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Assessment of Three Selected ZFF-PLGP-engaged Public Hospitals in Providing Quality Maternal Care Services
Team Members:
Christine T. Arcala, MD – Principal Investigator
Reynaldo O. Joson, MD – Co-investigator
Ma. Gay M. Gonzales, MD – Co-investigator
Introduction and Rationale
Introduction and Rationale
The Philippines’ commitment to the attainment of the 2015 Millennium Development Goals has paved a way to intensify efforts to decrease the maternal mortality in the country. Despite this, from the Maternal Mortality Ratio (MMR) of 152 in 1990, the pattern was unstable with periods of decreases and some increases, ending with an estimate MMR of 114 as of May 2015 (1).
The Zuellig Family Foundation, in partnership with the Department of Health, launched the Health Leadership and Governance Program (HLGP) in 2013 to help address the issue of maternal mortality. On the same year, it was noted that 1126 deaths were reported in HLGP regions (all regions except Region 2 and National Capital Region). Of the 1126 maternal deaths, 581 (52%) have unidentified place of death; 369 (33%) died in the hospitals; 15 (1%) died in transit; and 96 (9%) died at home (2).
From this data, it is clear that a closer look at the hospitals must be done to ensure that they are able to absorb and adequately manage the increasing number of deliveries brought about by continuing efforts to push for facility-based deliveries. The Provincial Leadership and Governance Program (PLGP), under the HLGP, was then tasked to look at public hospitals and capacitate them for this purpose.
As part of the efforts of PLGP to understand the current state of public hospitals in the provinces, a hospital scorecard (see Appendix 1) was used for evaluation. Though the use of hospital scorecard is very helpful in evaluating that the hospital has the capability to operate as a reliable Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facility (e.g. presence of blood, obstetricians, medicines), it is limited when it comes to help understand the flow of the hospital’s operations and the quality of maternal care being implemented in the hospitals. Indeed, some of the hospitals with highest mortalities such as Bicol Regional Training and Teaching Hospital fared well in the assessment using hospital scorecards (see Appendix 2). This seeming inconsistency is often blamed in congestion. Although this theory is supported by numerous studies that show direct relationship in hospital congestion and increase in mortality and adverse events (3,4), the specifics on how congestion affects hospital processes that impacts on overall quality of care in these engaged hospitals have not been looked into. This area of study poses a great potential as it can give an insight not just on the impact of congestion but also on what to do to address these consequences while waiting for a more permanent solution to the problem of congestion itself.
Thus, ZFF felt the need to understand the hospital’s processes on maternal care services that will lead to quality care and that may have an impact of maternal death control or reduction.
Statement of the Problem
There is a need to understand the hospital’s processes on maternal care services that will lead to quality care and that may have an impact of maternal death control or reduction.
Significance
Knowing which hospital processes and quality indicators in the maternal care services that will contribute to the reduction of number of maternal deaths in the hospital will facilitate accomplishment of the goals of ZFF-PLGP program in maternal mortality in engaged public hospitals.
Review of Literature – Theoretical and Conceptual Framework
After exhaustive literature search, the authors are unable to find a universally accepted, or at least a popular, blueprint of comprehensive quality standards and indicators that can be used for assessing the maternal care services of hospitals, especially one that have an impact on maternal death control or reduction in a hospital setting. There are published reports on quality standards and indicators on maternal care services or safe motherhood (see list below) but they are either not evaluated for validity and reliability or they are not comprehensive (or integrated) enough in the sense of lack of coverage of all risk factors for maternal deaths.
The clinical and cost-effectiveness of interventions reflected through the blueprint of quality standards and indicators in the hospital would ideally be determined through randomized, controlled trials (RCTs), since they provide the most reliable evidence. However, RCTs have not been used (5) because of the cost and complexity of trials because denial of services to a control group when they are widely believed to be beneficial may be considered unethical. Also, research studies on this topic is complex owing to their multiple components and the involvement of many variables (6). Given the current lack of RCTs to evaluate the effectiveness of interventions and blueprints of quality standards and indicators, the authors decided to just examine less rigorous research studies.
