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IMPROVEMENT COLLABORATIVE REPORT March to October 2012

KINDLY DIRECT ANY INQUIRIES TO ssodzi-tettey@ihi.org

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Table of Contents

Project Fives Alive!’s Strategic Objectives for 2012: ........................................................................................ 3

Key Planned Activities .................................................................................................................................. 3

Updates on Implementation of Planned Activities ...................................................................................... 3

Results and Achievements ........................................................................................................................... 4

Wave 1 Sustainability Results (3 Districts) ............................................................................................... 4

Wave 2 District-Wide Improvement Collaborative Network Results (38 Districts) ................................. 4

Wave 2 Hospitals Improvement Collaborative Network ......................................................................... 7

WAVE 3: 28 National Catholic Hospitals .................................................................................................. 9

Developing a Composite National Scale-up Model ................................................................................ 11

MNH REFERRAL .......................................................................................................................................... 13

Communication/Dissemination ............................................................................................................. 14

Key Challenges and Strategies to Address Them ................................................................................... 14

Objectives for Next Year (November 2012 to December 2013): ........................................................... 15

Project Team ……………………………………………………………………………………………………………………………….16

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Project Fives Alive!’s Strategic Objectives for 2012: To integrate PFA work into the health system in Upper East, Upper West, and Northern regions;

To complete Wave 3 scale-up from nine to 29 Catholic hospitals;

To finalize the design of a sustainable model for national scale-up in 2013; and

To disseminate information on project performance in Ghana and beyond.

Key Planned Activities Based on the above strategic objectives, the following key activities were planned for the period under review:

1. To conclude remaining Learning Sessions and site visits, change agents (CAs) training, and Data Quality Improvement (DQI) work.

2. To outline a sustainability plan with sustainability indicators in consultation with Regional Directors of Health Services for the three regions.

3. To propose a model for national scale-up and finalize same at the second External Advisory Board Meeting.

4. To conclude a baseline assessment and launch the Maternal and Newborn Health Referral project in innovation districts.

5. To disseminate project results through the project website, publications, conferences, etc.

Updates on Implementation of Planned Activities 1. With the exception of the third and final Learning Session for hospitals in the Northern and

Upper West regions, all other Learning Sessions and site visits in Waves 2 and 3 were executed as planned.

2. The second and third training of CAs in Northern and Upper West regions respectively were not carried out within the reporting period, but have since been executed.

3. Activity Period (AP) visits and Monitoring and Evaluation (M&E) activities planned for the period under review, including DQI, data extraction, collation, analysis and feedback to Project Officers, were largely carried out.

4. A sustainability plan tracked by indicators was outlined and implemented. Two review meetings were held with the three Regional Directors of Health Services of the Northern regions to review same. Project Officers (POs) are working with managers and CAs at all levels to deepen the QI institutionalization process within the Ghana Health Service (GHS) system.

5. The Maternal and Newborn Health Referral Project was launched in August-September 2012 in six innovation districts in the Central and Northern regions of Ghana.

6. Regarding dissemination of project results, eight abstracts were accepted for presentation at the 2012 International Forum on Quality and Safety in Health Care in Paris, France; 22 abstracts were submitted for the 2013 International Forum on Quality and Safety in Health Care scheduled to take place in London; and 9 abstracts were submitted and accepted for the upcoming ISQua conference in Ghana in February 2013. A more detailed account of dissemination activities of the Project is included below.

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Results and Achievements

Wave 1 Sustainability Results (3 Districts)

As at the end of September 2012, early ANC registration remained at 36%, while ANC registrants who had

made four or more visits before delivery continued to reduce consistently as reported previously (Figure

1). The reduction may be a reflection of improved data accuracy following health worker training aimed at

removing duplication in the number of women doubly counted previously.

Skilled delivery coverage was sustained at high levels (mean of 85% from previous mean of 87%), above

the Collaborative aim of 75% (Figure 1). Institutional neonatal death rate and still birth rate remained

unchanged at 5 and 16 per 1,000 skilled deliveries respectively (Figure 2).

