), there are other reasons to address
quality in the private sector One main reason
is that 60-80% of clients who seek private
sector services and pay significant amounts
out of pocket do so with the assumption they
5-1
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
centers. A number of items related to family
planning were drawn from EngenderHealth's
Client-Oriented Provider Efficient (COPE)
Self-Assessment Guide.
► developing a midwife’s action plan to:
• analyze the root causes to uncover
the principal reasons for quality per
formance gaps/problems identified
by completing the self-assessment
Purpose: ThisTraining Guide was developed
to support the program staff of professional
organizations, networks and franchises pre
pare for and conduct the training of supervi
sors to use the package of quality improve
ment materials and to prepare the private
sector midwives they supervise to use the
package.
tool
• prioritize the problem list
• develop appropriate interventions
and mobilizing resources to close the
performance gaps
• monitor progress and resolution of
identified gaps
3.
Objectives: Users of this Training Guide
will be able to plan and conduct a training of
midwives and their supervisors:
► scoring the midwife's QI self-assessment
tool
I. To describe the components and use of
the QI package
2.
For supervisors: to support private mid
wives to use the QI package, by:
► assisting the midwife in identifying root
causes of quality problems, and to de
velop and monitor her/his action plan
For private midwives: to use the QI pack
age, including:
► engaging the public sector (e.g., district
health teams, district nursing or mid
wifery officer) to mobilize resources
and give assistance in solving selected
problems
► completing and analyzing the statistics
compiled in the statistics form
► completing the QI self-assessment tool
5-2
SECTION SlTRAINING GUIDE FOR FACILITATORS
FLOWCHART FOR QUALITY IMPLEMENTATION AND TRAINING
GETTING STARTED
Step 2:
Assess Quality Using
QI Self-Assessment Tool
Time: Quarterly
Purpose:
Measure quality,
determine gaps, and
track improvements
Step I:
Review Statistics
Time: Quarterly
Step 3:
Develop/Revise
Action Plan
Time: Quarterly
Purpose:
Collect data to determine
if improvements result in
changes in health status
and service utilization
Purpose:
Facilitate problem
solving process
Step 4:
Identify Resources
with Supervisors
Time: Monthly or
Quarterly
5-3
SECTION STRAINING GUIDE FOR FACILITATORS
HOWTO USETHIS GUIDE
This training guide contains all the session
designs and handouts needed for conducting
an orientation to using the package of qual
ity improvement materials for private sector
midwives.
• Experiences are organized, logical, and
practical, include a variety of methods, and
guidelines are available.
• New information and skills are relevant to
participants' responsibilities and are applied
immediately.
Participants in the training for using the QI
package are midwives in independent practice
who provide care primarily to mothers and
children, and the midwives' supervisors.
• Training involves every participant in
active practice, and participants share
responsibility for learning.
• Trainers are knowledgeable in the subject
matter and competent in the skills, use
a variety of training methods to appeal
to individual learning preferences, pay
attention to individual participants’
concerns, and provide feedback and
Ideally, the training would be conducted by
one to two trainers for up to 20 participants
(15 midwives and approximately three to five
supervisors).The workshop is typically one day
for midwives and their supervisors followed
by an additional one and a half days for the
supervisors only.The recommended sched
ule runs from 8:30 am to 5:00 pm, including
appropriate breaks. A suggested workshop
schedule can be found at the end of this sec
tion.
reinforcement
• Feedback is immediate and focused on
behavior that the participants can control.
• Assessment of learning and skills is
based on objectives that the participants
understand.
APPROACH TOTRAINING AND
LEARNING
For more information about the adult learning
cycle and training methods used frequently in
this training guide, see Appendix I.
The workshop outlined in this manual is based
on adult learning principles. Learning involves
more than exposure to new ideas and ways
of solving problems and doing things. Rather;
learning involves changes in knowledge, atti
tudes and behaviors. Adults learn best when:
TRAINING METHODS
This training guide incorporates a variety of
methods suited to the stated learning objec
tives. As necessary, make adaptations to the
training plan to suit the participants and the
specific training situation.
• They are motivated and not anxious, know
what is expected of them and are treated
with respect.
• They are involved in establishing
EVALUATION
expectations/objectives for the training.
Evaluation or assessment of learning objec
tives allows trainers, program managers and
participants to know how successful a training
program has been. Ongoing evaluation and
assessment allow trainers to identify gaps in
• Learning experiences are interesting and
meaningful, build on what participants
already know, and encourage problem
solving and reasoning.
