Title: A nationwide quality improvement project to accelerate Ghanas progress towards Millennium Development Goal Four: design and

implementation of innovation and scale-up

Authors: Nana A. Y. Twum-Danso,1 George B. Akanlu,2 Enoch Osafo,2 Sodzi SodziTettey, 1 Richard O. Boadu,2 George A. Adjei,2 J. Koku Awoonor-Williams,3 Alexis Nang-Beifubah,3 Akwasi Twumasi,3,3 C. Joseph McCannon,1 Pierre M. Barker1,4
1

Institute for Healthcare Improvement

20 University Road, 7th Floor Cambridge, MA 02138 USA

National Catholic Health Service

P. O. Box KA 9712 Airport, Accra Ghana

Ghana Health Service

PMB Ministries Accra Ghana

Department of Pediatrics

School of Medicine 1

University of North Carolina at Chapel Hill Chapel Hill, NC 27516 USA

Corresponding Author: Pierre M. Barker MD Institute for Healthcare Improvement 20 University Road, 7th floor Cambridge, MA 02138, USA

Abstract Introduction 2

The gap between evidence-based guidelines and practice of care is particularly evident in low- and middle-income countries, as reflected by high maternal and child mortality rates. We designed a phased, rapid, national scale-up quality improvement (QI) intervention to accelerate the achievement of Millennium Development Goal Four in Ghana. Methods We used QI approaches that emphasize systems thinking, motivation of frontline providers, generating and testing of change ideas and learning from data at the local level, transparent data reporting, and sustainability. Working within an adaptable framework to address the underlying drivers of child survival, we redesigned implementation strategies in an iterative manner based on the lessons learned. Results After 50 months of implementation, we have completed two prototype learning phases, each of 18-month duration, and have begun regional spread phases that cover all 38 districts of the three northernmost regions of Ghana, serving a population of about five million, and all 29 Catholic hospitals in the south. To accelerate the spread of improvement to larger numbers of health staff, we developed two change packages of locally-inspired, rigorously-tested, effective process changes ideas along the continuum of care from pregnancy to age five in both outpatient and inpatient settings. Discussion We describe the design attributes and demonstrate the feasibility of implementing a large-scale QI initiative in a low-resourced health system, starting with small-scale

prototype phases for innovation and learning by frontline health staff, and scaling up rapidly over time and space with support from their managers and senior leaders. Keywords: quality improvement, health systems strengthening, large-scale improvement, maternal newborn and child health, Millennium Development Goal Four, low-resource setting

Introduction The gap between evidence-based guidelines and practice in health care is particularly wide in low- and middle-income countries (LMICs), where maternal and child mortality rates are high despite the availability of cost-effective interventions . In 2010, only 19 of 68 countries were on track to achieve Millennium Development Goal Four (two-thirds reduction in mortality in children less than five years old (Under5) from rates in 1990 by 2015) . Efforts to implement child survival programs in subSaharan countries have not had the expected effect of reducing child mortality (7).

Even when pilot projects are well implemented, they are rarely designed with scaleup as an explicit design strategy. Thus, many may scale up well in environments that are similar to the test circumstances, but are challenged by limited ability to adapt to local context. Likewise, unless designed carefully, scale-up may be challenged by the need for additional resources and the lack of a mechanism to sustain the intervention. Other scale-up design considerations include supervision, monitoring, evaluation, and accountability all of which are weaknesses commonly encountered in LMIC health systems .

In Ghana, the national maternal, newborn and child health (MNCH) program is evidence-based and cost-effective. Acceleration of this program began in 2005 with the High Impact Rapid Delivery approach, based on UNICEFs Accelerated Child Survival and Development initiative . In 2008, we sought to augment this effort by introducing quality improvement (QI) methods to improve reliability of 5

implementation through a phased rapid scale-up design that would engage every health facility in the public sector in the country over five years. Our ultimate aim was to accelerate Ghanas progress towards Millennium Development Goal Four (MDG 4). To understand the potential role of a faith-based health system in leading nationwide improvement, we focused the initial QI intervention on Catholic health facilities. Here, we report on the design and implementation progress of the first three phases of this nationwide QI intervention, highlighting lessons learned that will influence the design of the fourth and final phase.

