Scaling up and institutionalizing essential obstetric care in Ecuador
With USAID technical support, Ecuador’s Ministry of Health began in 2003 to apply collaborative improvement to address essential obstetric care. The program started with eight sites and within the first year grew to 55, all working on improving antenatal and delivery care. Quality improvement (QI) teams were formed and trained to monitor indicators of quality and test changes to ensure that evidence-based practices were routinely implemented. From a limited demonstration experience in eight sites, with significant external support from the Quality Assurance Project (QAP), the initiative evolved into a national scale obstetric and newborn care improvement program covering the whole country (more than 100 hospitals and 60 health centers), totally managed and financed by the Ministry of Health (MOH) of Ecuador.
The Process and Experience
Preliminary Phase: Form the Change Coordination Team
In early 2003 the MOH of Ecuador started a coordinated activity aimed at improving the quality of maternal health care. With technical assistance from the QAP, the MOH appointed a steering team composed of delegates from the Maternal and Child Health Directorate, as well as from the Free Maternity Program. This team embarked in preliminary activities such as defining quality standards and indicators for key maternal care processes as well as a standard procedure for facilities to report on these indicators to the MOH provincial offices. Key processes to be improved included antenatal care, delivery care, immediate post-partum care and care for complications such as preeclampsia, post-partum hemorrhage and obstetric infections. The steering team also developed a training curriculum on quality improvement methods and selected initial provinces and facilities.
Phase I: Define the Need for Change
A baseline assessment of quality of care, measured as compliance with maternal care quality standards was conducted early on. QI teams, formed in initial facilities, conducted self-audits of clinical records obtaining data that was transformed in percentages of clinical records in compliance with standards. These baseline assessments showed markedly low quality levels for most maternal care processes. The fact that these baseline measures were self-assessments helped facility-based teams to accept data depicting low quality of care and fostered a sense of need to improve.
Phase II: Plan for Demonstration and Future Scale-up
With the aim of reaching the entire country, an initial demonstration phase was planned. This phase comprised of 14 county hospitals in 8 out of the 22 provinces of Ecuador. Health professionals were selected from each of the 14 hospitals and 8 provincial MOH offices to be trained as local QI facilitators. QAP staff trained facilitators of selected hospitals and MOH provincial offices during three workshops conducted in 2003. Workshops took place at intervals of 8 to 10 weeks, each one lasting approximately 16 to 20 working hours. In turn, these provincial and facility-based facilitators were to form a QI team at each of the 14 hospitals and train team members.
The Coordination Team´s plans were to launch a scale-up phase after all 14 hospitals completed formation and training of a QI team to work steadily on improving maternal care. The planned scale-up phase consisted in expanding the QI model to all county hospitals in each of the 8 initial provinces. A follow-up second scale-up phase would expand the model to the rest of the 20 provinces in Ecuador. These scale-up plans could not be followed strictly as planned, since several other hospitals and health centers began to join the QI initiative early on, resulting in a first wave of around 55 hospitals in 2003-2004, a second wave of 21 facilities in a scale-up phase in 2005 and a third wave of 10 facilities in 2006-2007.
Phase III: Support and Implement the Demonstration
QAP trained around 35 facilitators from 14 hospitals in 8 provinces from 2003 to 2004. These facilitators formed CQI teams with staff from district hospitals or health centers in each of the 14 counties. Teams were composed of physicians, nurses, midwives, administrators and statistics staff, who attended three training workshops on quality improvement methodology replicated by the facilitators at their respective facilities. Provincial MOH facilitators followed up the work of teams from every facility through monthly visits to support monitoring and improvement activities. Every facility reported monthly measurements of compliance with standards, as well as improvement plans and teams’ activities.
Some of the features implemented by QAP and the MOH to consolidate this stage were:
- Technical visits to initial provinces: A QAP representative and MOH officials visited the eight provinces initially selected, holding planning meetings attended by the provincial director and coordinators from all county health areas. CQI methods, as well as the experience gained by facilitators and improvement teams from the initial facilities, were presented.
- The legal framework that supports the QI process and the leadership commitment of the MOH to expand to new provinces were also presented. The visit ended with the formulation of a work plan for the expansion to all county hospitals of each province.
- Training of QI teams in all facilities in the eight initial provinces: Improvement teams were created in every county hospital of the eight provinces and trained in QI methodology by skilled facilitators. The new teams conducted a base line assessment, initiated the implementation of rapid improvement cycles, and began monthly monitoring of compliance with standards for clinical processes. Facilitators conducted visits to provide technical support to teams. Workshops conducted in provinces were self-funded by health areas and provinces.
- National meetings to update facilitators: In November 2003 and March 2004, facilitators from the eight provinces held workshops to update their knowledge and to strengthen their functions. Facilitators shared achievements, difficulties and solutions taking place at their respective provinces.
- A “Facilitator’s Toolkit” with technical tools for continuous quality improvement was put together by QAP and given to each facility-based and provincial facilitator.
- Review of standards, indicators and tools: Initial standards and indicators were reviewed and modified by personnel from technical programs of the MOH and the Steering Team, based on guidelines for reproductive healthcare and taking into account the experience and local recommendations.
- System for monitoring and reporting compliance with quality standards: The MOH and QAP developed an electronic system based on an Excel spreadsheet, which enables facilitators and CQI teams to easily enter the numerators and denominators to build quality indicators. The program automatically produces percentages of compliance for each standard and a run chart showing the indicator’s performance. The team sends the spreadsheet to the provincial facilitator, who consolidates the information from the province and sends it to the MOH central level for analysis and feedback.
Phase IV: Going to Scale with Successful Change Efforts
Spread took place in three phases, or waves, shown in the graph. The first wave of implementation was followed in 2005 by a second wave of sites that joined the collaborative and had the advantage of the learning that had been generated by the first wave. These second-wave sites received less support from external technical advisors and much more from the MOH. In 2007, without external technical support, MOH staff initiated another wave of improvement activities in 10 new sites.
Figure 4. Ecuador: Percent of pregnant women receiving prenatal care according to norms
Figure 4 is an example of improvement of antenatal care, although QI teams worked also on delivery care, postpartum and newborn care, as well as care for the three main obstetrical complications, using the process previously described. As the graph shows, using learning from the previous wave, each successive wave achieved faster scale-up of best practices. By the end of 2007, all 86 hospitals in 12 provinces were reporting data and showing consistent results, with most women receiving care according to standards. In 2007, the MOH focused on a parallel activity, scaling up Active Management of the Third Stage of Labor (AMTSL) to the whole country of Ecuador, and in 2009, the MOH extended the entire essential obstetric and neonatal package to five more provinces with its own funding.