Quality improvement: the answers lie within
Self-assessment, Osh Oblast © GIZ/Maxime Fossat
For the past six months, staff at 13 hospitals, family medicine centers and maternity houses across Kyrgyzstan have been searching for answers to the stubborn problem of maternal mortality. Women in Kyrgyzstan continue to die at a higher rate during pregnancy, childbirth and after delivery than women anywhere else in the European region. According to the last Confidential Enquiry into Maternal Deaths (2014-15), nearly 40% of these deaths took place in secondary-level health facilities, such as regional (oblast) hospitals.
The Promotion of Perinatal Health in Kyrgyzstan project is trying to change this by introducing a new approach to quality improvement in selected health organisations in Bishkek, Chui, Issyk-Kul, Naryn and Osh oblasts. Two mentors are coaching quality improvement teams in each facility to assess performance, to identify areas for improvement, to select priorities, and to develop action plans to tackle these one by one. The premise of the approach is that health workers themselves are well-placed to identify solutions to gaps in their own workplaces – and that doing so together is an effective and sustainable way to improve the quality of perinatal care services.
Participatory standard setting
Doctors and managers from the 13 health facilities were directly involved in the selection of the standards and indicators for assessing the quality of perinatal care services. In June 2019, they took part in a two-day workshop in Bishkek, led by EPOS Health Management, a German consulting firm working on behalf of GIZ. There they worked in small groups to review and agree the content of a self-assessment tool. They identified 36 standards used by the Medical Accreditation Center to assess quality of care for pregnant women and newborns, and then matched these with relevant, clearly formulated indicators used by the Mandatory Health Insurance Fund and the World Health Organization.
According to Chinara Kazakbaeva, a technical advisor with GIZ who is one of the two mentors working with the health facilities, the workshop participants took full advantage of the opportunity to be part of standard-setting. ‘It’s is very important that medical specialists played an active role in selecting the standards. In the past, these have always been imposed from above.’
The self-assessment tool was then tested at three different health facilities in Bishkek and Chuy oblast to make sure that it would be suitable for use in family medicine centers, hospitals and tertiary-care institutions.
From external quality control to self-directed quality improvement
In August 2019, international quality experts and the two mentors travelled to each of the 13 facilities to train quality improvement teams how to work with the self-assessment tool. During these visits they worked alongside the team members to apply six of the standards in a facilitated assessment. This built familiarity with the tool and led to the establishment of a baseline value for each facility.
Gulbara Kenjebaeva, head of Osh Oblast Maternity Hospital © GIZ/Maxime Fossat
Since September, the teams have been conducting self-assessments, with support from project mentors, using the full tool. After applying all 36 standards, the teams review the results and prioritise areas which can be improved with few resources. These ‘quick wins’ sustain motivation and build a sense of ownership over the quality improvement process. They then work to develop quality improvement plans with mid- and long-term goals for the facility.
Dr Gulbara Kenjebaeva, the Head of the Osh Oblast Maternity Hospital, is positive about the process thus far. ‘I’ve learned about quality improvement through other assessment processes, but this is the first time that I’ve learned to identify detailed problems. And I find it good that this approach isn’t limited only to clinical issues, but to administrative and management issues as well,’ she says. ‘If we are able to improve our performance in relation to these standards, it will have an impact on the health of both children and mothers.’