Methods Setting Ghana is a lower middle-income country. Life expectancy at birth is 60 years and total fertility rate is 4.0 . The maternal mortality rate is between 380 and 580 per 100,000 live births , while the mortality rates in neonates, infants, and children Under-5 are estimated at 30, 50, and 80 deaths per 1,000 live births respectively . In 2004, a national health insurance replaced the previous fee-for-service policy, thus removing substantial financial barriers to accessing health care. In July 2008, this insurance was provided free of charge to pregnant women and infants under the age of three months. Implementation of the QI intervention, Project Fives Alive!, also began in July 2008 through a partnership between the Institute for Healthcare Improvement (IHI) and the National Catholic Health Service (NCHS), in collaboration with the Ghana Health Service (GHS). The NCHS provides about 25% of health care in the public sector, while the GHS provides about 70%; both are service delivery agencies of the Ministry of Health of Ghana. 6

Design Quality Improvement Approach The QI methods used in this project are based on well-described health system improvement approaches . Starting with a hypothesis that we could improve the drivers of preventable causes of death for children Under-5 (Figure 1), we challenged the status quo through development of transparent data reporting systems, generation and testing of local ideas for improvement, scale-up designs that rely on rapidly spreading locally-tested successful innovations, use of existing resources, and developing local capacity. This improvement approach emphasizes systems thinking, motivation of frontline providers and their managers, contextualization of implementation strategies, analysis and learning from data at the local level, redesigning strategies in an iterative manner based on lessons learned, reliability principles, local ownership, and sustainability .

The generation, testing and spread of ideas for improved performance were accelerated by IHIs collaborative model for achieving breakthrough performance . Health staff from clinics and hospitals were brought together with their managers into an Improvement Collaborative Network (ICN) with a shared aim that was ambitious enough to require substantial changes to their health care processes. Each health facility agreed to form a QI team which would lead the improvement work locally and attend two- to three-day structured workshops or Learning Sessions off-site every four to six months to share their progress with other 7

members of the ICN. The QI teams were multidisciplinary and varied in number from four to 10. In health centres, the QI team was typically led by a midwife, while in hospitals, it was typically a doctor.

At Learning Sessions, project facilitators taught QI methods and helped health staff analyze their local health systems and processes, identify process failures or implementation gaps and reasons for them, and develop and plan the testing of specific changes that they believed were likely to lead to improvement, using the Model for Improvement as their guiding framework. In between Learning Sessions, project facilitators accompanied Change Agents - typically public health nurses, disease control officers, and health information officers from the regional, district, and diocesan health management teams - to regularly visit each QI team in their facility. The facilitators and change agents coached teams to test their changes, analyse their data to assess whether their changes were resulting in improvement, and developing new changes to accelerate and sustain improvement. The successful change ideas from the initial prototyping phases were assembled into change packages, stratified along the continuum of MNCH care, for use in the scale-up phases.

The interval between site visits varied from four to 12 weeks, depending on the functionality and pace of improvement demonstrated by the facility-based QI team and the rate of learning by the Change Agents. During the sustainability phase of the district-based intervention, the Change Agents conducted independent site visits every four to six weeks (i.e. without the project staff); they were encouraged to 8

integrate these visits with other district field supervisory activities. Additional technical support was provided by telephone between site visits.

An explicit data quality improvement (DQI) component was also designed into the project to improve the routine health information system (RHIS) of the GHS. The health information officers in the hospitals and the district health offices formed a separate ICN focused on DQI. They were trained and coached in general QI methods as well as specific DQI strategies focused on the completeness, timeliness, and accuracy of the data collected and reported in the RHIS.

Capacity Building in Quality Improvement Capacity building in QI methods and facilitation skills was provided in a phased manner. In Phase 1, the project staff received an introduction to QI. This was followed by a 10-month in-depth longitudinal professional development course in QI, combining theory with on-the-job practice, during the early parts of Phases 2 and 3a. Throughout Phases 2 and 3b, project staff provided a simplified version of this course to the Change Agents. Further simplification of the course content was provided to the frontline providers during Learning Sessions and coaching site visits.

Local Ownership and Sustainability To promote local ownership and sustainability, we included the following features in the project design: 9

1. Increase in the number of project staff supporting the QI teams in Phase 2 by only three-fold while scaling up the number of QI teams by more than 10-fold as we relied more heavily on the Change Agents to implement and sustain the QI intervention; 2. Joint facilitation of Learning Sessions and site visits between the project staff and the Change Agents; 3. Convening of Learning Sessions by the regional, district, and diocesan health leaders independently of the project staff; 4. Quarterly review meetings for the Change Agents, led by the regional health leadership team, to review progress, successes, and challenges; 5. Funding and integration of Change Agents QI coaching site visits into routine monitoring and supervision of their MNCH work; 6. Inclusion of QI presentations and discussions in the agenda of the already established district and regional health twice-yearly performance review meetings; and 7. Increased reliance on the RHIS for project monitoring data and minimizing the introduction of new indicators.

