Quality Improvement Teams Improve Maternal and Newborn Health in Ecuador

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By: Katie Millar, Technical Writer, Women and Health Initiative, Harvard T.H. Chan School of Public Health

This post is part of the Maternal and Newborn Integration Blog Series, which shares themes of and reactions to the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting

Dr. Jorge Hermida, presenter at the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting, addressed global leaders on promising approaches to integration of care. In his presentation, Dr. Hermida proposed a global paradigm shift for health care and reviewed the success of a quality assurance project. This project implemented quality improvement (QI) teams, which constituted a variety of health worker cadres and healed a both horizontally and vertically fragmented system. We had a chance to ask Dr. Hermida a few questions. His answers help us better understand the needed paradigm shift, steps to healing health systems, and what is needed to sustain successful programs.

Q: In your presentation you presented a paradigm shift of “Best Practices” to “Implementation Effectiveness.” Can you expound on this shift?

A: The current paradigm has been, so far, one where the effort of international organizations has been focused in recommending countries and health systems what are the “best” interventions they need to put in place. The actual process of making it happen in the reality of those health systems has not been a priority.

A new paradigmmuch needed—that I call “implementation effectiveness” is to focus most of the efforts of international organizations and country health systems in understanding the process of actually implementing those best practices, including what are the main barriers and facilitating factors and what are the best ways to achieve large scale implementation with an acceptable level of quality. This approach refers too to integration of maternal and newborn care.

Q: The QI integrated teams you spoke of are wonderful and seem to be very effective. What were the factors that made these teams successful?

A: QI teams are an operational mechanism to continuously measure and improve access and quality of health care at the local level. They exist and thrive as much as there is in place a process to improve the quality of care in a health care system or hospital or health center. Among the many factors that support these teams, a strong leadership towards improving access and quality of care is essential.

QI teams represent a radical change in the way health care is managed at the operational level, much different from the hierarchical and authoritative, top-down, doctor-based common existing reality to make decisions on how care is organized. QI teams are collaborative among professional cadres, use data to base their decisions, use evidence to approach improvement on access and quality, and their work is patient-centered.

Q: You mentioned the health systems of Cotopaxi and how they were both vertically and horizontally fragmented. What were the key activities for transforming this health system as you did in the ASSIST project?

A: Prior to our project, Ecuador had existing national policies mandating the construction of a national health care system that integrates public and private institutions. However, there were few experiences on how to make it happen. Our project—which collaborated with the Ecuador Ministry of Health (MOH)—brought to the same table the different actors in the Cotopaxi province—traditional TBAs, MOH facilities, Social Security facilities, NGOs who had been working separately—and facilitated building a common vision of an integrated network.

This common vision aimed at reducing maternal and newborn mortality through increasing access to and quality of care and focusing on high-impact, evidence based maternal and newborn care. Increasing access meant reaching remote rural mothers and newborns by linking TBAs to the formal health care network and increasing the offer of essential care at district and provincial hospitals to 24 hours, seven days a week, among other changes. It also meant supporting communities to have mechanisms to transport emergencies to the nearest hospital, as well as strengthening the referral mechanisms among TBAs, health centers, district and provincial hospitals. Increasing the quality of care meant working with health care personnel organized in QI teams to introduce high-impact, evidence-based obstetric and newborn best practices; implement monitoring indicators of quality of care; detect deficiencies; and constantly improve care.

Q: What do you think are the most critical factors moving forward to ensure sustainability of this project?

A: The most important factor leading to the sustainability of the model is the MOH ownership of the initial demonstration process. It was also very important to carefully align at all times the objectives of the project with those larger ones that guide the action of the national government and in particular the MOH. Then the MOH needed to develop its capacity not only to understand the model but also to operate it. This was achieved through a constant insistence on working with the MOH on every decision and operational activity.

This may sometimes seem to slow down the pace of action of a project, but it certainly pays back at the end when the MOH has developed their own experts and advocates for the principles that guided the operations of the project. There is a need to obtain clear-cut results that are meaningful to the MOH and national government objectives and to show how the results of the project contribute to the larger aims of the country and the MOH. As long as these factors are clear, the chances for sustainability will exist.