Changes that improved maternal and neonatal health · Changes that improved maternal and neonatal...

Changes that improved maternal and neonatal health in Jharkhand

January 2015

The ‘needle and syringe’ represents health service delivery or a health product change ideas

The ‘classroom’ icon represents change ideas that were primarily related to classroom or on-the-job trainings, orientation and sensitization sessions.

The ‘notice’ icon represents change ideas where materials were created for ready reference or as reminders for action.

The ‘checklist’ icon represents change ideas that improved services by enhancing quality of reporting, recordkeeping and review.

The ‘box’ icon represents change ideas that improved procurement of products and services.

The ‘two bustheads’ icon represents change ideas which were either task shifting or was undertaken by introduction of a new health professional.

The ‘clock’ icon represents change ideas that were related to either increasing or reducing time of a service or product administration.

The ‘cart with goods’ icon represents change ideas that were related to relocation or creation of a facility.

The ‘crossing arrow signs’ icon represents change ideas that were related to supportive supervision.

The ‘people across a table’ icon represents change ideas that were related to counseling practices.

Icons used in the change package andhow to read them

District Hospital

PrimaryHealthCenter

Health facilities inJharkhand

where e�orts to improve care led to

this change package

CommunityHealth Center

Sahibganj Phudkipur

Rajmahal

DandeGodda

ChikoniaPoraiyahat

Jama

DevdanrBarapalasi

DumkaLaxmipur

Saraikela

Chaulibasa

KuruSalgi

KairoLohardaga

GumlaRaidih Tudurma

Kondra

Chandil

UdhwaTeenpahar

The USAID ASSIST Project also acknowledges contribution of facility managers and health service providers who, as members of the quality improvement teams, initiated and implemented change ideas to improve quality of healthcare services in their facilities.

The USAID ASSIST Project acknowledges the unwavering support of Dr. Rakesh Kumar, Joint Secretary (RCH), Minstry of Health and Family Welfare, Government of India in development of this change package.

Jharkhand is one of the new states in India, carved out of the state of Bihar. With introduction of the National Rural Health Mission and with priority being accorded to Jharkhand as one the eight Empowered Action Group (EAG)1 states, the state has made architectural correction in delivering public health services. Over the last one decade, the maternal mortality ratio (MMR) in the state reduced from 371 per 100,000 live births in 2001-032 to 219 per 100,000 live births in 2010-123. During the same period, the infant mortality rate (IMR) in Jharkhand has come down to 37 per 1000 live births in 20134 from 44 in 20095 and from 62 in 20016. The neonatal mortality declined sharply to 26 in 20137 from 29 in 20118. The recently concluded Annual Health Survey done in the state shows that only 46% of all deliveries in Jharkhand are institutional deliveries9. Of the remaining deliveries that happen at home a little over a quarter (27.4%) of those are attended by a skilled birth attendant. Put together with institutional delivery data, the state has only 56% of all deliveries attended by a skilled birth attendant10.

In order to accelerate reduction in maternal, neonatal and infant deaths in the state, there was an immediate need to improve quality of maternal and newborn health (MNH) services. The USAID ASSIST Project in Jharkhand is conceived with a mandate to improve quality of maternal and newborn care services by strengthening the public health system in the state. The quality improvement (QI) teams11 from the USAID ASSIST Project, in consultation with public health facility managers and key health professionals in the state, selected a set of catalytic, high impact interventions in antenatal, intranatal, postnatal care of mothers and essential care of newborns that would accelerate further reduction in maternal and infant deaths in Jharkhand.

CONTEXT

The quality improvement teams used a mix of observations techniques and in-depth interviews on the maternal and newborn health interventions being practiced at a select set of public health facilities in high priority districts in the state and identified the following gaps in provision of quality maternal and newborn health services.

Gaps in quality of maternal and newborn health services

● The practice of oxytocin administration was inconsistent, both in terms of timing and in appropriateness of dosage. It was a common practice among labor room staff to administered oxytocin after expulsion of placenta.

● Partograph was not being plotted correctly and consistently by the skilled birth attendants (SBAs) across several facilities in the state.

Gaps in maternal health services during intra-natal period

● Health providers were not counseling women on identification of danger signs in the postpartum period. ● There was inconsistency among staff in health facilities in monitoring vital parameters of postpartum women. It was found that labor room and post natal ward staff, especially those working

in facilities which had heavy case loads, would monitor vitals only after the woman or her attendant reported of complications.