Phasing Following a brief set-up phase, the project was implemented through two prototype testing phases, followed by three expansion phases as illustrated in Figure 2 and described below: 10

Phase 0 An eight-month assessment and planning phase, during which we collected detailed baseline MNCH performance data and identified early adopter sites for the prototype phase (Phase 1). A crucial period of willbuilding, where the project was explained in detail to regional, district, and diocesan health leaders, ensued.

Phase 1 Prototype phase including 25 health centres and two hospitals across three rural districts and one Catholic diocese in the three northernmost regions of Ghana, to test and develop a change package to improve MNCH care processes for use in the scale-up phases.

Phase 2 Initial scale-up phase including all the health facilities (both public and private sector) in the 38 districts of the north (population: five million), in addition to the three districts in Phase 1.

Phase 3 To develop a change package to improve care for infants and children admitted to hospital, and test the unique role of a faith-based health system in a nationwide improvement initiative, we enrolled all the Catholic health facilities in the seven southern regions of Ghana. Sub-phases were prototype testing in the nine worst-performing hospitals (3a), expanding to all 29 NCHS hospitals (3b) in the south, and finally, incorporating all 33 NCHS health centres in the south (3c).

Phase 4 National coverage of government and NCHS facilities, requiring rapid exponential scale-up to include all the remaining health facilities in the public sector in the south.

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Using Everett Rogerss model of the diffusion of innovations , we theorized that the project staff would be the innovators, while the early adopters would be those health staff in the prototyping phases (i.e., Phases 1 and 3a). The rest of the health staff/facilities would represent the early majority and the late majority (i.e., Phases 2, 3b, 3c and 4). The small-scale prototype phases were designed to achieve the objectives of demonstration, advocacy, and building more will for the next phase.

Evaluation Independent evaluation of this project was undertaken by a third party, which worked in a facilitative but independent manner from the project implementation team. Their evaluation, which covers the changes in process performance and outcomes will be reported elsewhere.

Data Collection We collected data at four levels: 1. Project implementation process indicators: (a) the number of Learning Sessions, site visits, and change ideas tested; (b) the frequency with which Change Agents conducted facilitative site visits without the project staff; (c) the frequency with which health information officers conducted DQI field work without the project staff; and (d) the frequency with which QI presentations and discussions were integrated in district health performance review meetings. 12

2. Detailed description of the specific change ideas tested by each QI team, including the dates testing began and ended, dates on which change ideas were modified, and observations and insights gained from the testing. These were documented by the project staff in notebooks during site visits and transferred subsequently to an electronic database, termed a change tracker.

3. Health process indicators reflecting the changes in the care processes for pregnant women and the Under-5 in both outpatient and inpatient settings. The majority of these were already being collected and reported to the RHIS, although a few new indicators (e.g., interval between identification of a sick child and initiation of definitive treatment) were developed. Most of the new indicators were in the clinical registers, while a few had to be developed de novo. QI teams also collected context-specific indicators based on the change ideas they were testing (e.g., monthly number of telephone calls to the midwife from women in labor); these were not aggregated at the project level. In Phase 1, we reconstructed data from the paper-based clinical registers at each facility every month, as the RHIS was not yet fully electronic. In Phase 2, we extracted most of the data from the summaries submitted to the RHIS; in Phase 3, almost all the process data were reconstructed from clinical registers.

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4. Health outcome indicators focused primarily on mortality, not morbidity, because the former were more likely to be present in the RHIS. Based on specific change ideas being tested, several QI teams collected morbidity data or case fatality data that were not required for the RHIS but were needed to determine whether change ideas were leading to improvement. In addition, we collected data from GHSs community-based surveillance volunteer data which captures births, deaths, and notifiable diseases that occur at the community level; these data are reported monthly by the volunteers to the health centres.

All the data reported into the RHIS are summarized at the sub-district, district, or regional level and are de-identified as are the other data collected by the QI teams, community volunteers, and project staff.

Data Analysis All project implementation process, health process, and health outcome data were assessed using time series analysis .. The health process and outcome data were analyzed by health facility, as well as at the district and regional level. We used a quasi-experimental approach to analyze the effects of the changes tested on the performance of different health processes and outcomes in individual facilities. We aggregated the data from facilities testing the same change idea, applying run chart rules to determine whether specific changes had led to an improvement. The qualitative data documented by the QI teams and the project staff in the change

14

tracker were used to confirm the exact nature of the change, when it was initiated or modified, and when it was terminated.

