endline3 11 13w new slides

Boston University School of Public Health

Endline Study for Queen ‘Mamohato Memorial Hospital Public Private

Partnership

World BankMarch 11, 2014

Taryn Vian, PhDNathalie McIntosh, PhDAria Grabowski, MPH

Brian Jack, MDElizabeth Limakatso Nkabane–Nkholongo, RN/RM, BSN

Bram Brooks, MPH, DrPH(c)

Boston University Slideshow Title Goes Here


Agenda Background Objectives and methods of study Findings (quantitative and qualitative) Discussion and recommendations

05/03/2023 2Lesotho Endline PPP Evaluation



Background




Goals: to extend / upgrade publicly funded health care services in the greater Maseru District and referral services for the country, and to engage the private sector in new ways for better outcomes in partnership with government.

Lesotho Endline PPP Evaluation 05/03/2023 4

Coelho & O’Farrell 2009; UCSF & PwC 2012



Baseline Study in 2009 IFC engaged Lesotho Boston Health Alliance

(LeBoHA) to collect baseline on access, use, quality, referrals, costs and health outcomes Data from 2006-2007

Purpose: to support monitoring and evaluation, help design of output-based aid (OBA) indicators, serve as comparison to endline.

74 indicators of Queen Elizabeth II (QEII) hospital and 3 filter clinics. Service data analysis, chart reviews, casualty flow, referral

study, step down cost analysis, patient & provider satisfaction, systems descriptions


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QEII at baseline




Photos: Mountains of Hope (video)

Overflow beds

Ward

Male surgical bath



Presentation Title 05/03/2023 8

Maternity labor room



Lesotho Endline PPP Evaluation



Kitchen




Laundry




Incinerator



Objectives and Methods




Endline Study Objectives

1. Describe endline situation of Queen ‘Mamohato Memorial Hospital Integrated Network (QMMH-IN) using quantitative indicators and narrative description;

2. Compare endline to baseline;3. Explore explanations for

changes and make recommendations.

Lesotho PPP Endline Study 05/03/2023 14



Endline Methods Collected administrative and clinical data from hospital

systems and reports, observed clinical activities (triage) Conducted 41 key informant interviews Time period: Endline data were collected Feb-April 2013.

Endline data were Jan. 1 – Dec. 31, 2012, compared to Baseline data from April 1, 2006 – March 31, 2007

Analysis: 24 quantitative and 14 qualitative indicators Descriptions of management systems: HR, facilities &

equipment, drug supply, patient registration, referrals Thematic analysis of performance drivers and changes




Findings





QMMH-Integrated Network (IN): 3 refurbished urban filter clinics (open 5/2010) and new 425-bed hospital and Gateway clinic (open 10/2011)



Quantitative IndicatorsLesotho Endline PPP Evaluation 05/03/2023 18

StatisticQMMH-IN

2012QEII-IN

2007 % Diff

Total beds

414

417 -1%

Hospital beds

390

409 -5%

Filter clinic beds

24

8 200%

Inpatient admissions (hospital)

23,341

15,465 51%

Inpatient Days (hospital)

116,648

91,808 27%

Outpatient Visits (incl. filter clinics)

374,669

165,584 126%

Deliveries (incl. filter clinics)

7,431 5,116 45%

Average length of stay (hospital) 5.00 5.94 -16%Hospital occupancy 82% 61% 33%

390+35 private beds not yet open=425 (original plan)

of which,




Mabote Qoaling Likotsi Gateway Hospital Outpatient (excluding casualty)

Hospital Casualty

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000 80,186

77,885

69,646

45,733

80,656

20,563 19,870

33,117

21,526

64,578

26,493

Hospital and Filter Clinic Ambulatory Visits

QMMH (2012) QE II (2007)

Am

bula

tory

Pat

ient

s



Quantitative Indicators


StatisticQMMH-IN

2012QEII-IN

2007 % Diff

Death Rate (incl. filter clinics) 7.1% 12.0% -41%

Maternity death rate (incl filter clinics) 0.21% 0.24% -10%

Pediatric pneumonia death rate (hospital) 11.9% 34.4% -65%

Still birth rate (incl. filter clinics) 1.9% 4.0% -53%Survival of very low birth weight infants, <=1,500 gr (hospital) 69.8% NA NA

C-section rate (incl. filter clinics) 26.8% 7.2% 272%

Patient satisfaction rate (incl. filter clinics) 86% 70.7% 22%




Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0%

5%

10%

15%

20%

25%

30%

35%

26%

25% 24%

31%32% 30%

33%

27% 27%25%

23% 20%

Monthly C-section Rate incl. filter clinics

Month

Perc

ent o

f C-S

ectio

n

Annual average: 26.8%




0%

10%

20%

30%

40%

12%

24%34% 44%

Pediatric Pneumonia Deaths

QMMHQEII

Perc

ent o

f Dea

ths

NICU patients <= 1,500 grams (n = 43, 46%)

NICU patients > 1,500 grams (n=51, 54%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

70%

82%

30%

18%

QMMH Neonatal Survival Rates

% Survived % Mortality

Perc

ent o

f Neo

nate

s in

NIC

U




QMMH (n=75) QE II (n=303)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% 84%

0%

Patients Triaged in Casualty

Perc

enta

ge C

asua

lty P

atie

nts

Tria

ged

by

Nur

sing

Sta

ff in

Und

er 5

min

.