5-5
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
learning and to immediately fill those gaps.
Evaluation also assists in revising learning
experiences to better meet participant needs
for later trainings.
tation to using the QI package. Each session
contains the following sections:
Session Title—The title of the session or
activity.
This workshop uses the following methods to
evaluate the participants' learning:
Session Objectives—The learning objectives
that state what participants should know or
be able to do after completing the session.
• Question and answer/group discussion
• Completion of QI self-assessment tool
and action plan for one to two quality
dimensions
Estimated Time—The time that each ses
sion will require depends upon the particular
group of participants, the amount of time
available and other constraints.The session
gives an estimated time to allow for flexible
scheduling.
• Measurement of actual use of tool over
time and change in self-assessed scores (to
be completed on a revisit)
This workshop uses the following methods to
elicit feedback on the training experiences:
• Daily participant reflection and comments
in the closing circle
Trainer Preparation—The specific prepa
rations that trainers should make for the
session include:
• End of workshop participant reaction forms
• ensuring the room is properly arranged
• ensuring that markers and a flip chart or
a writing board with chalk or markers are
available
The service provider participants will be fol
lowed up by their supervisors after the work
shop to assess the results of the workshop—
the extent to which the participants were
able to apply what they learned by complet
ing their statistics forms, QI self-assessments,
and action plans; and what facilitated or hin
dered their carrying out their action plans.The
recommended format for the follow-up is
through monthly meetings that the supervisor
conducts with the midwives she supervises.
The midwife brings a completed self-assess
ment form of her practice and shares some
of her identified problems.The supervisor
can then group and prioritize the problems
and conduct a brainstorming session to help
• reviewing the session plan
• reviewing steps for the activity used in the
training session
• copying materials that participants need
• ensuring the necessary handouts and
supplies are available for the practice
sessions
• thoroughly reviewing all course materials
Facilitation Steps—The steps for facilitat
ing the methods and activities that are used
in the session. Appendix I includes general
instructions for frequently used methods.
Instructions for suggested participatory activi
ties are included in these Facilitation Steps.
generate solutions for the identified problems
including mobilizing resources.
IN EACH TRAINING SESSION
Evaluation!assessment—Evaluation meth
ods for assessing the learning objectives are
listed.These typically include question/answer,
Each training session in this guide contains all
of the materials required to conduct an orien
5-6
SECTION STRAINING GUIDE FOR FACIUTATORS
Package, Action Plan, and Supervisor's Guide.
The complete QI Package is usually handed
out at the beginning of the training program,
and each session in theTraining Guide refers
to the part of the package that will be used
during the session. Additional handouts or
worksheets used in specific sessions are also
listed here and are usually handed out during
the session in which they are used.
discussion, and small group or individual exer
cises although other activities can be used to
assess deficits/gains in learning throughout the
course of the workshop.
Handouts—The primary handout for this
training program is the Private Health Sec
tor Quality Improvement Package, including
the Implementation Guide, Self-Assessment
5-7
Sample Schedule forTraining in How to Use the QI Package
Day 1 (Midwives and Supervisors)
Day 2 (Supervisors only)
8:00AM-5:00 PM
8:30AM-5:00 PM
Registration 8:00
Session 8. Opening Circle (30 min)
Session 1. Creating a Learning Environment (1 hr)
Introductions, Hopes and Fears, review of
Schedule & Learning Objectives, participant
Session 9. Reviewing the 5 Whys (1 hr)
materials
Session 10. Root Cause Analysis: Fishbone Diagram
Session 2. Why Address Quality in the Private Sector?