Ethics No institutional review board approval was required for this work, as the implementation and monitoring of the QI interventions to improve the MNCH program were considered part of the established and ongoing MNCH program of the GHS which is based on existing policies of the Ghanaian Ministry of Health. Program evaluation used routinely collected de-identified aggregate data of process performance and outcomes.

Results

We used Thomas W. Nolans triad of will, ideas, and execution for achieving system-wide improvement to report on the progress of the prototype and initial scale-up phases for the first 50 months (November 2007 to December 2011) of the project.

Will

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The first eight months of the project included a major focus on building will. We established the partnership between IHI and NCHS, and strengthened the existing partnership between NCHS and GHS at the corporate level. We introduced the project design to stakeholders at all levels of the health system. We visited hospitals and clinics and spoke to the health staff to ensure that we understood contextual factors affecting the quality of health care, supervision and management at the facility, district, and regional levels, and how the QI intervention could improve upon it.

After launching the project, we continued to build and maintain will through regular feedback sessions with the frontline providers and their managers after each round of coaching visits and Learning Sessions. We disseminated the results of the project at GHSs performance review meetings at district, regional, and national levels, as well as at national and international conferences. Four months before launching Phase 2, the project held a dissemination meeting for the three northernmost regions, sharing results to date and discussing readiness for scale-up. In Phase 3, the NCHSs annual management meetings and annual conferences served as the main venues for building will with the leadership and at the frontline. Finally, the QI work was summarized into technical reports and newsletters and circulated to all stakeholders in print or electronic media on a regular basis (two to three times a year).

Ideas Using driver diagrams, process maps, root cause analyses, affinity diagrams, and Pareto charts, multiple ideas were generated from frontline staff and their managers 16

and then tested and analyzed during the innovation phase of the project. By the end of Phase 1, the 27 QI teams had tested 104 specific change ideas, while by the end of Phase 3a, the nine hospital QI teams had tested 47 specific change ideas. These change ideas spanned pregnancy identification and registration for antenatal care (ANC) in the first trimester of pregnancy, receiving quality care during at least for four ANC visits, accessing skilled delivery on time and receiving quality perinatal care and postnatal care, early care-seeking for sick children and women in labor, triage, adherence to protocols for the most common causes of childhood illnesses in their local context, and DQI protocols.

We developed the description of drivers that we hypothesized would lead to better outcomes in the Under-5 population. Throughout the project we sought to better understand the contextual factors underlying preventable deaths in the Under-5s in both the community and health facilities. We summarized these factors into a construct known as a driver diagram, which we then populated with broad change concepts which we believed would lead to improved outcomes. We discussed each of these concepts with the participating clinics and hospitals, generating change ideas that were tested. (Figure 1 shows the most current version of the driver diagram in December 2011)

Execution Phase 1 lasted 18 months (July 2008 to December 2009). The first Learning Session was combined with the launch of the project and included health staff from all three 17

districts and the Catholic diocese convening in one location. Three subsequent Learning Sessions in the ICN were all held at the district level to enable greater participation by frontline providers, local ownership by the district leadership, and reduced travel time for the health staff. In total, ten Learning Sessions of two- to three-day duration were convened in Phase 1 (Table 1). By month 12 of Phase 1, there was sufficient evidence of process changes that were leading to improvements in antenatal, perinatal, and postnatal care processes; these were included in the first change package (Table 2). Other changes were characterized as no effect or insufficient time to determine effect. The former were discarded, while we continued to monitor the latter for several months. The first change package was promoted to other QI teams within Phase 1 that had not yet shown improvement, as well as new QI teams in the scale-up phase (Phase 2). These teams were encouraged to adopt or adapt changes from the change package that seemed relevant to their context; if they could not find a good fit, they were encouraged to develop their own changes.

Phase 2 was launched in the three northernmost regions in a phased manner over eight months after the first change package was available. In all three regions, implementation of the QI intervention to all districts was phased over time (range: five to 14 months). By August 2011, two years after the launch of Phase 2, we had fully scaled up the QI intervention and the first change package to all 38 districts. This represented a more than 10-fold increase from Phase 1 (Table 1). Additional change ideas that have since been found to lead to improvement were included in the change package in an iterative manner and presented to the QI teams during 18

subsequent Learning Sessions. To date, we have provided eight separate QI training and coaching sessions for district Change Agents. The DQI initiative with the health information officers in Phase 2 began five months after the launch of Phase 2. As of December 2011, 26 out of 38 (68%) districts were actively working on improving the accuracy, completeness, and timeliness of the data reported to them by the frontline providers in the clinics and hospitals.

