Improving obstetric

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Improving obstetric complications care in
Ecuador through a Collaborative approach
Jorge Hermida, M.D. The Health Care Improvement
Project, HCI
International Forum on Quality And Safety in
Health Care April 2008
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Ecuador background

• Maternal mortality ratio 73/ 100,000 in 2005
• 80 of reported maternal deaths occur at
  hospitals
• Ministry of Health and QAP carried out a
  Collaborative to improve Essential Obstetric Care
  in 2003-2005.
• Prenatal care, delivery, post-partum and
  immediate newborn care were all improved.
• The EOC Collaborative was not successful at
  improving hospital-based care for Pre-eclampsia,
  Hemorrhage and Sepsis

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Continuous Quality Improvement teams at work

• WHAT ARE WE TRYING TO ACCOMPLISH ?
• HOW WILL WE KNOW A CHANGE MADE AN IMPROVEMENT ?
• WHAT SPECIFIC, CONCRETE CHANGES CAN WE MAKE TO
  THE PROCESS ?

Plan

• IMPLEMENT
• AND TEST THE
• INTERVENTION

Act
Do
Study
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Testing improvement interventions and learning
what works and how
Changes That Result in Improvement in Practice
DATA and Learning
Implementation of adapted guideline
Wide-scale tests of adaptations
Clinical Research or Guidelines
Adaptation and follow-up Tests
Very small scale test
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Interventions implemented by CQI teams

• System
• Clinical guidelines (standards) for management of
  obstetric complications were developed
• Monthly rounds of auditing clinical records by
  the CQI teams were out in place, as well as
  monthly reports on compliance with standards.
• Regular coaching visits by a clinical expert to
  CQI teams
• Ministry of Health support to the process
• Maternal deaths audits with participation of
  hospital staff and MOH authorities

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Interventions implemented by CQI teams

• All complications
• Red code procedures
• Time limit standard for a physician seeing a
  patient
• Preeclampsia
• Assessment of proteinuria with dipsticks at the
  E.R.
• Mandatory use of Magnesium Sulphate
• Ensuring C-section availability on
  weekends/holidays
• Hemorrhage
• Active management of third stage of labor, AMTSL
• Hypovolemic shock prevention/management training
• Blood availability through Free Maternity
  program subsidies

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Lessons Learned

• The Collaborative Improvement approach is
  effective to improve hospital care for obstetric
  complications in a developing country
• It is more difficult to improve complications
  care than basic obstetric care
• Complications care could be improved without
  major additions of personnel and/or equipment
• Improving complications care can reduce
  in-hospital maternal mortality in a relatively
  short time