Gaps in maternal health services during post-natal period

● Vitamin K injection was administered only to low birth weight babies or to pre-term babies than to all newborns. ● The practice of keeping baby warm, either by skin-to-skin contact or by drying and wrapping newborns in warm clothes, was not practiced universally and regularly. ● Equipments to facilitate neonatal resuscitation were not available across all facilities resulting in health providers not providing assisted breathing when required. ● Health providers did not consistently use sterile material for cord care. ● Health providers were not counseling mothers on early initiation of breastfeeding resulting in delay in initiating breastfeeding by many mothers.

Gaps in newborn health services

ASSIST coaches training members ofquality improvement team

Orientation learning session facilitated by quality improvement teams

Delivering change in maternal and newborn health servicesPlotting of partograph for identi�cation and management complications during laborAIM#1

Change idea Logic for change How the change happened

Re-training and handholding of labor room staff on correct and complete use of partograph for monitoring labor

Review of the completed partograph and feedback by the medical officer/ SBA master trainer in the facility

While most of the labor room staff had undergone SBA training, they were hesitant to use partograph.

The partograph filled by labor room staff was not getting reviewed and given feedback or additional support for improvement.

Labor room staffs, who were in QI team, were trained to use partograph. They also mentored other labor room staff in correctly using partograph. QI team member assigned to ensure correct completion of partograph.

SBA master trainer and quality improvement team members jointly reviewed the partographs and provided feedback, orientation and mentoring support as needed to the labor room staff.

Change siteDH PHCCHC

Proportion of vaginal deliveries for which uterotonic was administered within one minute of birth

Administration of Injection Oxytocin 10 International Units (IU)/intramuscular (IM) within one minute of delivery to all women delivering in labor room for active management of third stage of labor (AMTSL)12AIM#2


Filling of Injection Oxytocin (10 IU) - at the time of perineal bulging

Placement of an additional staff in the labor room

Since most facilities had only one staff in the labor room to attend to deliveries, the staff was overloaded with care of both mother as well as the newborn, resulting in their inability to administer Oxytocin within one minute of delivery.

There was often only one staff available at the time of delivery, which did not provide opportunity to take care of the mother as well as the newborn.

The labor room staffs were trained to use the time of perineal bulging to load Oxytocin into syringes and keep them ready in the surgical tray or on a sterile surface for administration.

The Civil Surgeon15, on request of medical officer in-charge (MOIC) of the facility, approved placement of an additional staff in the secondary care facilities, i.e., Community Health Centers (CHCs), so that there are at least two staff in the labor room for each shift. SBA trained staff were moved from low load facilities in the district to those facilities where delivery load was high. The students of General Nurse Midwifery (GNM) course were used at the labor rooms in district hospitals to make up for the additional staff requirements.


Perc

enta

ge

Num

bers

Proportion of pregnant women for whom partograph was filled in District Hospital, Sahebganj, May – December 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mar-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Mar-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Review of the completedpartograph and feedbackby LMO/ SBA mastertrainer in the facility.

Printing of Partograph inthe back of BHT

0 200 400 600

Total no. of women admitted in labor in the last month

Retraining and hand holding of labor room staff on correct and complete use filling of Partograph for monitoring labor

Measuring and recording blood pressure levels duringevery ANC visit

A senior staff made responsible to ensure that no serviceis missed to a pregnant woman

Delivering change in maternal and newborn health servicesAdministration of Injection Oxytocin 10 International Units (IU)/intramuscular (IM) within one minute of delivery to all women delivering in labor room for active management of third stage of labor (AMTSL)12AIM#2


Orientation of labor room staff on identifying early signs of postpartum hemorrhage (PPH) and managing it in time.

Planned procurement (in time and in adequate quantity) of Oxytocin to ensure 24 x 7 availability

Timely indenting of Injection Oxytocin by the labor room staff.

Improvement in storage of Oxytocin to minimize loss due to loss of efficacy and/or breakage of vials.

Record keeping of Oxytocin usage

Only a few labor room staffs were knowledgeable about management of PPH, including importance of giving Oxytocin within one minute.

Some facilities experienced stock out of Oxytocin as it was not being procured on basis of delivery load at the facility.

There were cases when Oxytocin stock in the labor room exhausted despite it being available in the store at the facility.

Vials of Injection Oxytocin were not stocked in safe location and in correct temperature.

There was no practice of recording Oxytocin administration in the labor room, which limited the ability of MOICs to identify cases of PPH.