Day 3 (Supervisors only)
8:30AM-2:30 PM
Session 12. Opening Circle/ Reviewing Visits to Clinic
(1 hr)
Session 13. Scoring the Midwives' QI SelfAssessment (1 hr 50 min including break)
Break (IS min)
Break (15 min)
(1 hr 30 min)
(1 hr)
Session 11. Preparing for and Conducting the Clinic
Session 14. Working Together to Improve Quality
and Practice Conducting the Supervision Meeting (1
Break (1 5 min)
Visits (3-4 hrs)
hr 30 min)
Session 3. Statistics Form and Review of Data
(30 min)
Session 4. QI Self-Assessment Tool (2 hrs)
Lunch 1 hour
Session 4 (cant’d). Discussion of questions about
completion of Self-Assessment Tool (cont)
Lunch 1 hour
Session 11 (cant'd). Conducting the Clinic Visits
Session 5. Root Cause Analysis: 5 Whys (1 hr 30
min; continue after the break, if necessary)
Break (IS min)
Session 6. Action Plan for Midwives (45 min)
Session 7. Closing Circle (30 min)
Day Ends 5:Oopm
Day Ends s:oopm
Lunch I hour
Session 15. Evaluation and Closing Circle (45 min)
SECTION 5:TRAINING GUIDE FOR FACILITATORS
DAY I
Session I: Creating a Learning Environment
Session
Objectives
At the end of the session, participants will be able to:
• Identify observations of participants about their work in maternal and child health
• Share their hopes and fears (expectations and concerns) for the workshop and
compare with learning objectives
• Review the objectives and schedule for the workshop
• Begin contributing actively in the workshop
Time
1 hour
Trainer
Preparation
• Prepare index cards with words on one side of them (sample words: Inspiration,
Opportunity, Service, Benefit, Choice, Caring, Serious, Complex, Quality, Hopeful,
Option, Commitment, Perform, Challenge, Communication, Courage, Strength, Access,
Grateful, Cheerful, Purpose, Open-minded, Difference, Chance, Guidance, Informed,
Collaborate,Teamwork).
• Prepare flipcharts: "Welcome to Quality Improvement Training for Midwives,”
Schedule for Day 1, Workshop Objectives.
• Check that copies of the Workshop Learning Objectives handout, flipchart paper,
markers and masking tape are available.
• Arrange seating in a circle (without tables) for the participants and trainers.
Facilitation
Steps
Step 1. (5 minutes) Trainers and participants are sitting in a circle. A bell with a soft
tone may be used to call the participants together in the circle. Welcome participants;
provide a short introduction to the purpose of the workshop; introduce trainers
Step 2. (30 min) Introductions: Place index cards with words in the center of the
circle, face down, on the floor Ask participants to come forward and select a card.
When all seated, ask them to select a partner Once they are in pairs, ask them to stay
in silence and to think about what the word means to them as it relates to their work
as midwives. Then, they introduce themselves to each other and share their thoughts
about the word. Afterwards, each pair introduces the person they paired with by name
and tells some of that person's thoughts about the word, which the person has given
permission to share.
Step 3. (25 min) Expectations and Concerns: Ask participants to break into groups
of 3-4 and to take 15 minutes to flipchart their expectations and concerns about the
time together in the workshop, highlighting items to share with larger group. After 15
minutes, have the group reconvene in the circle, post notes/flip chart sheets on the
wall (leave on wall throughout the workshop), then participants take 5-10 minutes to
share expectations and concerns, identify common expectations and concerns.Trainer
talks about bringing expectations to fruition and that some concerns may be realized;
promise to revisit expectations and concerns at the end of the process. (Note: If you are
short on time, this activity can be done all together in the large group - 15 min)
5-9
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
Step 4. (5 min) Review Workshop Objectives and Schedule. Go over the materials
in the QI Package and explain that during the workshop they will learn the purpose of
each tool in the package and will practice using them.
Step 5. (5 min) Ask participants if they have any questions on the objectives, schedule
and design for the workshop. Briefly present outline of the day (on flipchart).
Evaluation/
Assessment
• Question/answer; discussion
Handouts
• Handout I. QI Package Workshop Learning Objectives or if it is difficult!expensive to
photocopy, write the objectives on flipchart
5-10
SECTION 5:TRAINING GUIDE FOR FACILITATORS
DAY I
Session 2: Why address quality in the private
sector?
Session
Objectives
At the end of the session, participants will be able to:
• Identify how improved quality of care affects clients, providers and the community
• Identify the parts of the QI package and their purposes
Time
1 hour
Trainer
Preparation
• Read Section 1: Implementation Guide for Midwives and Supervisors
• Find out what percentage of services in your country are provided in the private
sector
• Photocopy selected scenarios for group work
Facilitation
Steps
Step 1.(15 minutes) Divide participants into two to three groups (depending on size
of group) and give each group the written description of the chosen scenarios with
questions. Do not mention anything about quality or objectives of the session before
breaking into groups to discuss the scenarios.You may not use all three scenarios
depending on the cultural relevancy of the particular scenario or you may choose to
adapt it
Scenario 1: You are interested in having your hair braided. With the group discuss
1) how you go about choosing a particular hair braider and then 2) what makes you
want to return to this particular hair braider (what makes you a satisfied customer).