The published reports on quality standards and indicators on maternal care services or safe motherhood that the authors selected for study for the formulation of conceptual and theoretical framework are the following:
- A framework for the evaluation of quality of care in maternity services http://eprints.soton.ac.uk/40965/1/12757_Matthews.pdf
- A framework for the evaluation of quality of care in maternity services http://eprints.soton.ac.uk/40965/1/12757_Matthews.pdf
- Consultation on improving measurement of the quality of maternal, newborn and child care in health facilities (WHO – 2013)
http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf
- Safe Motherhood Indicators
http://www.cpc.unc.edu/measure/prh/rh_indicators/indicator-summary
- WHO Safe Childbirth Checklist
http://apps.who.int/iris/bitstream/10665/199179/1/WHO_HIS_SDS_2015.26_eng.pdf?ua=1
- Quality Standards in Kerala, India
http://f1000research.com/articles/5-166/v1
Vlad I, Paily V, Sadanandan R et al. Improving quality for maternal care - a case study from Kerala, India. F1000Research 2016, 5:166
- The 3 delays model in maternal care
http://www.maternityworldwide.org/what-we-do/three-delays-model/
- Floyd L. Helping midwives in Ghana to reduce maternal mortality. African Journal of Midwifery and Women’s Health. 2013 Jan-Mar; 7(1).
http://www.kybeleworldwide.org/uploads/6/8/4/7/6847709/liz_ajm_paper.pdf
- Quality Improvement for Emergency Obstetric Care : EngenderHealth
- Quality Improvement for Emergency Obstetric Care : EngenderHealth
https://www.engenderhealth.org/files/pubs/maternal-health/qi-for-emoc-manual.pdf
https://www.engenderhealth.org/files/pubs/maternal-health/qi-for-emoc-manual.pdf
- WHO Quality Improvement Model for Maternal, Newborn and Child Health-2013 http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf
- Quality Health Care as defined by Institute of Medicine
http://healthmatters4.blogspot.com/2011/06/iom-six-aims-of-quality-health-care.html
- ISO 9001:2015 Quality Management System Model
- Baldrige Healthcare Criteria for Performance Excellence Framework
A framework for the evaluation of quality of care in maternity services http://eprints.soton.ac.uk/40965/1/12757_Matthews.pdf
A framework for the evaluation of quality of care in maternity services http://eprints.soton.ac.uk/40965/1/12757_Matthews.pdf
Formulated in Egypt in 1998, the framework has 2 parts and 10 elements of care with their corresponding criteria and standards. The 2 parts consist of the quality of provision of care within the institution and the quality of the care as experienced by users. There are 6 elements under quality of provision of care within the institution: human and physical resources; referral system; maternity information systems; use of appropriate technologies; internationally recognized good practice; management of emergencies. There are 4 elements under the quality of care as experienced by users: human and physical resources; cognition; respect, dignity and equity; and emotional support.
Consultation on improving measurement of the quality of maternal, newborn and child care in health facilities (WHO – 2013)
http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf
The consultation meeting was organized in 2013 by the WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA) and the Partnership for Maternal, Newborn and Child Health (PMNCH) in collaboration with the WHO departments of Reproductive Health and Research (RHR), Health Statistics and Information Systems (HSI) and Patient Safety and Quality Improvement (PSQ).
The aim of the meeting was to achieve consensus on core indicators for global measurement and reporting on the quality of care provided for mothers, newborns and children in health facilities that could be used during the final years of work on meeting the Millennium Development Goals.
The five objectives of the global consultation were: to review assessment tools, methods and processes for measuring the quality of care in health facilities; to share global and regional experience in improving the quality of care for mothers, newborns and children in health facilities; to review and agree on a core and a supplementary set of indicators for global monitoring and reporting on the quality of care for mothers, newborns and children in health facilities; to agree on a framework for reporting on the quality of care for maternal, newborn and child health; and to discuss opportunities and future collaboration in improving the quality of maternal, newborn and child care.
The meeting was attended by 70 participants, who included regional and country experts and representatives of professional organizations and nongovernmental organizations working on quality of care and of bilateral and multilateral agencies.
