Human Resource Systems
Human resources are a critical factor in implementing national guidelines. Even the best guidelines cannot have the optimal effect if there are insufficient numbers of providers delivering maternal and neonatal health services, or if well-trained providers are leaving the service at rates faster than they can be replaced. Governments need plans for development of human resources that incorporate effective recruitment and deployment of personnel to meet the community's needs. Clearly defined job descriptions are an essential component of a human resources system, and in a system in which national policy guidelines have been appropriately implemented, these job descriptions are created using input from the guidelines. Job descriptions, based on the skills and standards described in the guidelines, then find further use in the development of preservice education and inservice training programs.
Governments also must address issues of retention, motivation and morale so that all cadres of healthcare providers are supported in their work. Low employee motivation and morale often are identified as issues in inadequate provider performance, and can have an adverse effect on the successful implementation of guidelines. Mechanisms need to be in place to recognize the efforts of staff to provide high quality care and to reinforce practices that institutionalize positive behavior change. Professional growth and continuing education opportunities have to be developed.
Training Systems
The desired result of any clinical training program, whether preservice or inservice, is that providers begin using newly acquired skills to improve patient care. When guidelines are used in the development of these training programs, the skills included in the training are carefully selected as key skills called for in the guidelines and needed to improve provider performance. This allows the training to be very focused and thus makes the most efficient use of time required for training.
A training system that supports the implementation of guidelines is the result of an integrated training strategy—a strategy that addresses all sectors, cadres and levels of the healthcare system. This integrated approach helps achieve standardization and increase collaboration. In addition, it fosters a focus on clients and the services they need rather than on the category of provider or level of the healthcare system.
Preservice Education
National training systems now recognize that the most sustainable training approach in the long term is preservice medical, midwifery and nursing education. When service delivery guidelines are used to develop preservice curricula, students learn from the start of their careers the basic principles of guidelines-based clinical practice and are taught how to apply them. As the new guidelines become the norm for providing patient care, performing procedures, following drug and supply standards and educating the public about warning signs, newly graduating students practice them accordingly. This result would be much more difficult, if not impossible, to achieve if medical, midwifery and nursing curricula developed without reference to the guidelines.
In many countries, preservice education still concentrates on acquisition of knowledge, while failing to provide students with the skills that they need to perform their jobs proficiently. When guidelines are used to develop preservice education programs, curricula are refocused to include competency-based clinical skills training, so that students graduate as qualified, proficient professionals and are able to provide the quality of care defined by the guidelines.
Inservice Training
Even though a shift to preservice training is the necessary long-term solution, inservice training must still take place. Most healthcare professionals now in service were not trained using a guidelines-based curriculum. And the guidelines will be revised in the future, requiring providers to learn more new skills. Inservice training is therefore necessary in the short term to bring the skill level of existing health personnel up to the standards set by guidelines. In this case, inservice is need-based training, conducted to fill an identified gap in healthcare providers' knowledge or skills. As in preservice curricula, inservice training programs are developed based on clearly defined job descriptions which, in turn, have been developed based on the guidelines.
Supervision Systems
Supervision is recognized as an essential element in the improvement of provider performance. In many countries, however, supervisory systems based on external interventions (coming from outside the health facility) are often weak due to the lack of resources required to implement a regular supervisory schedule. Therefore, alternative supervisory schemes based on internal interventions (within the healthcare facility) are proposed in an effort to strengthen supervision. Tools for self-assessment, the COPE (client-oriented, provider-efficient) approach developed by
AVSC International (now
EngenderHealth), or the manual on clinical supervision developed by JHPIEGO can help support providers in changing behaviors and improving performance in line with national guidelines. When new guidelines are introduced, it is often the responsibility of the clinical supervisor at the healthcare delivery site to ensure that the staff and facility follow them. Internal supervisory interventions based on guidelines also help staff monitor their own performance and address problems as they arise.
Case reviews of maternal deaths are internal supervision mechanisms used in facilities to indicate whether all parts of a service are functioning correctly. Review of the maternal deaths and "near misses"3 at an institution can illustrate why some women die and others are saved. Analysis of the maternal near misses acknowledges the staff's effort to avert maternal mortality and fosters a sense of pride in this effort. Recognition should be given to staff members who demonstrate good problem-solving skills and good case management. This positive feedback motivates staff to do their best and encourages them to follow the guidelines in providing healthcare services.
To be effective, supervision must be linked to training. Both training and supervision can be considered "tools" for fostering the implementation of guidelines and attaining improved healthcare. And training of supervisors is as important as training of healthcare providers. In addition to clinical skills, supervisors need training in management, mentoring, coaching and other interpersonal skills.