Wave 2 District-Wide Improvement Collaborative Network Results (38 Districts)

By the end of September 2012, the participation of health staff in Learning Sessions (LSs) remained at 2,392 at the Collaborative level (all three regions) for the district-wide ICN, while the cumulative number of site visits by POs increased to 2,118. The monthly breakdown is shown in Figure 5. The decline in frequency of site visits by POs over time was a sustainability design feature aimed at increasing the role of

Figure 1: Wave 1 Improvement Collaborative Network – Early Registration of ANC, 4th ANC Visit & Skilled Delivery Coverage: Jan’08 to September’12

Wave 1 start

Figure 2: Wave 1 Improvement Collaborative Network –Stillbirth Rate, Neonatal Death, Jan’08 to September

’12

Wave 1 start Wave 1 start

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trained change agents within the health system. It was also associated with increased demands on staff time with spread.

Figure 7: Wave 2 Improvement Collaborative Network – Skilled Deliveries as Percentage of Total Deliveries, Jan’09 to Sept’12

Wave 2 start Wave 2 start Wave 2 start

Figure 3: Scale-up from Wave 1 to Wave 2 Collaborative, Jul’08 to Oct’12

Figure 5: Site Visit Frequency in Waves 1

& 2, Jul’08 to October’12

Figure 4: Wave 2 Collaborative – LS

Participants by Region, Sept’09 to July’12

Figure 6: Wave 2 Improvement Collaborative Network – ANC registration in first trimester, Jan’09 to Sep’12

Wave 2 start

Wave 2 start

Wave 2 start

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Early ANC registration increased slightly, to 46% and 36 % in the UER and NR respectively, while the UWR

remained at 52% in the period under review (Figure 6). Similarly, the mean skilled delivery coverage remained

at 92% and 84% in the UER and UWR respectively, while NR increased to 57% (Figure 7). Facility-based

stillbirths also remained at 21 and 23 per 1,000 skilled deliveries in the UWR and NR respectively, while

that of UER increased to 19 from 17 per 1,000 skilled deliveries (Figure 8).

Institutional stillbirth rates remain above 10 per 1000 skilled deliveries across the three regions. The UER is at a

rate of 20 per 1000 skilled deliveries, compared with a regional target of 10 per 1000 skilled deliveries (Figures

8).

Figure 8: Wave 2 Improvement Collaborative Network – Facility-Based Stillbirth Rate, Jan’09 to Sep’12

Wave 2 start Wave 2 start Wave 2 start

Figure 9: Wave 2 Improvement Collaborative Network – Early Postnatal Care for Neonates, Jan’08 to Oct’12

Wave 2 start Wave 2 start

Wave 2 start

Figure 10: Wave 2 Improvement Collaborative Network – Neonates who Received Second Postnatal Care within First Week of Life, Jan’08 to Oct’12

Wave 2 start Wave 2 start

Wave 2 start

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For early postnatal care (PNC) coverage, 86%, 75%, and 42% of all PNC registrants were seen by day 2 of

life in the UER, UWR, and NR respectively as of the end of September 2012 (Figure 9). Similarly, 57%, 48%

and 22% of registrants were seen by day 7 of life respectively in the UER, UWR, and NR (Figure 10).

Institutional neonatal deaths, however, remained unchanged across the three regions (4, 5, and 2 per

1,000 skilled deliveries in UER, UWR, and NR respectively) (Figure 11).

Wave 2 Hospitals Improvement Collaborative Network

As noted earlier, the LS2 for hospitals in the NR was completed in this period and increased the number of

health staff participating in LS2 of the hospital ICN to 212, with the regional breakdown indicated in Figure

12. The low participation in LS1 from the UWR is because the participants’ evaluation form, which is the

main source of this data, was not filled by majority of the participants.

Overall under-5 mortality rate reduced marginally from 22 to 20, 18 to 14 and 30 to 27 per 1,000

admissions in the Upper East, Upper West, and Northern regions respectively (Figure 15), by the end of

September 2012. Similar gains were seen within the 12-59 months age group, where the mean mortality

rates now stand at 15, 14 and 22 per 1,000 admissions respectively in the UER, UWR and NR, showing a

reduction in the rate from reported second quarter performance (16 per 1,000 admissions for UER and

Figure 12: Wave 2 Hospitals ICN – LS Participants by Region

Figure 11: Wave 2 Improvement Collaborative Network – Facility-Based Neonatal Mortality Rate, Jan’09 to Sep’12

Wave 2 start Wave 2 start

Wave 2 start

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UWR and 24 for NR) (Figure 14). The infant mortality rate also reduced slightly across all three regions. The

UWR reduced from 13 to 12 per 1,000 admissions, while NR and UER improved from 43 to 39 and 39 to 38

per 1,000 admissions respectively (Figure 13). Similarly, overall under-5 malaria case fatality rate (CFR)

continues to improve in the UER, whereas in the UWR and NR, the CFR for malaria is worsening (Figure

16).