The participants agreed on a set of 13 global core indicators for measuring and reporting the quality of maternal care and on the tools, methods and processes required.
These are:
- Percentage of health facilities equipped with the medications and supplies necessary to provide evidence-based essential maternal health care Markers: Iron supplementation and syphilis screening
- Percentage of health facilities equipped with the medications and supplies necessary to provide evidence-based emergency obstetric care Markers: Oxytocin, magnesium sulfate
- Percentage of women: A. receiving oxytocin to prevent postpartum haemorrhage B. who underwent caesarean section for obstructed laboura or prolonged labour in the facility
- Intrapartum or fresh stillbirth rate
- Percentage of facilities that conduct maternal death audits or reviews at district level
- Density of midwives (no. of midwives actually deployed per 1000 births per district) Alternative: Midwife:birth ratio
Safe Motherhood Indicators
http://www.cpc.unc.edu/measure/prh/rh_indicators/indicator-summary
- Existence of a safe motherhood strategic or operational plan to promote access and/or quality of safe motherhood services
- Minimum package of antenatal care services defined
- Maternal neonatal program index (MNPI)
- Number of facilities per 500,00 providing basic and comprehensive emergency obstetric care
- Geographic distribution of EmOC facilities
- Percent of health facilities with skilled attendant (doctor, nurse or midwife) available 24 hours a day, 7 days a week
- Percent of communities that have an emergency transport plan in place
- Percent of audience that know three primary warning/danger signs of obstetric complications
- Percent of skilled health personnel knowledgeable in obstetric warning signs
- Percent of women attended, at least once during their pregnancy, by skilled health personnel for reasons relating to the pregnancy
- Percent women attended at least four times for antenatal care during pregnancy
- Percent of pregnant women whose blood pressure was checked at first ANC visit
- Percent of pregnant women who had weight checked at first ANC visit
- Percent of pregnant women attending antenatal clinics screened for syphilis
- Percent of women who received at least two doses of tetanus-toxoid vaccine in their last pregnancy
- Percent of pregnant women who receive anthelminthic treatment during pregnancy
- Percent of deliveries attended by skilled health personnel
- Percent of births in health facilities
- Percent of all births in EmOC facilities
WHO Safe Childbirth Checklist
http://apps.who.int/iris/bitstream/10665/199179/1/WHO_HIS_SDS_2015.26_eng.pdf?ua=1
The WHO Safe Childbirth Checklist has been developed to support the delivery of essential maternal and perinatal care practices. The Checklist addresses the major causes of maternal death (haemorrhage, infection, obstructed labour and hypertensive disorders), intrapartum-related stillbirths (inadequate intrapartum care), and neonatal deaths (birth asphyxia, infection and complications related to prematurity). It was developed following a rigorous methodology and tested for usability in ten countries across Africa and Asia.
There is a checklist of items under 4 headings: On admission; Just before pushing (or cesarean section); Soon after birth (within one hour); and Before discharge.
Quality Standards in Kerala, India
http://f1000research.com/articles/5-166/v1
Vlad I, Paily V, Sadanandan R et al. Improving quality for maternal care - a case study from Kerala, India. F1000Research 2016, 5:166
The Government of Kerala, India with the assistance from NICE International formulated 10 quality standards on 10 identified prioritized areas to reduce the maternal death rate. The 10 topics include the following:
1. Active Management of Third Stage of Labour 2. PPH Prevention – 4th Stage Management 3. Management of Post-Partum Haemorrhage with Blood and Blood Products 4. Obstetric Intensive Care 5. Placenta Praevia Accreta 6. Pre eclampsia 7. Anti-hypertensive Treatment 8. Severe Hypertension in pregnancy and in Immediate Postpartum Period 9. HELLP 10. Eclampsia
The 3 delays model in maternal care
http://www.maternityworldwide.org/what-we-do/three-delays-model/
Maternity Worldwide uses an integrated approach to address each of the issues women face when trying to access safe childbirth. This is based on the Three Delays Model* which identifies three groups of factors which may stop women and girls accessing the maternal health care they need:
1: Delay in decision to seek care due to;
The low status of women
Poor understanding of complications and risk factors in pregnancy and when to seek medical help
Previous poor experience of health care
Acceptance of maternal death
Financial implications
2: Delay in reaching care due to;
Distance to health centres and hospitals
Availability of and cost of transportation
Poor roads and infrastructure
Geography e.g. mountainous terrain, rivers
3: Delay in receiving adequate health care due to;
Poor facilities and lack of medical supplies
Inadequately trained and poorly motivated medical staff
Inadequate referral systems
Floyd L. Helping midwives in Ghana to reduce maternal mortality. African Journal of Midwifery and Women’s Health. 2013 Jan-Mar; 7(1).
