Observation of a quality improvement initiative to contextually adapt and use Robson classification in real time to collect data around CS delivery and to develop strategies to reduce CS rate.

The rising trend in caesarean section (CS) rate is a global concern and, in this hospital too, it rose from 21.5% in 2010 to 32.6% in 2018. The team followed the point of care quality improvement methodology and conducted a series of Plan-Do-Study-Act cycles to contextually modify and adapt Robson classification into the existing workflow to improve the process of documentation and data collection for CS in the first 6 months (January 2019-June 2019) and then to use these data to develop strategies to reduce CS rate below 30% in the next 18 months.To evaluate the impact of developed strategies, the team plotted the data on Statistical Process Control (XmR) chart. The baseline mean CS rate was 32.6%. The team observed a shift in the CS rate data twice, between April 2020 and December 2020 and between August 2021 and February 2021 with the mean 27.8% and 28.9%, respectively. October 2021 onwards, the team also observed a sustained reduction in the CS rate in women undergoing CS who had one previous CS. The mean CS rate reduced from 94% to 86%.The reductions in the CS rate were not sustained and followed by an increase again. The project highlighted the complexity of the factors related to CS delivery and the multidimensional barriers of sustaining the reduction in the CS rate. This is a well-sustained ongoing QI intervention and the team is further working on identifying the underlying factors to improve the efficacy of the interventions to sustain the reduction in the CS rate.This hospital represents the general population of North India seeking care in public healthcare facilities. Therefore, despite being a single-centre study, the population served and interpretations drawn from this study are generalisable to other hospitals with similar settings.

Preidentification of high-risk pregnancies to improve triaging at the time of admission and management of complications in labour room: a quality improvement initiative.

Complications can occur anytime during pregnancy and childbirth. Pregnancies associated with high-risk factors have a higher-than-normal risk for fetomaternal complications. Bhagwan Mahavir hospital is a public sector hospital catering to low-risk and high-risk pregnant women (PW) in the labour room (LR)). The obstetrics and gynaecology team observed that at times the LR team failed to identify high-risk pregnancy (HRP) during admission in LR and to manage complications timely and efficiently. Therefore, the team started a quality improvement (QI) project in January 2019 with the aim to admit preidentified HRP in LR from existing 0% to 80% in 3 months.The QI team followed the point-of-care quality improvement methodology to conduct this improvement process. They identified HRP in the outpatient department (OPD) during their antenatal care (ANC) visits, mentioned an HRP number on their ANC cards, and did risk stratification with yellow and red stickers into moderate and severe HRP respectively. Preidentified HRP were attended, admitted and managed on priority in the LR. The team achieved its aim in the ninth week of the QI initiative and sustaining to date. The team also measured and analysed the type of HRP identified in OPD, complications occurring around the process of childbirth in LR, maternal near-miss, maternal death and PW referred out from LR. They observed a 6.5%-point reduction (68.93%) in the median complication rate of major life-threatening complications following this improvement process.This new intervention facilitated the team in early initiation of management of HRP in OPD, their triaging in LR, preparedness towards managing complications, involvement of support staff, PW and their relatives in the patient care, and redistribution of human resources according to priority area. The lessons learnt are generalisable and can be used in other facilities with similar settings.

Development of a hub and spoke model for quality improvement in rural and urban healthcare settings in India: a pilot study.

OBJECTIVE: Hub and spoke model has been used across industries to augment peripheral services by centralising key resources. This exercise evaluated the feasibility of whether such a model can be developed and implemented for quality improvement across rural and urban settings in India with support from a network for quality improvement. METHODS: This model was implemented using support from the state and district administration. Medical colleges were designated as hubs and the secondary and primary care facilities as spokes. Training in quality improvement (QI) was done using WHO's point of care quality improvement methodology. Identified personnel from hubs were also trained as mentors. Both network mentors (from QI network) and hub-mentors (from medical colleges) undertook mentoring visits to their allotted facilities. Each of the participating facility completed their QI projects with support from mentors. RESULTS: Two QI training workshops and two experience sharing sessions were conducted for implementing the model. A total of 34 mentoring visits were undertaken by network mentors instead of planned 14 visits and rural hub-mentors could undertake only four visits against planned 18 visits. Ten QI projects were successfully completed by teams, 80% of these projects started during the initial intensive phase of mentoring. The projects ranged from 3 to 10 months with median duration being 5 months. DISCUSSION: Various components of a health system must work in synergy to sustain improvements in quality of care. Quality networks and collaboratives can play a significant role in creating this synergy. Active participation of district and state administration is a critical factor to produce a culture of quality in the health system.