Figure 13: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Deaths among Children 0-11 Months Old: Jan’09 to Sep’12

Wave 2 start Wave 2 start

Wave 2 start

Figure 14: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Deaths among Children 12-59 Months Old: Jan’09 to Sep’12

Wave 2 start Wave 2 start Wave 2 start

Figure 15: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Deaths among Children Under 5 Years Old: Jan’09 to Sep’12

Wave 2 start Wave 2 start

Wave 2 start

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WAVE 3: 28 National Catholic Hospitals

3a. Overall Under-5 Mortality

A hospitals initiative was launched in October 2009 with nine innovation hospitals in the South

and scaled up to 28 NCHS hospitals in June-July 2011. Overall Under-5 mortality for the Wave 3

hospitals currently stands at a median of 13.0 deaths per 1000 admissions, representing an 18.2%

reduction in U5 mortality between January 2010 and September 2012. Of a total of 32 hospitals

in the Catholic system, only 28 are accounted for in the analysis since the three NCHS hospitals in

the northern regions were included in the initial Wave 1 work, while the fourth is an Orthopedic

hospital where death is a rare event.

Figure 17: Under 5 mortality for Wave 3 Hospitals, Jan 2010- Dec 2012

In this reporting season, about 42% of the hospitals (12 out of 28 hospitals) made significant

reduction in the U5 mortality rate, ranging from 27% to as high as 72% reduction. The hospitals

and their percentage reduction in mortalities are as follows:

Figure 16: Wave 2 Hospital Improvement Collaborative Network – Rate of Institutional Malaria Case Fatality Among Under 5s, Jan’09 to Sep’12

Wave 2 start Wave 2 start

Wave 2 start

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Hospitals % Reduction in Mortality (January 2010 to September 2012)

Comboni Hospital, Sogakope 72.6 Our Lady of Grace Hospital, Asikuma 69.5 St. Martins de Porres Hospital, Agomanya 60.9 Margaret Marquart Hospital, Kpando 57.0 John of God Hospital, Duayaw Nkwanta 57.0 St. Francis Xavier Hospital, Foso 50.0 St. Dominic's Hospital, Akwatia 49.7 St. Mary's Hospital, Drobo 45.6 Mathias Hospital, Yeji 42.1 St. Martins de Porres Hospital, Eikwe 35.7 Catholic Hospital, Battor 34.9 Mary Theresa Hospital, Dodi Papase 27.4

3b. Post-Neonatal Mortality

Post-neonatal deaths for 26 hospitals in the Wave 3 Collaborative show a 25.6% reduction from January

2010 to July 2012. Two hospitals are currently undergoing checks for data quality and thus have their data

omitted in respect of this age group.

Figure 18: Postneonatal mortality for 26 hospitals, January 2010 to July 2012

3c. Infant Mortality

The Infant (1 to 11 months) mortality rate has been reduced by 33.8% between January 2010 and July

2012 for 26 hospitals.

Wave 3

Scale Up

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Figure19: Infant Mortality for 26 Wave 3 Hospitals, Jan 2010-July 2012

3d. Neonatal Mortality

Neonatal mortality rates have not changed within the Catholic system during the intervention period. Similar to the result obtained for Wave 2 facilities, mean mortality rate is stagnant at 13.4 deaths per 1,000 live births since January 2010. Figure20: Neonatal Mortality for 26 hospitals in Wave 3, January 2010 to July 2012

Developing a Composite National Scale-up Model

4a. Development of a Wave 4 Scale-up Model

Over the past 12 months, the Project has outlined and implemented a sustainability plan, resulting in

further extension of QI capacity of Change Agents (embedded within the health system), increased plans

for independent site visits by Change Agents, provision of resources by Regional Directors resulting in

Wave 3

Scale Up

Wave 3

Scale Up

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increased independent site visits, and a broader application of QI approach in non-PFA activities (e.g.,

Family Planning Services in UER).