http://www.kybeleworldwide.org/uploads/6/8/4/7/6847709/liz_ajm_paper.pdf
The Kybelle Model of health service system in reducing maternal and neonatal deaths.
The Kybelle Model of health service system in reducing maternal and neonatal deaths.
Quality Improvement for Emergency Obstetric Care : EngenderHealth
Quality Improvement for Emergency Obstetric Care : EngenderHealth
https://www.engenderhealth.org/files/pubs/maternal-health/qi-for-emoc-manual.pdf
https://www.engenderhealth.org/files/pubs/maternal-health/qi-for-emoc-manual.pdf
Quality improvement for Emergency Obstetric Care: it involves a state of readiness that will enable you and the team to respond appropriately to obstetric emergencies in a way that fulfills the needs and rights of your clients.
Readiness: Achieving and maintaining a state of preparedness in the facility to provide quality EmOC. This includes staff available with requisite skills and a willingness to respond to clients 24 hours a day, 7 days a week, available and functional equipment and supplies, and adequate infrastructure.
Response: Providing prompt, appropriate care when emergencies arise, according to acceptable clinical standards and protocols.
Rights: Providing services in a manner corresponding to the rights and needs of all clients.
WHO Quality Improvement Model for Maternal, Newborn and Child Health -2013
The model consists of eight interrelated domains: the six domains of the WHO framework (information, patient and population engagement, leadership, organizational capacity, regulations and standards and models of care) and two other domains (communication and satisfaction).
Quality Health Care as defined by Institute of Medicine
http://healthmatters4.blogspot.com/2011/06/iom-six-aims-of-quality-health-care.html
- Safe: Care should be as safe for patients in health care facilities as in their homes;
- Effective: The science and evidence behind health care should be applied and serve as the standard in the delivery of care;
- Efficient: Care and service should be cost effective, and waste should be removed from the system;
- Timely: Patients should experience no waits or delays in receiving care and service;
- Patient centered: The system of care should revolve around the patient, respect patient preferences, and put the patient in control;
- Equitable: Unequal treatment should be a fact of the past; disparities in care should be eradicated.
Recognizing that aims must be accompanied by observable metrics, the IOM defined sets of measurements for each aim. For example:
- Safe: Overall mortality rates or the percentage of patients receiving safe care;
- Effective: How well evidenced-based practices are followed, such as the percentage of time diabetic patients receive all recommended care at each visit;
- Efficient: Analysis of the costs of care by patient, provider, organization, and community;
- Timely: Waits and delays in receiving care, service, or results;
- Patient centered: Patient and family satisfaction;
- Equitable: Differences in quality measures by race, gender, income, and other population-based demographic and socioeconomic factors.
ISO 9001:2015 Quality Management System Model
Baldrige Health Care Criteria for Performance Excellence Framework
Theoretical Framework
Quality maternal care services in a hospital should have an ultimate impact on the maternal death reduction or control.
Quality maternal care services in a hospital include both quality of provision of services in the hospital and quality of care as perceived by the clients (patient, family and community).
Quality is “the degree of excellence; the extent to which an organization meets clients needs and exceeds their expectations”. Key attributes of high quality healthcare systems, as defined by the Institute of Medicine (U.S.) include safety, timeliness, effectiveness, efficiency, equity and patient centeredness.
Quality maternal care services in a hospital are influenced by a multiplicity of factors and multiple elements of care. Thus, there will be corresponding multiplicity of standards and indicators. There will be general and specific standards and indicators in the various elements of care. There will be standards and indicators for the structures and inputs; processes; and outputs of the maternal care system.