The quality improvement teams organized a one-day orientation and training for all labor room staff on PPH management, including AMTSL. The staffs were also trained on how and when to pre-fill Injection Oxytocin and keep it ready for use.

The staffs involved in procurement were oriented to calculate average delivery load of the facility and keep three months of Injection Oxytocin supply in stock.

A process of periodic indenting between labor room and the store, based on average delivery load in the labor room, was set up to ensure 24 x 7 availability of Injection Oxytocin in the labor room.

The refrigerator available in the facility was relocated to the labor room for keeping Oxytocin safe. The MOICs made one of the many vaccine carrier cases available exclusively for storing Injection Oxytocin wherever refrigerator was not available. In some cases, the Oxytocin was kept at the refrigerator in operation theatre (OT), with daily indenting from labor room to OT in-charge and supply from OT to the labor room.

The delivery register was updated to provide details of Oxytocin administration, including timing, was provided to labor room staff. The MOICs were oriented to review use of Injection Oxytocin to pick cases where the usage was in excess of recommended vials and indirectly assess cases of PPH.


Proportion of vaginal deliveries for which uterotonic was administered within one minute of birth

Perc

enta

ge

Num

bers

Proportion of vaginal deliveries for which uterotonicwas administered within one minute of birth of baby in

Devdanr PHC, December 2013 – December 2014

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14


1. Orientation of labor room staff. 2. Pre filling of Injection Oxytocin. 3. Recording of administration of injection Oxytocin.

Planned procurement of Oxytocin.

Improvement instorage of Oxytocin

05

10152025

Total no. of vaginal deliveries observed/reviewed/C-sectionwhere only this is done

Checking and recording hemoglobin levels duringall ANC visits

Line listing of severely anemic cases in ANC clinics ofthe maternity homes

Monitoring and documentation of vital parameters (blood pressure and pulse) in the post partum period to identify and manage complication in mothersAIM#3

Delivering change in maternal and newborn health services


Orientation to health facility staff on importance of monitoring and recording vital parameters of the woman regularly during the postnatal period.

Labor room staff to monitor and record the postpartum vital parameters and bleeding P/V at least once before shifting the woman from the labor room

Documenting vital parameters taken during the postpartum period in the Bed Head Ticket (BHT)

Transferring responsibility of checking and recording vital parameters to the additional staff placed in labor room to assist in administering oxytocin

The staff used to measure and record the vital parameters only once after delivery as they were not aware of the importance of repeated monitoring of vitals during the postnatal period.

Postpartum checks were not being performed in the labor room. Monitoring of vitals during immediate postpartum period, during which the woman is mostly in the labor room, is critical to identifying and managing complications.

Recording and tracking of vital parameters postnatal was absent in a large number of facilities because recording/ reporting sheets were not available.

Due to availability of only one staff in the labor room, vitals were being taken only for the patient whose condition was critical. The placement of an additional staff in the labor room provided an opportunity to shift tasks.

Staffs of the labor room and post natal ward were oriented on the importance of frequently monitoring vital parameters during the postnatal period and how to use the collected data for identifying and managing complications.

Labor room staffs were oriented to monitor and record the vital parameters at least once post partum, when the woman is on the labor table after delivery and manage complications in case they identify any parameter outside the normal range.

A new template of Bed Head Ticket, which has separate columns to not only record vital parameters but also mention the time when they were taken, was introduced in the health facilities for use during postnatal period.

It was decided among the QI team members in the facility to check BP, pulse and bleeding P/V for all women at least three times within the first six hours of delivery to start with and gradually increase the frequency of checking vital parameters. The additional staff placed on rotation basis in the labor rooms was assigned to monitor and record the vital parameters.


Average number of times vital signs (BP and pulse) were checked and recorded within the �rst six hours of delivery

Num

bers

Num

bers

Average number of times vitals (both BP and pulse) checked and recorded within first 6 hours post partum

in Godda DH, December 2013 – December 2014

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8



1. Orientation offacility staff. 2. Documentationof vitals on back of BHT.

Taking vitals before shiftingmother to post natal ward.

0 200 400 600

Total no. of women whose records were reviewed

Monitoring vital parameters (BP and Pulse)in the postpartum period

Administration of Injection Oxytocinwithin one minute of delivery

Delivering change in maternal and newborn health servicesCounseling to mothers on postpartum care, detection of danger signs and adoption of family planning methods postpartumAIM#9


Counseling to mothers about contraception and danger signs by either the labor room staff or the Sahiyyas.