Phase 3a was launched in the nine worst-performing hospitals in the NCHS (see Table 1) in October 2009 and ended in April 2011 (18 months duration), with the development of a second change package (Table 3) using the same approach as in Phase 1. We promoted this change package to the remaining 20 NCHS hospitals in the south in Learning Sessions grouped according to three Catholic provinces over the course of six weeks starting in June 2011. We also promoted this change package to all 36 hospitals in Phase 2 during Learning Sessions which began in June 2011. As of December 2011, all 29 hospitals in this scaled-up phase of the NCHS, Phase 3b, were actively testing ideas for improvement from the change package or developing new ideas that better suited their varying contexts. Coaching visits for this phase have decentralized beyond the core project staff to include eight facility-based experienced physicians and managers from Phase 3a who distinguished themselves as improvers and the diocesan health staff.

Discussion 19

Our approach, which emphasized creating of partnerships across the health sector, engaging frontline providers and their managers and senior leaders, and demonstrating and disseminating early results regularly to all stakeholders, served to build will, secure buy-in for the current work, enhance preparation for subsequent phases of the project, and engage in policy dialogues at all levels of the health system. Our intervention drew heavily on change ideas generated by frontline providers, taking account of local context and working within the boundaries of the national MNCH program. Frontline staff and managers were empowered to test those changes and learn from them, resulting in the assembly of locally proven adaptable change packages that could be credibly spread to exponentially larger numbers of frontline providers working in similar and different contexts during the scale-up phases, using Everett Rogerss model for diffusion of innovations .

In addition to the project execution design, two QI methods evolution of adaptive driver diagrams and development of change packages proved to be powerful tools to accelerate our understanding and spread of the intervention. The adaptive driver diagram provided a common framework for exploring the change ideas that were required to promote our goal of child survival across the continuum of care from the community to health centers and to hospitals. The driver diagram will guide evaluators to systematically monitor changing dynamics in project implementation and identify contextual variation across sites . The change packages we report here provide a rich set of specific ideas that can assist frontline workers and supervisors in other resource-constrained settings to overcome barriers to implementation of MNCH programs. 20

The projects explicit aim for large-scale implementation was conceptualized right from inception. We embedded a sustainability strategy into the design that included ownership of the change process by regional, district, and diocesan leaders, development and coaching of large numbers of local health system supervisors (Change Agents). Through a rapid weaning strategy, we progressively decreased reliance of Change Agents on project staff (e.g., increasing the hand-over of independent site visits as the Change Agents became more skilled in QI and facilitation).

Iterative learning and testing of the project design itself was a key part of executing this project. In addition to the continuous internal assessment of results, which has allowed for design flexibility and rapid improvement of performance, a formal evaluation of the project is underway, undertaken by an external evaluator, using quasi-experimental techniques .

In conclusion, we have demonstrated the feasibility of designing and implementing a large-scale QI initiative in a low-resourced health system, starting with small-scale prototype that promotes innovation and learning by frontline health staff, assembling this knowledge into a change package that can used rapidly scaled up interventions that are adopted or adapted by larger numbers of health staff over time and space with support from their managers and senior leaders. The reporting of mid-term, rather than end-of-project implementation results represents a limitation of this 21

paper, as the project design continues to iterate and the full benefit of this design is yet to be realized. Another limitation is the focus on the progress of implementation of the project design without inclusion of health process and outcome data; as such, we have yet to demonstrate that this QI intervention is on track to achieve its intended aim of accelerating the achievement of MDG 4 in Ghana. A formal evaluation is underway, and interim process and outcome results will be reported shortly.

Acknowledgements We would like to express our gratitude to Patrick Ansu and Linda Azumah for data collection and analysis and to Jane Roessner for copy-editing.

