Sustaining Quality Improvement through Regional Capacity BuildingPaul Blumenthal, MD, MPHGlobal Medical Director- PSIProfessor of Obstetrics and GynecologyDirector, SPIRESStanford University

“Top Down”• Perceived as

potentially punitive• M&M model• Guilt and Blame

• Intermittent with little continuity

• Outside - In

Traditional Approach to “Quality”

• Often initiated • with new services• after an adverse

event• Needs to be built from

the ground up• Will need outside

support during the building process

• Eventually, inside - out

Realities of QA/QI Implementation

“Clinical” Services Offered

“STANDARDS”

Training

Evaluation Service Delivery

1. Technical Competency2. Client Safety3. Informed Choice4. Privacy and

Confidentiality5. Continuity of Care

Five Components of PSI Service Delivery Standards

ObservationsConclusionsRecommendationsAction Plan

Audit “Matrix”O, C R AP

Enhance local capacity for local supervision Enhance local/regional expertise in QA/QI programs

and philosophies Enhance likelihood of “sustainable” network (and

possible QA/QI programmes) Enhance ability to put the audit recommendations to

work

Regionalization Strategy

58 total External Audits. 26 regional Auditors trained

– representing 14 countries. – Consistent with a “cascade” approach

Regional teams have carried out service quality audits in 14 countries.

Feedback from more senior auditors, programs, and the newly trained auditors:– regional auditors gaining the skills to lead future audits. – the use of regional staff has facilitated cross program

learning– the training process itself has improved internal quality

assurance systems in the trainee’s programs.

Regionalization Progress: 2008-2015

Regionally based staff – Audit training/experience– Leadership qualities

• Clinical AND Programmatic Enhanced role:

– Audit follow up (current)• Development of Action Plans and follow through• CME – Webinars, Clinical Updates

– Audit Response (SIFPO-II)• Increases Regional focus

– Total Audit/QA Process (Goal)– Adverse event management, adjudication and drills

Regionalization Evolved: Quality Assurance Regional Leaders (QARL)

Combination of External and Internal Audits plus routine supportive supervision is an effective quality improvement strategy

Can be undertaken in non-threatening, constructive manner The regionalization of auditor pool and instutionalization of both

internal audits and routine supportive supervision has the potential to be “sustainable”

Sustainability will depend on– Level of internal commitment– Local commitment to fund QA/QI activities– Ability of “QA Regional Leads (QARLs) to provide continuing

guidance and feedback, eventually eliminating the need for primary GMD oversight

Conclusions

Thank you.