Check the understanding among mothers and her relatives post-counseling and, if needed, counseling them once again.

Clearly visible display of a postpartum counseling on the walls of the labor room for quick and ready reference.

There was no staff dedicated to counsel the mother and her family members, who had limited knowledge on postpartum care, detection of danger signs and adoption of family planning methods.

The counseling by labor room staffs was not sufficient to establish clear understanding on postpartum care, danger signs and family planning. It was important to reinforce the counseling messages.

In absence of a ready reckoner, the staffs of labor room, postnatal room and Sahiyyas were missing many components of postpartum counseling.

The QI team oriented Sahiyyas on counseling mothers and relatives on postpartum care, detection of danger signs and adoption of family planning and made them responsible to facilitate this practice.

Postnatal ward staffs were made responsible to check the mother's knowledge on postpartum care, danger signs and family planning methods, and counsel them once again before discharging them from the facility.

All the points that need to be covered in postpartum counseling was compiled into an eight point checklist and displayed on a wall in a clearly visible format, placed at a point which was in direct line of vision of the labor room and post natal room staffs at the facility to serve as a ready reckoner.


Proportion of women counseled on postpartum care, detection of danger signs and adoption of family planning methods

Trained nursing staff administering Injection Vitamin Kto a newborn

Recording of postpartum vital parameters (BP and Pulse)in the delivery register

Administration of Injection Vitamin K to all newborn to prevent Vitamin K de�ciency bleedingAIM#5


Orientation to nursing staff on administration of Injection Vitamin K to all neonates

Documenting Vitamin K administration in case sheets

Planned procurement (in time and in adequate quantity) of Injection Vitamin K to ensure 24 x 7 availability

Vitamin K was being administered only to those newborns that were either pre-term or underweight.

It was not a standard practice to keep record of Vitamin K administration to newborn.

While Vitamin K was available at all facilities, it was not procured on the basis of delivery load at the facility.

The QI team organized an orientation for the labor room staff to orient them on importance of administering Vitamin K to all newborns and the dose to be administered.

The labor room staffs were encouraged to record the date and time of administering Vitamin K in the case sheet.

The staffs involved in procurement were oriented to calculate average delivery load of the facility and keep three months of injection Vitamin K supply in stock.


Proportion of newborns given Injection Vitamin K within 24 hours of birth


Drying and wrapping of all newborns to prevent hypothermiaAIM#6


Using clean towels to dry and wrap newborn

Labor room staffs were using clothes brought by the family to dry and wrap the newborn, which was often not appropriate for keeping babies warm and clean.

The quality improvement teams advocated with medical officer in-charge (MOIC) of the facility to procure towels for drying and wrapping newborn by utilizing funds earmarked for Janani Shishu Suraksha Karyaram (JSSK)14, Rogi Kalyan Samiti (RKS)15 or untied funds, as the case may be.


Proportion of newborns who were dried and wrapped after birth Perc

enta

ge

Num

bers

Proportion of newborns made dry and provided warmth immediately after birth out of total newborns

observed in District Hospital Dumka, July 2013 – December 2014

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 0

100 200 300

Total no. of newborns observed in the labour room

Using clean towels to dry and wrap the newborn

Training to nursing staffs on administration of InjectionVitamin K to all newborns within 24 hours of birth

Baby tray kept ready in facilitiesfor emergency newborn care

Breathing assessment and, if required, assistance to newbornsAIM#7


Introduction of baby tray in labor rooms and ensuring that all equipments like mucous extractor, suction machine and ambu bag are working.

The labor room staff usually had to rush out to stores or to nursing stations for materials needed for newborn care. There was no practice of keeping a baby tray ready in labor room.

Labor room staffs were sensitized on preparing a baby tray as part of their delivery preparedness. In addition, mucous extractor, a suction machine and ambu bag are kept in working condition.


Proportion of newborns who were assisted in breathing after birth

Sterile cord clamping to prevent infections among newbornsAIM#8


Use of umbilical cord clamp

Orientation of labor room staff regarding use of sterile cord clamp

Planned procurement (in time and in adequate quantity) of sterile cord clamp to ensure 24 x 7 availability

Timely indenting of sterile cord clamp by the labor room staff

There was no practice of using sterile, disposable cord clamp. In some cases, threads were used to tie the umbilical cord, increasing risk of infection.

Labor room staffs were not aware about the effectiveness of cord clamp in preventing infection in newborns.

