Phase III: Supporting and Implementing the Demonstration

To build on this intervention’s momentum, the MOH asked ESD for additional strategies for rapidly improving the quality of care. As a result, ESD introduced the Yemen Team to the Improvement Collaborative (IC) methodology. In 2009, the MOH, the country team and BHS scaled up the eight best practices in six major hospitals in six governorates: Aden, Amran, Ibb, Lahaj, Sa’ada and Taiz. 


The main steps of this phase include: 

  • An initial training and workshop for establishing the Improvement Collaborative was held in January 2009 for six hospitals in the six governorates where the initial scale-up would take place. Teams from the hospitals were composed of physicians, nurses and midwives, who were oriented to the IC approach and trained in the best practices, clinical guidelines, standards and job aids. In addition, the teams were introduced to QI tools and methodologies with focus on root cause analysis, problem solving, working in teams, data quality and monitoring. The teams developed quarterly work plans and  scheduled quarterly meetings to share challenges and progress. 
  • The QI teams conducted a baseline assessment against shared indicators, initiated the implementation of rapid improvement cycles and began monthly monitoring of compliance with the clinical guidelines.
  • The Improvement Collaborative was conducted and managed by a combination of staff from the MOH and BHS. The Collaborative coordinator made periodic visits to each hospital team to assist with the identification and testing of improvements while monitoring monthly indicators. BHS provided management support and a staff statistician who compiled the hospital data. District MOH facilitators followed up the work of facility teams through monthly visits to support monitoring and improvement activities. Every facility reported monthly measurements of compliance with standards, as well as improvement plans and team activities.
  • The QI teams met every three months in a learning session where they shared progress and challenges, received additional training in QI and clinical aspects of the best practices and developed plans for the next quarter.
  • The MOH Population Sector endorsed the action plans developed by the teams and integrated them into the 2009 Population Sector Work Plan.
  • ESD and BHS provided additional training, including:
  1. Postpartum training on family planning and counseling services, including skills for specific family planning methods.
  2. Several orientation courses based on the Family Planning Handbook, including seminars on the benefits of family planning and additional technical information.
  3. One-week course for providers on Contraceptive Technology Updates and the Balanced Counseling Strategy for family planning.
  4. Training on immediate postpartum IUD insertion, which was conducted for a group of doctors as part of the HTSP counseling best practice.

In addition to the eight previous best practices, two more were added by the summer of 2009: active management of the third stage of labor (AMTSL) and newborn resuscitation. At the individual hospital sites, the teams identified and tested several of the following solutions:

  1. To reduce infection in the nursery, nurses in Lahaj designed culturally acceptable scrubs and veils that they washed and wore only in the nursery. Prior to this, they had worn scrubs on top of their daily clothes and niqab (full face veil).
  2. All hospitals added a discharge and counseling room with a private space for discussing family planning.
  3. All hospitals provided BCG vaccinations for the newborns and family planning counseling for fathers and mothers.
  4. Some hospitals have posted a midwife in the postpartum room to counsel mothers on exclusive and immediate breastfeeding and family planning.
  5. Some hospitals created a private space for nursing mothers.
  6. Staff trained cleaners on infection prevention and assigned each one to a specific area to control the spread of infection.
  7. Staff placed bottles of antiseptic hand cleaning solution on the trolley when making rounds, for use between exiting one patient’s room and entering the next. 
  8. Staff in Ibb created a “missed opportunity” room for family planning counseling and services and an internal referral for mothers and their babies. The women can receive family planning counseling and contraception during the same visit. A documentation system for patient referrals measures the effect of this change. Initial data shows this approach is very effective and should be generalized at other hospitals.
  9. In Ibb, staff provided mothers of low birth weight babies with demonstrations on KMC and printed instructions to take home.

Phase IV: Going to Scale with Successful Change Efforts