QMMH (n=400) QE II (n=54)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%93%

0%

Infection Control Compliance

Perc

ent o

f Han

d w

ashi

ng S

tatio

ns w

ith c

lean

sing

so

lutio

n an

d w

ater

with

in 1

0m o

f pat

ient

bed

Lesotho PPP Endline Evaluation 05/03/2023 24

QMMH QE II0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

100%

70%

Compliance with Maternal PMTCT protocol

% o

f Del

iver

ies

Compli

ant V

itamin

K

Compli

ant O

phtha

lmia

Neona

torum

Prev

entio

n

Ove

rall N

ewbo

rn Com

plian

ce0%

30%

60%

90%

100% 100% 100%49% 58% 54%

Newborn Protocol Compliance

QMMH QE II

% N

ewbo

rns

QMMH (n=134) QE II (n=378)0%

20%

40%

60%

80%

100%

100%

3%

Complete and Accessible Medical Records

% M

edic

al R

ecor

ds

QMMH IM (n=77)

QMMH BU (n= 319)

QE II (n=139)0%

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

100%

100% 89%

73%

Medical Record Accessibility

% M

edic

al R

ecor

ds A

vaila

ble

Afte

r D

isch

arge



Lesotho PPP Endline Evaluation 05/03/2023 25

QMMH (n=61,517)

Likotsi (n=11,169)

Mabote (n= 15,187)

Qoaling (n=8126)

QE II (n=391)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

86.1%91.8%

77.2%

69.0% 70.7%

Patient Satisfaction Survey ResultsPe

rcen

tage

of O

vera

ll Po

sitiv

e



Main Entrance and Gateway Clinic

Lesotho Endline PPP Evaluation 2605/03/2023



Security Monitors

27Lesotho Endline PPP Evaluation 05/03/2023



Improved FacilitiesLesotho Endline PPP Evaluation 2805/03/2023



New EquipmentLesotho Endline PPP Evaluation 2905/03/2023

When you are just out of school, you want to work and practice what you’ve been taught. But at QEII, you had nothing to use.

Now that we have the equipment, we can do the procedures. People are very happy that they can stay in the country for treatment.



Improvements in SOPs, upkeepLesotho Endline PPP Evaluation 3005/03/2023



Improvements in upkeep, SOPs The cleaning company is outsourced now, and maybe

that’s why it’s best. Before, an old woman would put her new mop in the bucket once and would do the whole floor without changing it. If you talked to her, she would say ‘You do your job, I’m doing mine.

There are standard operating procedures (SOPs), like a recipe. For example, this is how you admit a patient, these are the steps. It gives you an ease, because you know what you are supposed to do.

Here we are made to be part of the [hospital] policies and we are asked to adapt them to be relevant to our situation. We disseminate them to all teams, so they know how they should conduct themselves.




Use of work orders for non-scheduled repairs or equipment problems

32Lesotho Endline PPP Evaluation 05/03/2023

“Back then, at QEII, we were doing ‘breakdown maintenance’ only. But here [at QMMH] we do a lot of preventive maintenance.”



Patient Double Room



Hand washing stations; infection control



Major improvements in pharmacy management




Improvements in Pharmacy

Real time inventory control Less waste of medication (lowers cost) More flexibility in ordering (ability to adjust to need) Less stockouts (ability to shift medications among

clinics or pharmacy locations) Less theft Better ability to track medication use (e.g. days on

antibiotic)




Information Systems

Extensive improvements in hospital data collection

State of the art computer systems for hospitals

Paper file, electronic record, and bukana




Fully Accredited by COHSASA through 2015Lesotho Endline PPP Evaluation 3805/03/2023



Human Resource Management39Lesotho Endline PPP Evaluation

Hospital Staff (as of Dec 2012)Number of

QMMH StaffNumber of QE II

Staff%

DifferenceTotal 882 642 37%Sub-Categories Clinical Nature 563 345 63%Physicians 70 57 Dentists 5 6 Registered Nurses 284 130 Nursing Assistants 98 71 Other Clinical (i.e. Lab, Radiology etc.) 106 81 Non-Clinical Positions 319 297 7%Administrative Management 12 18 Support Staff 121 244 Catering 37 2 All Other 149 33



Kronos “Hands-on” Biometric Scanner40

Time and Attendance Monitoring




Nurses in the Neonatal Intensive Care Unit41Lesotho Endline PPP Evaluation



Staff empowermentAt QEII my role was limited. I wouldn’t take on big decisions such as planning changes or developing the budget. But here I am involved with budgeting and recruitment of staff.

[Before,] they would give you a promotion but they didn’t help you learn your new responsibilities. By contrast, I knew what was expected of me by the time I started at Tsepong.

QEII was ruled politically…here I can talk to anybody and we can see how to address things.

Lesotho Endline PPP Evaluation 42



Discussion and Recommendations




Discussion

Information systems and coding Indications for C-section High volumes, outpatient wait time, time to surgery Inexperienced staff, getting staff buy-in on changes Further analysis of referral systems, patient

satisfaction after discharge, staff satisfaction, and costs




Conclusion Basotho in Maseru District have access to better

quality health care services, and people around the country have access to excellent referral services.

Health outcomes are much better at QMMH-IN, with about 693 fewer deaths per year, better infection control, greater amenities and more satisfied patients and empowered staff.

The Lesotho PPP may be a model for other low- and middle-income countries. This experience and lessons learned should be discussed broadly.




Thank you!Kanako Yamashita AllenCassandra De SouzaCatherine O’FarrellYoko ShimadaLeslie VillegasToyin AjayiLauren BabichRich FeeleyDoug FieroMark HellowellKasey OliverKristin ShawNthati Lefuma, Moleboheng Mofolo, and the staff of LeBoHA in MaseruGlobal Partnership for Output Based Aid

Me Makhakhe, Ntate Leaooa, Dr. Letsie and other key informants from the Ministry of Health and GoL

Karen Prins and all of the staff of Tsepong working at QMMH and the Gateway, Likotsi, Mabote, and Qoaling Clinics

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