Scenario 2: You are going to buy fresh fish. With the group discuss 1) where you
go and how you select a particular fish seller; and 2) what makes you return to buying
fish from this particular fish seller (what makes you a satisfied customer).
Scenario 3: You are having an engagement party for your son. With the group
discuss 1) how you would select a specific caterer or hotel for the event, and 2) what
would make you use that caterer/hotel again when your younger son gets engaged
(what makes you a satisfied customer).
Instructions to participants: Answer the questions for your scenario. During
the discussion, list on a flip chart 1) the characteristics that help you choose the hair
braider; fish seller or caterer and 2) the characteristics that make you a satisfied cus
tomer who returns.
Circulate around to each group to make sure participants understand the instructions
and are following them. Make sure their answers reflect local realities.
Step 2. (15 minutes) Ask participants to reconvene in large group and ask each group
to present the characteristics. Guide the discussion so that all relevant characteristics are
mentioned and clumped into initial selection and return/repeat business. (Some
characteristics may only emerge for one scenario and not all, which is why different sce
narios are used for this exercise.)
5-11
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
Answers: These are common answers:
Initial selection:
•
word of mouth/reputation
•
convenience of location
•
reported cost of services
•
general appearance and cleanliness of vendor and/or shop
Repeat Business:
•
friendliness of sales person (treats you nicely, is gentle)
•
•
knowledge of the person providing the service
quality of product or service
•
satisfaction with their service/product (e.g., freshness of fish, the way my hair
•
waiting time to obtain service or product
actual cost or value for money to buy product or service
looks, how guests enjoyed the engagement party)
•
Step 3. (5 minutes) Ask participants,"Is there any difference between the characteris
tics you look for in the quality (of fish sellers or hair braiders or caterers/hotel) and the
characteristics clients look for in clinical services midwives provide?” (They are more or
less the same characteristics.)
Step 4. (2 minutes) Discuss the following definition of quality: "Doing the right thing
right the first time."
Step 5. (3 minutes) Explain to participants that
• In many developing countries, 60-80% of health services are provided by the private
sector (for-profit, NGOs, FBOs).
• Often, people spend money for private services expecting the quality to be better
than that of the public sector.
• Nationally, in Uganda, private expenditures account for 72% of the total expenditure
on health and out-of-pocket expenditures account for 52% of the private
expenditure on health. Sixty-five percent of women seeking care for their child with
fever/cough sought care from a private source and 59% of those seeking care from
private sources were from the poorer or poorest quintile.Therefore, it is important
that the private sector provide quality health services
Step 6. (5 minutes) Ask participants the question, "Why is quality important for private
sector midwives?"(Points discussed will depend on local context but may include):
•
•
Satisfied customers lead to repeat business
Quality services result in decreased maternal and infant mortality
•
If the midwife provides quality services, she will become well known in the com
•
To minimize the transmission of infection
•
To address competition
•
To be in harmony with the public sector (re: national standards, etc.)
munity and new clients will come to her
5-12
SECTION STRAINING GUIDE FOR FACILITATORS
Step 7. (5 minutes) Ask participants, "What unique challenges do private midwives
have in providing quality services?" (Points discussed will depend on local context but
may include):
•
•
Relative isolation of provider in private practice
Exclusion of provider frequently from public sector trainings/updates
•
•
Invisibility of private provider - how to become known
Lack of supervision/support system
•
High taxes
•
•
Non-payment by clients
Cost of making an improvement to quality of services versus how much income
she is making
•
Lack of commodities
•
No pension; no paid leave
•
Competition of qualified staff; difficulty in paying them competitive salaries
Step 7.(10 minutes) Hand out the Quality Improvement Package (different versions
for the midwives and for the supervisors). Have participants turn to the page for each
part/component of the package:
• Section I: Implementation Guide
• Section 2: QI Self-Assessment Package: Review of Statistics and Self-Assessment Tool
organized by 6 dimensions—with questions under each quality—that are grouped by
indicator within the dimension. (Link through discussion the characteristics of service
in the two scenarios to the dimensions of quality.)
