A major barrier to the improvement of quality of care in Russia is the size of the country and the limited opportunities within the health care and educational systems for sharing of experience and innovation. To overcome this barrier, the Health Care Improvement Project (HCI) seeks effective ways to disseminate information and share experience among collaborating regions and health care facilities. HCI/Russia’s “Improving Care for Mothers and Babies” project has built on traditional methods to share improvement experience and innovation, such learning sessions and distribution of documents, by developing an internet portal, www.healthquality.ru, through which participating quality improvement teams can document and share their implementation of changes and the results of that implementation. This strategy presents a challenge in a country where surveys indicate that less than a third of the population says they use the internet, and health facilities have few computers. The project assisted facilities in accessing and using the portal, which if successful should lead to rapid uptake of effective changes by other participating QI teams. Sharing this learning should not be limited just within the region or implementing partner where the change originated, but should spread to other regions supported by other partners as well: the ability to build on learning both within regions and partners, and across regions and partners is important for efficient and effective achievement of better care and outcomes in maternal, child and reproductive health.

This study, which measures the level of sustainability of improvements in maternal child care and the Institutionalization of Continuous Quality Improvement (CQI), is being undertaken at the end of a 10 year period (2000 – 2010) of technical assistance on CQI for maternal child care (MCH) to Ministry of Health (MINSA) facilities in Nicaragua. USAID – Nicaragua, in coordination with MINSA, will use the results of the study to prioritize their continued support for CQI within specific health facilities in Nicaragua.

Based on the results of this sustainability/institutionalization study, one can see that the 30 health units from 10 SILAIS included in the sample in this study have qualities and factors that have put each of these health facilities in different pathways all with the same end goal of sustainability of best practices and institutionalization of CQI leading to improved health outcomes. The largest impact that the QAP/USAID - USAID/HCI intervention has had can be seen in the progress achieved in two aspects: the sustainability of clinical best practices and the institutionalization of the development of clinical skills and abilities and CQI. The variability seen in the different health units can help identify certain challenges and optimizing conditions, already in place or in the process of being developed, that can be used and replicated to achieve sustainability and institutionalization of CQI at the national level.

USAID has supported the introduction and implementation of Continuous Quality Improvement (CQI) activities in Nicaragua since the year 2000, first through the Quality Improvement Project (QAP) and most recently through the Health Care Improvement (HCI) Project. These quality improvement activities focused primarily on Ministry of Health (MINSA) facilities. However, private health care facilities were invited to participate. The Medical Association of the West (La Asociacion Medica de Occidente, S.A.) (AMOCSA) was one of these private health care facilities and has participated in CQI activities since 2004. AMOCSA, through this collaboration with QAP/HCI/USAID, participated in a series of improvement activities in order to improve the quality of services offered to clients with a specific focus on maternal and infant health, family planning, and prevention of infections. Assistance was provided for: standardization of the care process, monitoring the compliance with care standards using relevant indicators, guaranteeing the right to proper care for newborns including breast feeding, strengthening the team approach, and measuring the satisfaction of patients in the facilities. In 2007, through technical assistance from HCI/USAID, a Quality Management Program was developed for AMOCSA in order to ensure sustainability of continued quality improvement activities into the future.

This study is a qualitative cross sectional study where a sample of heath care professionals working in AMOCSA facilities in Chinandega are surveyed on their exposure to different aspects of continuous quality improvement (CQI). Most of the survey questions refer to CQI activities that are currently being implemented in AMOCSA, while some survey questions refer to activities that may have happened over a longer period of time. Responses from the study participants are used to measure the level of institutionalization achieved in AMOCSA facilities. A convenience sample of 27 study participants was selected. Each of the participants answered a self-administered questionnaire that included questions on the development process for CQI, the enabling environment for CQI, evidence of institutionalization of CQI and other external factors.

The USAID Health Care Improvement has demonstrated the efficiency of the dissemination of improved care practices to new regions within a country or health care system. However, while the spread within a country has been studied, there is little or no research on transferring quality improvement processes and improved health practices from one country to another. This study aims to analyze how a list of changes was transferred from the Niger in Mali, the methods used to reproduce the improved care and costs associated with its implementation.