While sterile cord clamp was available at some of the facilities, it was not procured on the basis of delivery load at the facility.

There were cases when cord clamp stock in the labor room exhausted despite it being available in the store at the facility

The health facility staff were oriented on the advantages of using disposable cord clamp and trained on sterile cord cutting practices.

QI team oriented all labor room staff regarding the use of sterile cord clamp.

The staffs involved in procurement were oriented to calculate average delivery load of the facility and keep three months of sterile cord clamp supply in stock.

A process of periodic indenting between labor room and the store, based on average delivery load in the labor room, was set up to ensure 24 x 7 availability of cord clamp in the labor room.


Proportion of newborns who were provided sterile cord clamping


Perc

enta

ge

Num

bers

Proportion of newborns who were provided sterile cutting and clamping of cord out of total newborns

reviewed in Godda DH, December 2013 – December 2014

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%



200400600

Total no. of newborns observed in the labour room

1. Use of sterile cord clamp. 2. Orientation to labor room staff

1. Planned procurement of sterile cord clamp. 2. Timely indenting of cord clamp by labor

room staff.

Poster reminding nursing staff to inject Vitamin Kafter initiating breastfeeding to the newborns

Delivering change in maternal and newborn health servicesEarly initiation of breastfeeding in all newbornsAIM#9


Initiate breastfeeding, right in the labor room, immediately post delivery.

Counseling of mothers on breastfeeding practice by Sahiyyas16

There was lack of clarity in health facility staff on when to initiate breastfeeding. Delays in shifting the mother and newborn to the ward often resulted in delayed start of breastfeeding practice.

There was no staff dedicated to counsel the pregnant woman and her family members, who either had limited knowledge on early and exclusive breastfeeding or had misconceptions regarding child feeding practices.

The labor room staffs were made responsible to facilitate early initiation of breastfeeding before shifting the newborn and the mother out of the labor room.

The QI team oriented Sahiyyas for counseling mothers and relatives to initiate breast feeding within one hour of time and made them responsible to facilitate this practice.


Proportion of newborns who were assisted in breathing after birth

Perc

enta

ge

Num

bers

Proportion of newborns breastfed within one hour of birth in Poreiyahat CHC, December 2013 – December 2014

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%



Counselling of mothers on breastfeeding by Sahiyas

0 100 200 300

Total no. of newborns observed

Initiation of breastfeedingin the labor room

References1. Empowered Action Group on population stabilization to focus on Bihar and UP. Special session to be held at Patna.PIB Releases dated 20 Jun 2001. Accessed

http://pib.nic.in/archieve/lreleng/lyr2001/rjun2001/20062001/r200620011. html on 25 December 20142. Sample Registration Estimates (2001-03). Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.3. Special Bulletin on Maternal Mortality in India 2010-12. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.4. SRS Bulletin, Volume 49 No.1, September 2014. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.5. SRS Bulletin, Volume 45 No.1, January 2011. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.6. SRS Bulletin, Volume 36 No.2, October 2002. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.7. SRS Statistical Report 2013. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India. Accessed from

http://www.censusindia.gov.in/vital_statistics/SRS_Reports_2011.html on 25 December 20148. SRS Statistical Report 2011. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India. Accessed from

http://www.censusindia.gov.in/vital_statistics/SRS_Reports_2011.html on 25 December 20149. Annual Health Survey, Factsheet Jharkhand, 2012-13. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.10. The Government of India considers the skilled birth attendant as a person who can handle common and major obstetric and neonatal emergencies as well and recognizes when the situation reaches a

point beyond his/her capability and refers the woman or the newborn to a First Referral Unit/appropriate facility without delay. GOI. Handbook for ANMs, LHVs and staff nurses as a skilled birth attendant. New Delhi: Department of Family Welfare, Ministry of Health and Family Welfare; 2006. Accessed http://mohfw.nic.in/NRHM/MH/Facilitors_Guide.pdf on 12 December 2014

11. Quality Improvement team consisted of select medical and paramedical staffs of the participating public health facility.12. Guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/ LHVs/SNs, 2010. Maternal Health Division, Ministry of Health & Family Welfare, Government of India.13. The Civil Surgeon in Jharkhand is equivalent to a Chief Medical Officer or a Chief Medical and Health Officer, the most senior official in a district administering public health services.14. Janani Shishu Suraksha Karyakram is a national initiative to provide free and cashless services to pregnant women including normal deliveries and caesarean operations and sick new born (up to 30 days

after birth) in Government health institutions in both rural & urban areas. Accessed from http://www.nhp.gov.in/health-programmes/national-health-programmes/janani-shishu-suraksha-karyakaram-jssk on 15 Jan 2015

15. Rogi Kalyan Samiti, i.e., Patient Welfare Committee, is a registered society established by Government of India, which acts as a group of trustees to manage the affairs of a public health facility. It consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials from Government sector who are responsible for proper functioning and management of the facility. The Rogi Kalyan Samiti prescribes, generates and uses the funds with it as per its best judgment for smooth functioning and maintaining the quality of services.

