Metodologia Puentes hacia la Calidad de Atencion

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(No Transcript)
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Building Bridges for QualityA Community
Mobilization Approach to Improve Quality Health
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Why Puentes was born?

• Intercultural interpersonal relationship
  between clients and providers is a major barrier
  to services utilization
• Differences on understanding illness and health,
  and cultural, educational and socio-economic gaps
  between clients and providers lead to poor
  interaction and communication

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Usual Remedies

• Traditionally efforts to improve quality focus
  on strengthening providers clinical skills and
  management systems
• Less focus on intercultural and interpersonal
  communication
• Minimal participation of community in defining
  and improving quality of care
  
  

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Barriers to Quality and Utilization of Services

• INTANGIBLE FACTORS
• Paternalistic attitude
• Abuse of power
• Discrimination
• Feeling of being cheated
• Rupture of confidentiality
• Lack of empathy
• Limited opportunities for interaction

• TANGIBLE FACTORS
• Cost
• Lack of supplies, medicines, equipment
• Scarcity of human resources
• Physical space

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Where is Puentes located?

• PERU, Puno Health Region
• Huancané Hospital
• Community Azangarillo
• Moho Health Center
• Community Casani
• Colque Health Post
• Community Colque
• Camicachi Health Center
• Community Vilcachili

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Project Goal

• Increase communities sense of ownership for
  public health services in order to improve
  quality services, and community and family health
  standards

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Objectives

• Establish a joint venture between communities and
  health services to bring client and community
  perspectives into a QUALITY Improvement Program
• Increase utilization of public health services
• Improve interaction and communication between
  clients and health service providers

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Community Action Cycle to Improve Quality
I GETTING ORGANIZED Learning to work
together, establishing relationship inviting
to participate
V PARTICIPATORY EVALUATION
Assessing results collective efficacy to
improve QUALITY
II PROMOTING COMMUNITY DIALOGUE
Exploring QUALITY perceptions by conducting
self collective diagnosis through
participatory videos
IV TAKING COLLECTIVE ACTION
MANAGING IMPLEMENTATION Community action
mobilizing resources
III BUILDING CONSENSUS PLANNING TOGETHER
Defining QUALITY and planning together to
improve it
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I. Getting Organized Learning to work together,
establishing relationships and inviting to
participate

• Create trust,
• credibility and build
• a sense of
• ownership

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II. Promoting Community Dialogue Exploring
quality perceptions by conducting self and
collective diagnosis

• Participatory Video for Self
• Collective Diagnosis
• Analyze how services are and how they should be
  from the community and health providers
  perspective
• Used interviews, group discussions, frank
  testimonials socio-dramas !!
• Video skits performed by each group depict an
  ideal CPI and an actual encounter

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III. Building Consensus and Planning
TogetherDefining quality and taking action to
improve it

• Getting to understand each other a visit
  to
• the health center and to the community

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III. Building Consensus and Planning
TogetherDefining quality and taking action to
improve it

• Defining Quality together
• Planning together to improve services and
  community health
• Presenting Plans to the rest of the community

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IV. Taking Collective Action Managing
Implementation Community action and mobilizing
resources

• Reach consensus formal agreement
• on the draft Action Plan
• Implement Action Plan
• Assure participation from community
• Solve conflicts/problems to move on
• Monitor project progress
• Resource mobilization to assure
• success in Action Plan objectives

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V. Participatory Evaluation Assessing results
collective efficacy to improve QUALITY

• Participatory evaluation creates the opportunity
  to assess the implementation of the Joint Action
  Plan what has been done and identify next steps
  to continue implementation
• Evaluation team community members and health
  providers

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Levels of Evaluation to Measure Quality
Improvement and Individual and Social Change

• 1. Monitoring of Joint Action Plans
• Implementation Results
• 2. Community Provider Assessment
• Joint Group Discussions
• 3. Service Utilization
• Monthly Clinic Data
• 4. Client -Provider Interaction
• Roter Interaction Analysis System (RIAS) video
  taped CPI
• Semantic Differential scale
• 5. Social Change
• Group discussion w/community women, men leaders
  
• In depth interviews with providers Puentes team

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Levels of Evaluation 1. MONITORING OF JOINT
ACTION PLANS (1)

• Planned Accomplished
• Replacement of Midwife Nursing technician is
  hired
• Access to MD specialist OBGYN/Pediatrician
  visit community
• Available affordable drugs Increased stock of
  drugs
• Purchase of medical equipment, Post are equipped
  adequately
• supplies and materials
• Rapid attention Waiting time is reduced
• Access to 24 hours service 24 hrs emergency
  service is established
• Access to transportation
  Motorcycle for home visits emergencies

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Levels of Evaluation 1. MONITORING OF JOINT
ACTION PLANS (2)

• Planned Accomplished
• Respectful/caring CPI CIRI Training/Positive
  CPI
• Indigenous language during Aymara speaking
  staff is interaction be utilized relocated as
  host
• Maternal/Child emergency fund Emergency fund is
  created at the community level
• Health Post remodeled Electricity provided,
  remodeling ongoing with community
  (labor) and providers participation
  (bricks, cement, paint)