• Section 3: Action Plan for Midwives
• Section 4: Supervisor's Guide
Evaluation/
Assessment
Handouts
• Question/answer; discussion
Quality Improvement Package
Handout 2: Scenarios. Fish Selling, Hair Braiding, Engagement Party
5-13
SECTION ^TRAINING GUIDE FOR FACILITATORS
DAY I
Session 3: The Statistics Form and Review of
Data
Session
Objectives
At the end of the session, participants will be able to:
• Define the service indicators used in the Statistics Form
• Complete the contraceptives table
• Complete the Statistics Form
Time
30 minutes
Trainer
Preparation
• Review the Statistics Form.
Facilitation
Steps
Step 1. (3 minutes) Ask participants "What are statistics?" and "Why do we collect
• Gather and copy the local statistics form from MOH (whatever indicators
midwives are required to report to MOH).
statistics?” (To have a record of wha t you’ve done, to help you plan, to give you a
picture of your performance).
Step 2. (2 minutes) Hand out the local statistics form for MOH (if available) and
ask the participants to turn to Section 2, page 3 of the QI Package.
Step 3. (20 minutes) Ask each participant to read aloud the definition of one
indicator (Section 2, pages 3 and 4) until definitions of all 13 indicators have been
read. Answer any questions about the indicator definitions. Have the participants
look at the two forms on Section 2, pages 4 and 5 and explain that monthly
totals will be entered under the number for each indicator to the right of the
month for which they are recording totals. Explain that the numbers and types of
contraceptives distributed are entered similarly on the form found on Section 2,
page 5.
Step 4. (3 minutes) Compare the indicators in the QI Package Statistics Form
(Section 2, page 2) and the MOH form.
Step 5. (2 minutes) Ask if there are any questions about the monthly
documentation of clinic statistics.
Evaluation/
Assessment
• Question/answer; discussion
Handouts
Local statistics form from MOH (if available)
5-15
SECTION STRAINING GUIDE FOR FACILITATORS
DAY I
Session 4: QI Self-Assessment Tool
Session
Objectives
At the end of the session, participants will be able to:
• Explain the rationale for self-assessment
• Describe the six dimensions of quality in the QI Self-AssessmentTool
• Identify where to find the indicators for each of the quality dimensions
• Complete the Self-AssessmentTool, rating her practice on all six quality dimensions
• Identify her strengths and areas for improvement on one quality dimension
Time
2 hours
Trainer
Preparation
• Read and complete Section 2:The QI Self-AssessmentTool for Midwives.
Facilitation
Steps
Step 1. Explain that we chose to use self-assessment because evidence suggests that
midwives' self assessments of their own practice correspond closely to those of trained
supervisors. In many settings because of remote locations, difficulty of transport, arid
lack of trained supervisors, midwives are often practicing without any direct supervision.
This tool enables midwives themselves to assess their practice in areas that have been
identified to influence quality.
Step 2. Ask participants to turn to Section 2, page 7. Point out that there are six di
mensions to the QI self-assessment tool, one for each quality dimension, and that each
dimension is divided into indicators with questions.These dimensions, indicators and
questions were selected because they are associated with quality according to interna
tional evidence on quality of health services. Write the six dimensions on a flipchart to
use as a reference throughout the workshop.
Step 3. Point out that there are instructions for completing the self-assessment tool on
Section 2, page 7. Ask participants to turn to Section 2, page 9 (the first page of Dimen
sion 1, Physical Environment) and look at the chart while you read the instructions. Have
the other trainers circulate to make sure the participants are following what you are
saying.
Step 4. Go through the instructions for completing the tool. Be sure that they under
stand the scoring key (2,0, 1, and NA). Give an example of when to use NA—for exam
ple, if you do not provide immunizations that require a cold chain or you do not keep
vaccines in your clinic that require a cold chain (Question 1. 17). If needed, go through
all of the questions for Dimension 1, to make sure they understand the indicators and
questions.
Step 5. State that the midwives should assess themselves using the tool every 3
months.
Step 6. Ask the participants to individually complete the entire QI self-assessment.
Circulate to answer any questions, paying special attention to make sure that participants
are putting a number or tick or X under the appropriate column.
5-17
PRIVATE HEALTH SECTOR QUALITY IMPROVEMENT PACKAGE
DAY I
Step 7. After lunch, reconvene the group and lead a short discussion about the expe
rience of completing the QI self-assessment tool. Was it clear? What questions do the
participants have, if any? State that the next steps are to analyze the root causes of the
gaps identified in their QI self-assessments and to develop an action plan for making
quality improvements.
Evaluation/
Assessment
• Question/answer; discussion
Handouts
None
• Completion of the QI self-assessment tool
5-18
- Media
15963.pdf
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