16. Sahiyyas in Jharkhand are equivalent to an Accredited Social Health Activist (ASHA) in other states of India.17. Langley GJ et al. the Improvement Guide – a Practical Approach to Enhancing Organizational Performance. Second Edition. 2009

List of contributors (in alphabetical order)

The USAID Applying Science to Strengthen and Improve Systems (ASSIST) is a USAID funded project managed by University Research Co., LLC (URC) to support the government and to strengthen and improve the health system so that the quality of maternal & newborn care becomes better and more lives are saved. URC’s global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard University School of Public Health; Health Research, Inc.; Institute for Healthcare Improvement; Initiatives Inc.; Johns Hopkins University Center for Communication Programs; and Women Influencing Health Education and Rule of Law, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write [email protected].

• Amit Kumar, District Improvement Coordinator, Gumla, USAID ASSIST Project, URC CHS• Bijaya Kumar Nayak, District Improvement Coordinator,Godda, USAID ASSIST Project, URC CHS• D P Taneja, State Improvement Coordinator, USAID ASSIST Project, URC CHS• Enisha Sarin, Senior Advisor, Research and Evaluation, the USAID ASSIST Project, URC CHS• Malay Bharat Shah, District Improvement Coordinator, Saraikela , USAID ASSIST Project, URC CHS• Mirwais Rahimzai, Deputy Project Coordinator, USAID ASSIST Project, URC CHS

• Nilanshu Kumar, District Improvement Coordinator, Sahebganj, USAID ASSIST Project, URC CHS• Rakesh Kumar, District Improvement Coordinator, Lohardaga, USAID ASSIST Project, URC CHS• Rashmi Singh, Quality Improvement Advisor, USAID ASSIST Project, URC CHS • Subir Kole, Data and Research Manager, the USAID ASSIST Project, URC CHS• Vijay Kishor Dubey, District Improvement Coordinator, Dumka, USAID ASSIST Project, URC CHS

QualityImprovementApproach

The QI approach used in the USAID ASSIST Project consists of seven steps17:1. Defining the improvement aim2. Forming the improvement team3. Understanding the current system4. Developing a measurement system5. Developing changes6. Testing changes7. Implementing and sustaining changes

What are we trying toaccomplish?

What change can we make thatwill result in improvement?

How will we know that a change is an improvement

DoStudy

PlanAct

Model for improvement

AbbreviationsAMTSL Active Management of Third Stage of LaborANM Auxiliary Nurse MidwifeASSIST Applying Science to Strengthen and Improve SystemsBHT Bed Head TicketBP Blood PressureCHC Community Health CenterDH District HospitalEAG Empowered Action GroupGNM General Nurse MidwifeGOI Government of IndiaIM IntramuscularIMR Infant Mortality RateIU International Units

JSSK Janani Shishu Suraksha KaryakramMMR Maternal Mortality RatioMNH Maternal and Newborn HealthMOIC Medical Officer In-ChargeOT Operation TheaterP/V Per VaginalPHC Primary Health CenterPPH Postpartum HemorrhageQI Quality ImprovementRKS Rogi Kalyan SamitiSBA Skilled Birth AttendantSC Sub CenterUSAID United States Assistance for International Development

For more information, contact: Dr Mirwais Rahimzai, Deputy Country DirectorUSAID ASSIST India. University Research Co., LLC

Alps Building, 1st Floor, 56 Janpath, New Delhi - 110001. TEL 91-11-48987700www.usaidassist.org / www.urc-chs.com / [email protected]

Disclaimers This ‘Change Package’ is made possible by the generous support of the American people through USAID’s Bureau for Global Health, Office of Health Systems. The contents are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of USAID or the United States Government. The

USAID ASSIST Project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101.

Many change ideas mentioned in this change package were context and facility specific. They may not necessarily be applicable across the board in their current form and may require modifications to achieve desired results.

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