Quality maternal care services in a hospital should utilize a system perspective in designing, implementing and evaluating the program. The systems perspective frameworks that can be used are those of WHO (2013); ISO 9001:2015; and Baldridge Health Care Criteria for Performance Excellence.
There must be alignment and integration of the various elements of care.
In formulating the standards and indicators for a quality maternal care service that should have an impact on maternal death reduction, the risk factors or usual causes of maternal death in the community should be used as bases.
Conceptual Framework
Operational Definition of Variables
Cause mapping refers to the identification of risk factors for the occurrence of maternal deaths in the hospital. This is derived from both actual information and potentiality of occurrence.
Quality standards are statements on how things should be done to produce quality maternal care services.
General standards are those statements on how things should be done at the macrolevel whereas specific standards are those statements on how things should be done at a microlevel. Example: There must be formulation of clinical practice guidelines on the top 3 discharge diagnosis of maternal patients is an example of a general standard. There must be a formulation of clinical practice guidelines of pre-eclampsia is an example of a specific standard.
Quality indicators are measures that indicate quality has been achieved.
Systems perspective means managing the whole organization, as well as its components, to achieve excellence or success. It also means managing the whole system with its parts. The Baldrige Framework and ISO Framework utilize systems perspective. The Baldrige Framework requires that the following elements or processes of an organization are aligned and integrated (Leadership, Strategic Planning; Customer Focus; Workforce Focus; Operations Focus; Measurement, Analysis, and Knowledge Management; and Results). The ISO Quality Management System Framework requires that the following elements or processes of an organization are aligned and integrated (Needs and Requirements of Customers; Leadership; Planning; Support and Operations; Performance Evaluation; Improvement).
Structures refer to the setting, material and human resources and organizational structures, standards and regulations, etc.
Processes refer to giving and receiving care.
Outputs refer to improvements in health outcomes, health behavior, patients’ knowledge and patients’ satisfaction, etc.
Deployment means introducing, orienting, and educating the quality standards to all concerned stakeholders and applicable areas of the hospital.
Evaluation as differentiated from review refers to assessment of the performance on the quality standards. Review refers to examination of the quality standards formally with the possibility or intention of instituting change if necessary.
Self-assessment refers doing an evaluation on its own on the performance based on the quality standards.
Maternal audits refers to the in-depth systematic evaluation and review of the quality of maternal care services and critical events (sentinel, adverse, and near-missed) in order to identify areas of improvement.
An audit is a “systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled". *(ISO 9000:2005) Persons who conduct an audit are auditors. Auditors can be internal or external auditors. Internal auditors are those belonging to the organization for which an audit is going to be made, meaning insiders. External auditors are those not belonging to the organization for which an audit is going to be made, meaning outsiders.
Safe: Medical care should be safe for patients in the hospital.
Effective: The science and evidence behind health care should be applied and serve as the standard in the delivery of care.
Efficient: Care and service should be cost effective, and waste should be removed from the system.
Timely: Patients should experience no waits or delays in receiving care and service.
Patient centered: The system of care should revolve around the patient, respect patient preferences, and put the patient in control.
Equitable: Unequal treatment should be a fact of the past; disparities in care should be eradicated.
Control of maternal deaths refers to the reduction and avoidance of maternal deaths in the hospital.
Objectives
Objectives
General Objective:
To determine the hospital’s processes on maternal care services that will lead to quality care and that may have an impact of maternal death control or reduction.
Specific Objectives:
· To formulate a checklist of quality standards on maternal care services in a hospital setting that has an impact on maternal death control or reduction.
· To evaluate three (3) ZFF-PLGP-engaged public hospitals services using a formulated checklist of quality standards on maternal care services.
· To determine the validity of the formulated checklist of quality standards on maternal care services in promoting quality care and in reducing maternal deaths in the hospital.
· To determine the reliability of the formulated checklist of quality standards on maternal care services in promoting quality care and in reducing maternal deaths in the hospital.
