Health Reform in Kyrgyzstan

1
Journey to Quality Improvement Ferghana QI
projects Husanbayev Sh. U. Deputy Chief of
the Oblast Health Department Ferghana, Uzbekistan
2
Outline

• Strategy and Structure of a QI project
• Improvement Objectives
• Standards and indicators - monitoring system
• Changes and interventions
• Results
• Successes and challenges
• Next steps

3
Basic improvement concept

• No improvement in quality of care will happen
  without changes
• In the content of care
• In the healthcare system
• Targets of intervention/change
• Healthcare Providers (introduce standard
  treatment guidelines based on EBM)
• Patients Population (empower patients through
  information, provide choice of services, increase
  self responsibility for health)
• Health System (decentralized decision making,
  organization of healthcare system, financing)

4
Steps of an Improvement Logic

• Identify the improvement goal and objectives
• Know/describe the system to improve
• Identify the QI team members
• Express improvement opportunities/objectives
• Monitor system performance
• Develop a set of interventions/changes
• Identify root causes of poor performance
• Identify interventions that address root causes
• (Re)Design components of the system of care
• Implement interventions/changes and study their
  impact
• Implement the Plan-Do-Study-Act learning cycle
• Measure impact of changes

5
Improvement objectives

• We wanted to improve the quality of care at
  primary health care level in three pilot rayons
  for
• Adults over 18, with arterial hypertension
• Children 1 week to 5 years with diseases
  addressed by the Integrated Management of
  Childhood Illnesses (IMCI) guidelines
• Women of reproductive age (15-49) with
  iron-deficiency anemia

6
Structure of the teams
7
Examples of standards of care
8
Standards and Indicators of Quality
Care Process
Standard

• New patients diagnosed with hypertension have
  baseline assessment of their health status
• EKG, Proteinuria, Blood glucose, Eye exam (fundus
  oculus)

• Screening
• Diagnosis
• Referral
• Treatment
• Counseling
• Follow-up

Indicator
Out of all new patients diagnosed with
hypertension how many underwent full (all four
tests) assessment of their health status
9
Quality Monitoring System

• Standards defined
• What providers do (process)
• How patients benefit (outcomes)
• Indicators of achievements of standards
  developed
• 5 for anemia
• 7 for hypertension
• 11 for IMCI
• Data collection system organized
• Data collection forms
• Computerized and institutionalized
• Quality assurance

10
How QIPs work

• QI teams collect data monthly, display on run
  charts and discuss at the weekly meetings
• QM team hold meeting monthly on QI
• Teams interpret run charts, identify barriers and
  implement interventions
• A quarterly bulletin Journey to Quality is
  produced to help measure progress and address
  challenges

11
Interventions/Changes

• Change Calibration of Sali hemometers
• Result Incidence of Anemia decreased
• Change a reception nurse appointed to measure BP
  of all patients gt18 coming to the SVP. She
  registers the results in a tonometry journal and
  informs the physician if the BP exceeds 140/90
• Result early detection of Hypertension

12
Incidence of Anemia (Kuva rayon)
13
Screening System for Hypertension (3 pilot SVPs)
14
Issues/causes

• Issue Low rate of complete testing for newly
  diagnosed patients with Hypertension
• Cause Three tests can be conducted at SVP and
  the fourth one can be conducted in CRH only
• Issue Low effectiveness of treatment for Anemia
• Cause Iron sulfate side effects (nausea, blood
  taste), affordability of treatment, patients non
  compliance

15
Four tests for Hypertension (Tashlak rayon)
16
Effectiveness of treatment for Anemia (Kuva
rayon)
17
The benefits of QI

• Providers self assess their performance against
  the standards
• Providers performance improved over time
• Providers acquired skills to analyze data and
  plan changes. Data was not used to blame
• Some changes were implemented to improve quality
• New modern management style of working

18
Challenges

• Teams have focused on monitoring and not so much
  on changes
• Performance varies across teams
• Strengthening collaboration with the national
  level is needed
• Decentralized decision making remains limited
• Patients are not enough involved in the QI effort

19
Next Steps

• Address the QI issues at all levels follow the
  patient
• The best practices need to be replicated
• Link national level with the field through local
  QI experts
• Introduce high level system changes (access to
  drugs benefit package for drugs)