The above sustainability plan complemented a new design started in August 2011 in three districts

(Tamale Metropolis, Central Gonja, and Tolon-Kumbungu) in the NR, where Change Agents were provided

with more in-depth QI training to support frontline staff at the sub-districts to run improvement projects

in place and under the guidance of Project Officers. This model (Wave 2B) represents a leaner, more

hands-off approach by Project Officers, who gave a more active lead role to the Change Agents from the

onset of the project. It is hope that this model will also serve as a guide for scaling up QI activities in the

other Regions in 2012 and guide the development of a final model for national scale-up.

By September 2012, the number of Change Agents trained (25 and 26 for LS1 and LS2 respectively) (Figure

17) and the number of improvement projects in each district were unchanged. Early ANC registration was

45%, while skilled delivery coverage stood at 67% for the district-wide improvement projects in the three

districts (figure 18). The mean rate of institutional stillbirths shows a promising downward trend from the

mean value of 38 per 1,000 skilled deliveries. Neonatal mortality remained unchanged at 7 per skilled

deliveries as at end of September 2012 (figure 19).

Frequency of support visits to Change Agents continues as a bimonthly activity for hospitals and monthly

for districts.

Figure 21 : Wave 2B – Change Agents trained and Participation in Hospital Collaborative from 2B Districts

Figure 22: Wave 4 scale-up Model Improvement Collaborative Network: Jan’09 to September’12

Wave 2B start Wave 2B start Wave 2B start

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4b. Composite National Scale-Up Model

Learning from the Scale-Up Model/Wave 2B above coupled with Project-wide experiences formed the

basis of a new composite National Scale-Up model focusing on design and the QI capacity needed for

successful execution. This was outlined in two phases:

1. Phase 1: Sequential scale-up in communities and hospitals of the south

a. High-intensity district Collaboratives: Seed the primary care/community Collaboratives in the

seven regions of the south, using a mix of high-performing and challenged sub-districts (as

determined by MCH outcomes and political will in the district) in each Collaborative (year 1).

These district-level ICN would have a high level of support from PFA but would be led by trained

Improvement Coaches who are officers of the Ghana Health Service.

b. Low-intensity district Collaboratives: Network of Improvement Coaches supporting the remaining

districts (data feedback and QI support in 1 – 2 sub-districts each) that have demonstrated

reasonable functionality and good leadership – low level of support from PFA.

c. Region-wide hospital Improvement Collaborative Network (ICN) using the existing NCHS hospitals

from Wave 3 and first set of GHS hospitals in the three regions of the North as mentor hospitals.

These hospital ICN would be led by Project Officers from PFA.

2. Phase 2: Scale-up of QI intervention in remaining Districts (year 2)

a. Hospital ICN continues: Takes remaining GHS hospitals into the Collaborative

b. District ICN continues: Collaboratives expand to include all facilities in Districts. New District

Collaboratives are formed to ensure saturation coverage of all regions.

c. Continue training/mentoring ICs, IAs , system leaders, DIOs and HIOs. Maximize project-wide

capacity (using Project Officers across all Waves of the project).

MNH REFERRAL Project Fives Alive! received supplemental funding from the BMGF to improve maternal and newborn

health outcomes and access that had been adversely affected by faulty referral processes.

The baseline assessment for the MNH referral work was completed in July 2012 by the independent

project evaluators and the report subsequently submitted to the Foundation. The project was launched in

August 2012 in the following innovation districts: Gomoa West, Assin North, and Asikuma Odoben Brakwa

Figure 23: Wave 4 scale-up Model Improvement Collaborative Network: Jan’09 to September’12

Wave 2B start

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(Central Region) and in September 2012 in Nanumba South, Nanumba North, and Gushiegu (Northern

Region) using a design emphasizing a strong community voice and leveraging multisectoral partnerships

(e.g., local government authority). Forty Improvement Teams have since been created at district, sub-

district and hospital levels, with the first round of Learning Sessions and activity period site visits being

concluded. The first Community of Practice meeting was held in late May/early June 2012 in Addis Ababa,

Ethiopia, to share learning and experiences with Gates-funded projects in Nigeria and Ethiopia.