· To determine the practicality of the formulated checklist of quality standards on maternal care services in promoting quality care and in reducing maternal deaths in the hospital.
· To identify areas of improvement in the formulated checklist of quality standards on maternal care services and make the necessary recommendations for change.
· To compare the formulated checklist of quality standards on maternal care services with the ZFF Hospital Scorecard.
Methodology
A checklist of quality standards on maternal care services with impact on maternal death reduction or control will be formulated based on cause mapping of maternal deaths in a hospital setting, experience of other and current authors, and systems perspective quality management system framework of ISO and Baldrige.
The formulated checklist of quality standards will be used to evaluate three (3) ZFF-PLGP-engaged public hospitals.
These three (3) ZFF-PLGP-engaged public hospitals will be selected based on the following parameters: 1) with the highest number of maternal deaths during the period of 2014 to 2015 and a good ZFF hospital scorecard evaluation. A good hospital scorecard evaluation means that at least 4 of the 7 critical indicators are achieved while the remaining 3 are at least halfway done with their corresponding sub-indicators. (see Table 2 and Appendix 1 on sub-indicators)
Table 2. 7 Critical Indicators
A team of 3 researchers consisting of an obstetrician, an experienced hospital administrator, and an experienced quality control or patient safety person will go the sites of study to observe hospital practices and processes, do client flow analysis, examine pertinent documents and conduct key informant interviews using the formulated checklist of quality standards on maternal care services as guide.
The key informants will at least be the hospital director or his representative; the chairman of the department of obstetrics; the nurses in charge of the emergency room, OB wards, delivery room, and operating room; the head of the department of laboratory and blood bank; the head of pharmacy; the head of medical supply or inventory service; and head of finance and PhilHealth. Other staff members of the hospitals, like the heads of procurement department, human resource department, and social service may be asked to be key informants. An advance notice will be given for the meeting of the team of researchers with the key informants.
The team will gather data to determine the validity, reliability and practicality of the items in the formulated checklist.
To determine validity, the team will correlate the checklist items with the number and causes of the maternal deaths. If a customer feedback is present, it will also be used for validation. The team will also ask the key informants on their perception of validity.
To determine reliability, the team will correlate the checklist items with the consistency of evidences being produced. The team will also ask the key informants on their perception of reliability.
To determine practicality, the team will see if the checklist is easy to follow, score and interpret. The team will also ask the key informants on their perception of practicality.
The team will come up with a comprehensive assessment of the quality of maternal care services within the hospitals and come up with unified recommendations on the use of the formulated checklist and the areas for improvement. The team will also compare the formulated checklist with ZFF Hospital Scorecard and determine areas of similar or differing strengths and weaknesses.
Confidentiality of the interviews and document review will be observed.
Key Deliverables
Key Deliverables
The expected output for this study is a terminal report containing the results of the quantitative and qualitative assessment of the three (3) ZFF-PLGP-engaged public hospitals in providing quality maternal care services that have impact on maternal death reduction; assessment of the formulated checklist; and comparison of the formulated checklist and the ZFF hospital scorecard. The itemized deliverables with their respective timelines are seen in the Gantt chart below.
Schedule of Payment to the Team of Researchers
25% of allotted professional fees – after approval of research proposal
50% of allotted professional fees – after field work
25% of allotted professional fees – after presentation and submission of full report
Duration and Time frame
Duration and Time frame
The duration of work would be spread over a period of four months as shown in the Gantt chart below.
Required Expertise
Required Expertise
A three-man team comprised of an obstetrician, a hospital administrator, and a quality control /patient safety person will be commissioned for this study.
Budgetary Requirement
Budgetary Requirement
The total budget for this study is Php 941,480.00. This already includes the professional fees and logistic costs.
Professional Fees PHP 560,000.00
Logistics PHP 381,480.00
_____________
TOTAL PHP 941,480.00
Professional Fees
Logistics
References
1. World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), World Bank Group, United Nations Population Division (UNPD). Trends in maternal mortality: 1990 to 2015. Geneva: WHO; 2015.
