Virtual Quality of Care Coaches Training in Ethiopia

Followed by the virtual Quality Improvement(QI) workshop^[1] held by UNICEF ESARO, WHO, UNFPA and the Ministry of Health in Kenya in June, a virtual training for Quality of Care(QoC) coaches was organized by health section of UNICEF Ethiopia country office(ECO) supported by UNICEF ESARO and in collaboration with Ministry of Health(MOH) Ethiopia via Zoom from 5th to 9th October 2020.

WHO definition of quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.[2] However, women often experience abuse, lack of respectful compassionate care, and exclusion from care decision-making during childbirth and in relation to infant care. Newborns are exposed to harmful procedures, lack of respectful care, neglect and separation from parents in the care process.[3] Inadequacies in quality of care have serious impact on maternal and newborn health outcomes. Globally 295,000 mothers and 2.5 million newborns die annually around the time of childbirth and many are affected by preventable illness; more than 2 million stillbirths each year.[4] Thirty million small and sick newborns require access to quality services every year.

Ethiopia has one of the world’s highest rates of maternal deaths in the world and high numbers of newborn deaths, despite the significant progress made in reducing mortality in mothers and children. The stagnation of neonatal mortality rate (NMR) highlighted in the recent Ethiopian Demographic and Health Survey (EDHS) was particularly alarming, which was 37 deaths per 1,000 live births in 2011 and 30 deaths in 2019. Maternal mortality rates (MMR) showed some progress from 676 deaths per 100,000 live births in 2011 to 412 in 2016.[5] However, it is far below the government target, 119 deaths per 100,000 live births. Quality of care in health services is essential for achieving universal health coverage and the ambitious targets of ending preventable maternal, newborn and child mortality, as defined under the health-related Sustainable Development Goals.[6]

The virtual training for QoC Coaches aimed to prepare and equip a pool of resource personnel for effective implementation of the Quality Improvement (QI) agenda at the national, regional and health facility level. A total of 38 participants from MOH, Regional Health Bureau(RHB), UNICEF ECO and field officers and learning health facilities joined the three-hour daily training for five days through Zoom. The training was formally opened and closed by MOH Health Service Quality Directorate.

Preparation

To facilitate the training, UNICEF ECO and ESARO teams had planning calls to discuss:

• Collaboration with MOH and other organizations, training plan finalization and selection of facilitators
• Stakeholders participation – Invitations were sent to clinical staff in newborn and delivery ward from Newborn Intensive Care Unit (NICU) learning facilities,[7] facility QI focal person, QI team member in RHBs including Maternal Child Health team members at the RHBs and MOH.
• List of participants, zoom invitation and data bundles/internet access for participants
• Participants technology brief and orientation to introduce prerequisite self-learning. A link for pretest and online workbook were also sent to participants by emails
• Google drive link for all the resources to be shared with participants
• A link for post-test and evaluation sent to participants by emails
• Creation of WhatsApp Group for communication

Training methods and topics covered

Just like the previous regional virtual QI workshop, the training was divided into six phases –

1) Preparatory where participants take online course using Point of Care Quality Improvement workbook, 2) online facilitated learning phase for five days, 3) knowledge into practice phase where participants implement their own QI project or coaches a QI team, 4) experience sharing phase in which participants share their experience in carrying out QI project and coaching experience, 5) certification phase and 6) continued work of coaches to support quality improvement for maternal and newborn health services.

The preparatory and online facilitated learning were completed in the first week of October in Ethiopia. The main teaching methods for online facilitated learning were virtual lecture presentations, video shows, group work, discussions, case studies and exercises. The topics below were covered during the QI coaching training:

• Overview of Quality of Care in Ethiopia
• Introduction to Quality of Care in the context of COVID and beyond
• Quality of Care and Health System Strengthening
• Starting QI program – the four QI STEPS:
• STEP 1 – Identifying a problem, forming a team and writing an aim statement
• STEP 2 – Analyzing and measuring quality of care
• STEP 3 – Developing and testing changes (PDSA)
• STEP 4 – Sustaining improvements
• Coaching: Objectives of coaching, roles of QI coaches, successful coaches, roles of external/internal coaches and preparing for external coaching visits
• Implementation of projects as the next step

At the end of the training, participants agreed on follow up actions and are now developing their own QI project or coaching plans. A journey to institutionalize QI in their work has just begun.