Once training is complete, the provider needs appropriate support from a supervisor and clinical peers to work toward the desired level of service embodied by the guidelines. New skills brought into the work environment may be contrary to what has been done routinely. For example, introduction of the practice of active management of third stage of labor may create professional dissonance. While active management of third stage has been shown to prevent postpartum hemorrhage and reduce blood loss after birth, many providers have practiced physiologic management of third stage all of their professional lives, waiting for the placenta to separate on its own. Introducing active management may meet intense resistance on the part of these providers who may see no reason to change. Supervisors can use the guidelines to support the introduction of this essential practice and coach providers to improve their skills.
| Introduction of the PROQUALI Model in Brazil Facilitates the Implementation of Guidelines
PROQUALI, a performance and quality improvement model implemented in the states of Ceará and Bahia, Brazil, supports implementation of national guidelines. PROQUALI is essentially a system to "accredit" health centers that meet a pre-established, standardized set of quality criteria for delivery of selected reproductive health services. In the PROQUALI model, an external assessment tool, which incorporates provider perspectives and clients needs and expectations, is used to: 1) identify the basic functions and services of the reproductive health system based on national, regional and local policies and priorities; and 2) determine key standards and indicators based on norms, protocols and/or service delivery guidelines. The PROQUALI model requires that standards be translated into specific actions, that these actions be organized around processes that occur at the facility level, and that all processes necessary for the provision of quality services be included.
Implementation of the PROQUALI model has demonstrated that these operationalized standards:
- highlight the importance of having norms and protocols and show their usefulness
- facilitate supervision that is interactive, focused, objective and efficient
- facilitate decision-making for problem solving
- empower providers and supervisors
- facilitate transfer of training
- strengthen the regulatory role of different levels of government
- provide tools for local advocacy and resource mobilization
- facilitate information and empowerment of clients and communities to demand and participate in the provision of quality
services
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Supply Systems, Logistics, Drugs and Equipment
It is not unusual to hear that women have died because supplies and equipment to stabilize them or treat their complications were not available. Implementing guidelines requires that specific supplies, drugs and equipment be available to the provider. For example, if health centers and hospitals do not regularly stock magnesium sulfate in the pharmacy, providers cannot manage eclampsia most effectively. When guidelines are fully implemented, a committee or
division of the ministry of health responsible for performance improvement or improved quality of care will ensure that the essential supplies and materials necessary to implement the standards of care are part of the essential drug list for the country, and that managers know how to order these supplies. WHO has developed a standard list of essential drugs for antepartum, intrapartum and postpartum care. Many countries have used this list as a starting point in deciding what supplies, equipment and drugs are necessary to implement their guidelines.
Referral Systems
Effective referral and transport systems must be in place so that the high quality care required by the guidelines can be achieved. Virtually all countries' standards require that every woman have access to a continuum of care during pregnancy, childbirth and the postpartum period in order to reduce both maternal and neonatal mortality. This continuum of care starts in the home and community and does not end until the woman receives the definitive care she needs, often in a healthcare facility. It means that appropriate care is provided not only at home and within facilities but also between facilities during occasions of referral. Each link in the continuum of care chain has to operate efficiently and effectively to provide high quality care in order to ensure that women and neonates do not arrive at a health facility in such poor condition that their chance of survival is greatly reduced.
Effective referral and transport are required to save lives. Both health facilities and the community need to be ready. Each facility should have a clinical emergency action plan. Whether or not it has its own transport system, the facility should know how to access emergency transport to receive patients or to transfer them to the next higher level of care. The guidelines should assist providers in determining when to move a woman to the next level of care and how to stabilize her and ensure continuity of care until she reaches that level. Basic emergency supplies also must be readily available at each level of care.
Since many, if not most, births occur outside the healthcare facility, the community is usually the initiator of care. Members of the community need to recognize early danger signs and have an emergency readiness plan in the event of complications. This will include ensuring access to a means of transport on an urgent basis as well as to the funds to pay for it.
Monitoring and Evaluation Systems
The ultimate goal of implementing guidelines for maternal and neonatal care is the reduction of maternal and neonatal mortality. It would seem logical, therefore, that monitoring changes in maternal mortality would demonstrate whether or not guidelines have been implemented effectively. Lessons learned from the first decade of the Safe Motherhood Initiative, however, have shown that it is not that simple. Practical methods do not currently exist for measuring small changes in maternal mortality over relatively short (5 to 7 years) periods of time. Routine data sources are often incomplete. Survey-based estimates of maternal mortality are very expensive to perform, may be highly imprecise and do not usually permit trend analysis. For this reason, international agencies now recommend monitoring of process indicators. Process indicators are those indicators that reflect changes in the processes that determine the ultimate maternal/neonatal outcome. Several United Nations agencies
(WHO, UNICEF,
UNFPA) have developed a set of process indicators for monitoring the availability and use of obstetric services. (There is no evidence yet, however, that process indicators actually point to maternal mortality results.)
In addition to systems for monitoring and evaluating maternal mortality and quality of care, methods for directly monitoring the implementation of guidelines are also essential. The Attachment at the end of this paper shows certain indicators that are appropriate for monitoring guidelines implementation. Routine reporting on the coverage of essential obstetric care, facility-based quality of care indicators and indicators of compliance with standards have been found to be useful for monitoring and evaluating implementation of guidelines. Once a country has selected the indicators that most accurately demonstrate implementation of its guidelines, planners and providers develop a plan for data collection to routinely and accurately generate information on these indicators. Each facility or district then becomes capable of analyzing and interpreting its own data and plans for timely feedback to concerned staff about how implementation of the guidelines is progressing. Data can be collected to assess the impact of guidelines implementation at three levels: in each facility, across all facilities and in the country's population as a whole. The purpose of collecting a variety of data is to generate a minimum number of indicators that will reflect dissemination and actual implementation of guidelines for maternal and neonatal healthcare.
3A "near miss" is a life-threatening complication that could have resulted in a death if all systems had not responded to the emergency adequately.