2. Zuellig Family Foundation. Three Delays Model: Understanding Maternal Deaths to Attain MMR 52. Paranaque: ZFF; 2015.
3. Kuntz L, Mennicken R, Scholtes S. Stress on the Ward: Evidence of Safety Tipping Points in Hospitals. Management Science [Internet]. 2014 May; 61(4). Available from: http://pubsonline.informs.org/doi/10.1287/mnsc.2014.1917.
4. Schilling PL, Campbell DA Jr, Englesbe MJ. Davis, MM. A comparison of in-hospital mortality risk conferred by high hospital occupancy, differences in nurse staffing levels, weekend admission, and seasonal influenza. Medical Care. 2010 Mar; 48(3):224-32.
5. Smith JB, Coleman NA, Fortney JA, Johnson JD, Blumhagen DW, Grey TW. 2000. The impact of traditional birth attendant training on delivery complications in Ghana. Health Policy and Planning 15(3):326–331.
6. Sorensen G, Emmons K, Hunt MK, Johnston D. 1998. Implications of the results of community intervention trials. Annual Review of Public Health 19:379–416.
7. A framework for the evaluation of quality of care in maternity services http://eprints.soton.ac.uk/40965/1/12757_Matthews.pdf
8. Consultation on improving measurement of the quality of maternal, newborn and child care in health facilities [WHO – 2013]
http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf
9. Safe Motherhood Indicators
http://www.cpc.unc.edu/measure/prh/rh_indicators/indicator-summary
10. WHO Safe Childbirth Checklist
http://apps.who.int/iris/bitstream/10665/199179/1/WHO_HIS_SDS_2015.26_eng.pdf?ua=1
11. Quality Standards in Kerala, India
http://f1000research.com/articles/5-166/v1
Vlad I, Paily V, Sadanandan R et al. Improving quality for maternal care - a case study from Kerala, India. F1000Research 2016, 5:166
12. The 3 delays model in maternal care
http://www.maternityworldwide.org/what-we-do/three-delays-model/
13. Floyd L. Helping midwives in Ghana to reduce maternal mortality. African Journal of Midwifery and Women’s Health. 2013 Jan-Mar; 7(1).
http://www.kybeleworldwide.org/uploads/6/8/4/7/6847709/liz_ajm_paper.pdf
14. Quality Improvement for Emergency Obstetric Care : EngenderHealth
14. Quality Improvement for Emergency Obstetric Care : EngenderHealth
https://www.engenderhealth.org/files/pubs/maternal-health/qi-for-emoc-manual.pdf
https://www.engenderhealth.org/files/pubs/maternal-health/qi-for-emoc-manual.pdf
15. WHO Quality Improvement Model for Maternal, Newborn and Child Health-2013 http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf
16. Quality Health Care as defined by Institute of Medicine
http://healthmatters4.blogspot.com/2011/06/iom-six-aims-of-quality-health-care.html
Appendix 1. PLGP Hospital Scorecard.
Appendix 2. Critical Hospitals in PLGP Areas for 2014 – 2015 with Comparison of Number of Maternal Deaths and Scorecard Performance.
*Number of maternal deaths
Appendix 3: Checklists of Quality Standards for Maternal Care Services in a Hospital Setting
Name of ZFF-PLGP-engaged Public Hospital:
Essential Background Description of Hospital:
· Location
· Primary and secondary catchment communities
· Total bed capacity
· Level 1, 2 or 3 (based on DOH classification)
· Total manpower in the entire hospital
· Departmentalized into at least 4 principal clinical departments (OB-GYN, Pediatrics, Internal Medicine, and Surgery)
· Emergency Room bed capacity
· Department of Obstetrics and Gynecology:
o Bed capacity of department (charity and pay wards)
o Bed capacity of Delivery Room
o Operating table capacity of Operating Room
o Manpower:
§ Number of Obstetricians [Board-certified, non-board-certified (formal training, short-course training)]
§ Number of nurses and midwifes assigned in wards, delivery room, operating room, etc.