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Levels of Evaluation 1. MONITORING OF JOINT
ACTION PLANS (3)

• Planned Accomplished
• Selection of health promoter Comm.
  selects promoter
• Increase authorities community City
  Halls organized commitment to quality
  improvement municipal leaders, health and
  health care authorities community
  renew commitment
• Access to health information Dialogo de
  Saberes sessions Community radio
  Dont keep your doubts just ask!!
• Print materials

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DIÁLOGO DE SABERES An Initiative to Promote
Intercultural Communication and Healthy
Behaviors
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Level of Evaluation 2. COMMUNITY PROVIDER
ASSESSMENT (1)

• Perceived Changes as Result of Puentes
• Community-Providers Relationship
• Better interaction
• Closer communication
• Relationship of trust
• Joint problem solving
• Changes among Health Providers
• Attention to the community perspective on quality
  of service
• Respect for health-related traditional practices
• Providers respond to community complaints

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Level of Evaluation 2. COMMUNITY PROVIDER
ASSESSMENT (2)

• Changes at the Health Service level
• Better organization of services
• Wider range of services is provided
• Reduced waiting time
• Increased number of clients
• Changes at the Community level
• Higher value and interest about health
• Community seeks health information/education
• Community knows more about services offered by
  the Post
• Timely health care seeking behavior
• Women participate and speak more with no fear

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Level of Evaluation 3. SERVICE UTILIZATION (1)

• Puno Health Region has benefited from multiple
  national and donor collaboration
• MOH/PAG
• PERU 2000
• CARE
• ReproSalud
• Substantial improvement in health indicators in
  the last 5 years
• Acceptable quality of clinic data in Melgar
  Health Red
• Selection of comparison Health Post (Quishuara)
  within same Red
• Intervention Health Post Colque

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Level of Evaluation 3. SERVICE UTILIZATION (2)

• Colque Quechua speaking community
• Selected characteristics of Puno
• 67.2 is rural area
• 22 of women have no education
• 35.8 of women have some primary
• 61.4 using any method (DHS CPR 2000)
• 24.2 using a modern method
• 17.6 ARI and 17.5 diarrhea prevalence (2000)

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Level of Evaluation 3. SERVICE UTILIZATION (3)

• Colque community has access to a health post, a
  health center and a hospital
• Colque Health Post serves 5 communities
• total estimated population of 803 in 2001
• Colque community represents about 60 of this
  total (around 500)
• about 119 (15) are children under 5
• about 199 (25) are women 15-49
• estimated number of births 22

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Total number of ARIs in Intervention and
Comparison Posts by Month
Puentes Meetings
Dialogo de Saberes
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Total number of ARIs and Predicted Time-Series
Line in Comparison Post
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Total number of ARIs and Predicted Time-Series
Line in Intervention Post
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Difference of ARIs between Intervention and
Comparison Post and Predicted Line
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Number of Pneumonia Cases Reported by Post
Puentes Meetings
Dialogo de Saberes
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Puentes Meetings
Dialogo de Saberes
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New Acceptors of Modern FP Methods as reported by
Post
Technician Enters
Midwife Removed
Puentes Meetings
Dialogo de Saberes
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Number of Modern FP Continuing Users as Reported
by Post
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Level of Evaluation 4. Client -Provider
Interaction (1)

• RIAS Video Taped CPI
• Assess specific CPI behaviors, consultation
  setting and materials utilization as result of
  CIRI training, Providers Self and Group
  Assessment.
• Semantic Differential Scale
• Assess the Overall Affective Behavioral
  Dynamics of the consultation in three dimensions
  (1) Providers Facilitative Skills (2)
  Rapport/Emotional Tone and (3) Technical Skills
• Two time measurements
• 1st Measurement 74 videotaped interactions
  (ongoing analysis)
• 2nd Measurement 160 videotaped interactions
  (data collection ongoing)

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Level of Evaluation 4. Client -Provider
Interaction (2)
Semantic Differential Scale 1st Measurement
(April 02)
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Level of Evaluation 5. Social Change (1)

• Objectives
• 1. Analyze from the point of view of providers
  and communities what has Puentes meant to them
  and how has Puentes changed their own perception
  and acting as community.
• 2. Assess community and providers perception of
  individual and collective self-efficacy as a
  result of Puentes.
• 3. Assess community understanding of rights and
  responsibilities as they relate to quality of
  care, and individual and family preventive
  health behavior.

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Level of Evaluation 5. Social Change (2)

• Dimensions under study
• 1. Leadership
• Perceived changes in new and renewed leadership
  among community members to bring out the voice of
  the community.
• 2. Level and Equity of participation
• Perceived changes in access to and levels of
  participation of community members particularly
  of women and providers in different fora.

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Level of Evaluation 5. Social Change (3)

• 3. Sense of Individual and collective self
  efficacy
• Perceived efficacy by clients to ask questions
  and raise concerns during interactions with
  providers.
• Perceived efficacy to raise individual and
  community concerns in meetings that gather
  providers and clients.
• Perceived efficacy to take action as a group to
  improve the quality of services and other
  development issues.
• 4. Social Cohesion
• Perceived sense of identification with community
  initiatives and efforts