 Lessons learnt

• Adapted approach in COVID-19 context: With public gathering and travel restrictions, virtual training became an innovative approach for programme continuity. Technology brief conducted before the training to familiarize participants with Zoom features was helpful. Participants were able to engage in learning throughout the training. Data bundles provided to the participants also ensured internet access
• To increase effectiveness, virtual trainings need to be interactive: Facilitators used quizzes, group sessions and tools such as polls and jamboard to actively engage participants in the training. During group sessions, participants also discussed QI project with their team and jointly developed a presentation
• Virtual trainings are effective for knowledge and capacity building: Pre and post-tests conducted showed test score increase from 9.2 (pre-test) to 13 (post-test) out of 16
• Learning should be embedded and inclusive: Participants were from all levels – MoH, RHB, health facilities and UNICEF ECO. Participants from the MoH, RHB and Woreda are expected to be external coaches while those from facilities will be internal coaches. Participants were groups by regions or by facilities so they could develop work together and develop QI plan for their respective projects. The QI project initiated during the virtual training will be a continuous process

Opportunities for QI in Ethiopia

The MoH plans to scale up learning, knowledge management and quality coaching systems. Mechanisms to measure quality will also be established. MoH also plans to integrate QI training in preservice and post graduate programs for continuous capacity building. UNICEF’S QI work will be harmonized with MoH plan. Support will be provided to institutionalize and scale-up QI. WhatsApp group was created among training participants to continue dialogue and share information.

Constraints/Challenges

• Poor internet connection mainly for participants from Somali, Benshangul-Gumuze RHB and learning facilities is challenging
• Some participants had conflicting schedule. Some also mentioned three hours per day seemed to be too long to fully participate

Next steps among Participants

• Submission of draft QI project plan and coaching plan by 23 October, 2020
• Short virtual session will conducted for training participants by December 2020, to provide support for implementing their QI project
• Experience sharing and certification by December 2020.
• Collaborations MOH and contextual support as needed to institutionalize QI

Participants Feedback & Evaluation – 20 responses received

100% stated either strongly agree or agree to the following statement:

• The instructors knew their subjects
• I know how to continue building my QI skills
• The audiovisual presentations were easy to see and follow

95% stated either strongly agree or agree to the following statement:

• I feel that I have the capacity to assist QI teams to improve QoC
• I understand my responsibilities toward implementing the standards
• I feel confident about being able to carry out this QI project
• I will recommend this training to others

90% stated either strongly agree or agree to the following statement;

• The virtual training platform facilitated learning.

However, 10% of participants disagreed that the virtual training platform facilitated learning. This is because of internet connectivity problems in some region. To resolve this issue, a make-up session is planned for those who could not join some part of the training due to internet problem. All session were also recorded and will be shared with participants.

Pre-test and Post-test Results

Pretest results

Post-test result

Frequently missed questions in the pre-test and improvements in post-test

[1] UNICEF ESARO Quality Improvement Workshop https://web.yammer.com/main/threads/eyJfdHlwZSI6IlRocmVhZCIsImlkIjoiNzc5NTAxMjQxMzY4NTc2In0

[2] What Is Quality of Care and Why Is It Important? Retrieved from https://www.who.int/maternal_child_adolescent/topics/quality-of-care/definition/en/

[3] World Health Organization. (2016). Standards for improving quality of maternal and newborn care in health facilities (Rep.). Retrieved from https://cdn.who.int/media/docs/default-source/mca-documents/qoc/quality-of-care/standards-for-improving-quality-of-maternal-and-newborn-care-in-health-facilities.pdf

[4] The Network for Improving Quality of Care for Maternal, Newborn and Child Health. Retrieved from  https://www.healthynewbornnetwork.org/issue/network-improving-quality-care-maternal-newborn-child-health/

[5] Central Statistical Agency. (2017). Ethiopia Demographic and Health Survey 2016. Retrieved from http://dhsprogram.com/pubs/pdf/FR328/FR328.pdf

[6] World Health Organization. (2016).

[7] FMoH, in collaboration with UNICEF, selected and supported 15 learning facilities of the 80 NICUs in the country to provide high-quality care for sick newborns through functional NICUs, which in turn can become learning and demonstration sites for other facilities through appropriately utilizing NICU level III life-saving equipment.