· Support clinical departments:
o Number of Anesthesiologists
o Number of Internists
o Number of Pediatricians
o Number of Surgeons
· Support non-medical departments:
o Medical records – presence, established with manual of operations
o Human resource – presence, established with manual of operations
o Facility service – presence, established with manual of operations
o Finance – presence, established with manual of operations, with PhilHealth accreditation
· Maternal Death (particularly Direct) Statistics (for at least past 3 years –2013 - 2014-2015 and past several months – January to June 2016 at least)
Availability and Accessibility of Medicines and Equipment
Availability and Accessibility of Medicines and Equipment
· Obstetric medicines
· Emergency medicines
· Anesthesia
· Ultrasound, Doppler, CTG
· Gloves, Gown, other supplies
· Blood
Assessment key:
· 0-Not compliant
· 1-Starting to comply or just initiating
· 2-Partial compliant or developing
· 3-full compliant or fully developed
· 4-institutionalized for at least 2 years
Note: The time (at least approximate year and month) when the criteria and indicators are developing (with assessment of 2), fully developed (3), and institutionalized (4) are noted and then compared with the 3-year mortality death statistics of the hospital to see if there is any causal correlation. Statistical treatment of data is done as indicated.
Obstetrical Outpatient Medical Management
Obstetrical Outpatient Medical Management
· Adequacy of the number of health professionals
· Adherence to CPG for patients w/o co-morbidity
· Adherence to CPG for patients with co-morbidity
· Patient education
· Respect for patients and cultural sensitivity
· Referral system from catchment area
Assessment key:
· 0-Not compliant
· 1-Starting to comply or just initiating
· 2-Partial compliant or developing
· 3-full compliant or fully developed
· 4-institutionalized for at least 2 years
Note: The time (at least approximate year and month) when the criteria and indicators are developing (with assessment of 2), fully developed (3), and institutionalized (4) are noted and then compared with the 3-year mortality death statistics of the hospital to see if there is any causal correlation. Statistical treatment of data is done as indicated.
Obstetrical Inpatient Medical Management
Obstetrical Inpatient Medical Management
· Adequacy of the number of health professionals
· Use of partogram
· Adherence to CPG for patients w/o co-morbidity
· Adherence to CPG for patients with co-morbidity
· Patient education
Assessment key:
· 0-Not compliant
· 1-Starting to comply or just initiating
· 2-Partial compliant or developing
· 3-full compliant or fully developed
· 4-institutionalized for at least 2 years
Note: The time (at least approximate year and month) when the criteria and indicators are developing (with assessment of 2), fully developed (3), and institutionalized (4) are noted and then compared with the 3-year mortality death statistics of the hospital to see if there is any causal correlation. Statistical treatment of data is done as indicated.
Patient Care Processes
Patient Care Processes
· Triage and high risk units
· Referral system process and response time
· Charting and endorsement
· Supportive care
o respect for privacy
o emotional support
o pain relief and patient comfort
o family friendly
· Process for indigents
o PhilHealth process for indigents
o Cost recovery program
Assessment key:
· 0-Not compliant
· 1-Starting to comply or just initiating
· 2-Partial compliant or developing
· 3-full compliant or fully developed
· 4-institutionalized for at least 2 years
Note: The time (at least approximate year and month) when the criteria and indicators are developing (with assessment of 2), fully developed (3), and institutionalized (4) are noted and then compared with the 3-year mortality death statistics of the hospital to see if there is any causal correlation. Statistical treatment of data is done as indicated.
Mortality and Morbidity Audit
Mortality and Morbidity Audit
· Able to identify events resulting in adverse outcomes for the patient
· Mistakes are acknowledged by health professionals and addressed
o Medical error
o Adverse events
o Near-miss events
· Accountability for high quality care is emphasized
· Insights gained from discussion are identified and disseminated
Assessment key:
· 0-Not compliant
· 1-Starting to comply or just initiating
· 2-Partial compliant or developing
· 3-full compliant or fully developed
· 4-institutionalized for at least 2 years
Note: The time (at least approximate year and month) when the criteria and indicators are developing (with assessment of 2), fully developed (3), and institutionalized (4) are noted and then compared with the 3-year mortality death statistics of the hospital to see if there is any causal correlation. Statistical treatment of data is done as indicated.
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