Conflict of Interest None declared

Funding This work was supported by the Bill & Melinda Gates Foundation [grant number 48930]. 22

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References

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Figure 1. Conceptual framework of the underlying drivers of preventable deaths in children Under-5 in Ghana

Legend: NHI=National Health Insurance

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Figure 2. Design of rapid, sequential scale up of a quality improvement initiative to reduce child mortality in
Ghana

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Table 1. Implementation progress of Phases 1, 2, 3a and 3b of the QI interventions Phase (timing) No. of distric ts Learning Sessions as of December 2011 Mean no. of Total no. participa of nts per sessions session 10 35 4 3 85 54 35 47 Joint Site Visits as of December 2011 Mean no. of visits per QI team 14.6 5.5 8.6 1.9

Health Facilities No. of health posts/centr es

No. of hospitals 2 36 9 29

Total 27 576 9 29 3 38

Total no. of visits 394 1424 77 54

Phase 1 (07/2008 to 12/2009) Phase 2 (09/2009 to present) Phase 3a (10/2009 to 04/2011) Phase 3b (06/2011 to present)

25 540 0 0

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Table 2. Summary of changes found to be effective in improving processes of care for the antenatal, perinatal and postnatal periods after Phase 1 Care Pathway
ANTENATAL

Successful Change Idea(s)

1A. Community stakeholder meetings with opinion leaders and other influential groups about the importance of early and regular ANC 1B. Community stakeholder meetings followed by registration of pregnant women by community volunteers on monthly basis 2A. Increase number of days ANC is offered at static site AND redesign clinic processes to reduce visit duration per client to < 1hr 2B. Offer ANC as outreach service as well as at static site AND redesign clinic processes to reduce visit duration per client to < 1hr 3A. Video show in communities on the risks of labour & delivery 3B. Male advocacy group in communities to promote skilled delivery 3C. TBA engagement on risks of unskilled delivery and provide incentives 3D. Use ANC register to identify women at 36+ weeks gestation for home visits to remind them & family members about skilled delivery & confirm transport plan 3E. Provide domiciliary delivery if, upon notification by mobile phone, labour too advanced, woman has no means of transport from community or health staff cannot arrange transport from clinic or hospital 3F. Create a welcoming, patient-friendly environment in health facility for labouring women 3G. Create systems to ensure consistent and correct use of partographs 3H. Create systems for reliable neonatal resuscitation C C

Facility Type*

1.

Regi stration in 1st Trimester

2. At least 4 visits before delivery 3. Skill ed Delivery & Immediat e Postnatal Care

C&H C C C C C C C&H C&H C&H

POSTNATAL

PERINATAL

4. Care on Day 1 or 2

4A. If facility skilled delivery detain for observation for 24hrs if possible. If not, discharge after minimum of 6hrs and follow-up on Day 2 with facility or home visit 4B. If domiciliary skilled delivery follow-up on Day 2 with facility or home visit. 4C. If unskilled delivery ask family members or volunteers to notify health staff immediately by mobile phone/bicycle/motorbike. Woman comes to facility on Day 1 if possible or health staff follow-up with home visit on Day 1 or 2

C&H C C

5. Care on Day 6 or 7

5A. During Day 1/2 visit, make appointment for Day 6/7 visit at facility or home. Use reminder systems at community, clinic/hospital to improve reliability. 5B. If woman lives in different sub-district or distant community within CHPS zone, refer to other sub-district or CHO for Day 6/7 visit. Contact CHO to follow-up if no show.

C&H C&H C

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5C. If woman lives in distant community without CHO AND return facility visit not possible AND health staff home visit not possible, train IMCI volunteers to provide Day 6/7 care.

Legend: *C=Health centre, clinic or health post; H=hospital

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Table 3. Summary of changes found to be effective in improving processes of care in the hospital outpatient and inpatient setting after Phase 3a
Driver Area of Clinical/ Community Care Change Concept Careseeking behaviour Referral Targeted health education Engaging primary providers Triage Delay in Providing Care Prompt Diagnosis and Treatment 2A Fast Track

Packag e# Description of Successful Change Ideas 1A 1B 1C Targeted health education on early care-seeking using interactive platforms (e.g. radio) Community engagement and education via durbar or place of worship Engagement with health providers (both traditional and allopathic) on need for early referral and early warning signs Triage system for screening and emergency treatment of critically ill children Separate Under-5 OPD services from adult OPD service Prioritize Under-5 outpatient care Prioritize Under-5 inpatient care Training staff on protocols followed by regular coaching and mentoring which include ad hoc testing on site with immediate feedback Training postpartum women and other care givers on hygienic cord care through demonstration, practice and immediate feedback Mother-to-mother support group on food choices and frequency of feeding while on admission under mentoring of nurses Empowering nurses to start acting on standard treatment protocols before doctor arrives

Delay in Seeking Care

NonAdherence to Protocols

3A Training/Coaching/ Mentoring 3B 3C Task-shifting 3D

Adherence to Protocols

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