Communication/Dissemination

The following were achieved:

Seven (two oral and five posters) abstracts were accepted for presentation at the 2012 International Forum on Quality and Safety in HealthCare in Paris, France.

22 abstracts were submitted for the 2013 International Forum on Quality and Safety in Healthcare scheduled to take place in London.

9 abstracts were submitted and accepted for the upcoming ISQua conference in Ghana in February 2013.

In November 2012, the International Journal for Quality in Health Care accepted the following for publication: A nationwide quality improvement project to accelerate Ghana's progress toward Millennium Development Goal Four: design and implementation progress.

The Project website was revamped and relaunched with new design and updated information and in-house capacity built for maintaining same.

The project secured the following prime slots on the Ghana Medical Association platform as part of will building for Wave 4 national scale-up:

2012 Annual Public Lectures – September 2012 by leads for Waves 2 and 3, Isaac Amenga-Etego and Dr. Ernest Asiedu respectively

Scientific Session – 54th Annual General Meeting – November 2012 by Isaac Amenga-Etego and Dr. Ernest Asiedu

Keynote Address – 54th Annual General Meeting – November 2012 by Prof. Pierre Barker, Senior Vice President, Low and Middle Income Countries, Institute for Healthcare Improvement

Keynote Address was delivered by Dr. Sodzi-Tettey at the ISQua meeting in Geneva, Switzerland, in October 2012.

24 human interest stories from PFA! have been finalized and are awaiting publication pending final editorial permits in lay Ghanaian media.

Key Challenges and Strategies to Address Them

Conflicting schedules and reporting delays continue to be major challenges in executing Learning Sessions according to plans. Discussions are ongoing to find suitable dates for these Learning Sessions. The Project’s exit from Northern Ghana would be delayed to enable completion of outstanding Learning Sessions in Northern and Upper West regions in first quarter of 2013.

The persistent high rates of neonatal mortality continue to be a daunting challenge for the Project. To tackle this, a working group has been formed and tasked with outlining a change package of effective neonatal interventions that could be more effectively deployed in the Wave 4 national scale-up.

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Challenges with documentation of non-routine process measures. POs will continue to encourage and provide the necessary support/feedback to QI teams. Attempts will be made in Wave 4 to align these measures with similar ones/proxies already being reliably reported into the District Health Information Management Systems (DHIMS).

Objectives for Next Year (November 2012 to December 2013):

1. Exit frontline project implementation in three regions in the North 2. Data Quality Improvement Focus in the Catholic Health Service 3. Launch Wave 4 National Scale-Up 4. Develop a specific package of neonatal interventions 5. Continue MNH Referral innovation phase 6. Have a greater focus on submitting more peer-reviewed scientific publications and getting

published in the lay/social media

Appendix 1 PFA TEAM

No. Name

Position

1. Dolores Mensah Hervie Administration & Communication Officer

2. John Sunyera Administration & Finance Officer

3. Ivan T. Essegbey

Senior Monitoring & Evaluation Officer

4. Solomon Abotiba Atinbire

Senior Monitoring & Evaluation Officer

5. Ane Adondiwo

Senior Project Officer – Northern Region Lead

6. Ernest Kanyoke

Senior Project Officer – Upper West Lead

7. Elma Yabang

Senior Project Officer – Upper East Lead

8. Eric Adjei Boadu

Senior Monitoring & Evaluation Officer

9. Linda Azumah Monitoring & Evaluation Assistant

10. Patrick Ansu Monitoring & Evaluation Assistant

11. Francis Ashagbley Senior Project Officer

12. Salomey Dery

Project Officer

13. Lauren Macy Project Officer

14. Alexander Zuuk-Laar

Project Officer

15. Dennis Ocansey

Project Officer

16. Jonas Akpabli Monitoring & Evaluation Officer

17. Roberta Asiedu Project Officer

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18. Josephine Agyemang-Duah Project Officer

19. Dr. Ernest Konadu Asiedu Wave 3 Lead

20. Isaac Amenga-Etego Wave 2 Lead

21. Ireneous Dasoberi Referral Lead

22. Dr. Sodzi Sodzi-Tettey Director