An evaluation of the USAID Healthcare Improvement (HCI) Project summarizing the results of collaborative improvement in 12 countries by over 1300 teams during 1998-2008 has shown that teams were able to achieve large increases in compliance with health care standards and in some cases, in health outcomes, across all care areas addressed, regardless of the baseline level of quality (Franco 2009). Several other reports also demonstrate the cost-effectiveness of collaborative quality improvement in achieving high compliance to standards of care and in improving outcomes. However, due to operational restrictions, most assessments of quality improvement collaboratives (QICs) have been uncontrolled pretest–post-test designs that cannot rule out other plausible causes for observed improvements, such as secular trends (Mittman 2004).

1. 1. Do pregnant and delivering women in QIC intervention facilities receive better care (screening/diagnostic and treatment of pre-eclampsia/eclampsia) than those in BCT-only facilities?
2. 2. Do pregnant and delivering women in QIC intervention facilities have better clinical outcomes, in terms of eclampsia incidence than those in BCT-only facilities?
3. 3. What is the incremental cost-effectiveness of the QIC intervention compared to the BCT-only intervention in terms of process and outcome indicators for mothers?
4. 4. Does adherence to eclampsia/pre-eclampsia norms become higher in BCT-only sites when clinicians are trained on the QIC methodology?
5. 5. Does adherence to eclampsia/pre-eclampsia norms in the QIC intervention facilities change in the six months following the active intervention period?

Continuous quality improvement (CQI) efforts in health care often rely on quality improvement (QI) teams performing self-assessments of compliance with standards of care. This is often the most efficient method of data collection for performance indicators and is therefore frequently used in resource-constrained settings (L Franco 2009). Some have found health provider self-assessment to be effective in improving performance in circumstances where higher level supervision is unavailable (E Kelly 2003). Information from such assessment is crucial to design the CQI intervention, identify performance gaps that require attention and allow the QI team to monitor its progress in improving the process of health care delivery (Vos 2010). It is therefore essential that these data be a valid representation of performance.

1. 1. To what extent are the data reported on patient charts and the register representative of what happened during childbirth?
2. 2. What factors are associated with the validity of the self-assessment data collected from participating maternity hospitals? Factors to be tested include the cadre of the health worker, their level of experience, the type of facility and the time of day of the delivery.
3. 3. What is the level of compliance to standards of clinical practice seen in the deliveries observed?

The collaborative model of quality improvement aims at testing and implementing Quality Improvement (QI) interventions on a small scale, synthesizing the most robust and effective changes, and spreading them at scale. Collaborative improvement not only generates improvements in the quality of care delivered in these initial sites, but also develops organizational learning. However, there still exist knowledge gaps on how to successfully spread evidence practices and ensure up-take and continuous application of these practices in resource-limited settings.

The study examines the process of spread of improvements from the demonstration phase of the MNCH Facilities Collaborative in Balkh and Kunduz to three new provinces: Parwan, Herat, and Bamiyan.  In the demonstration phase, different change ideas are tested and an intervention package composing of these change ideas and interventions that yield high outcomes will be prepared and used for scale up to the three new provinces. The aim of the spread study is to evaluate the uptake and implementation of a package of changes—which originated in the demonstration phase—in Bamyan, Parwan and Herat.

• How sites in new provinces react to and take up improvements coming from the demonstration phase
• How the applicability and effectiveness of QI methodology in improving quality of health care differs in new settings

• Which ‘change ideas’ were adopted, modified or rejected by health facilities in the three new provinces
• How were the ‘change ideas’ communicated to the sites, and what were the reasons behind the uptake of each ‘change idea’?
• Were there specific reasons that facilitated or hindered the uptake of change ideas? What were they and what are QI participants perspectives on them?
• What were the most successful means of spreading of quality improvement changes?

This web portal was developed by the Federal Research Institute for Health Care Organization and Information of the Ministry of Health and Social Development of the Russian Federation, in partnership with the USAID Health Care Improvement Project.  It includes a library of over 400 Russian language documents and links on application of improvement methods to maternal and child health and other clinical topics. The site also features a distance learning course on improvement methods and reports on applications of quality improvement methodology in the Russian Federation.