Successful implementation of a combined learning collaborative and mentoring intervention to improve neonatal quality of care in rural Rwanda

Abstract

BackgroundGlobally, neonatal mortality remains high despite interventions known to reduce neonatal deaths. The All Babies Count (ABC) initiative was a comprehensive health systems strengthening intervention designed by Partners In Health in collaboration with the Rwanda Ministry of Health to improve neonatal care in rural public facilities. ABC included provision of training, essential equipment, and a quality improvement (QI) initiative which combined clinical and QI mentorship within a learning collaborative. We describe ABC implementation outcomes, including development of a QI change package.MethodsABC was implemented over 18 months from 2013 to 2015 in two Rwandan districts of Kirehe and Southern Kayonza, serving approximately 500,000 people with 24 nurse-led health centers and 2 district hospitals. A process evaluation of ABC implementation and its impact on healthcare worker (HCW) attitudes and QI practice was done using program documents, standardized surveys and focus groups with facility QI team members attending ABC Learning Sessions. The Change Package was developed using mixed methods to identify projects with significant change according to quantitative indicators and qualitative feedback obtained during focus group discussions. Outcome measures included ABC implementation process measures, HCW-reported impact on attitudes and practice of QI, and resulting change package developed for antenatal care, delivery management and postnatal care.ResultsABC was implemented across all 26 facilities with an average of 0.76 mentorship visits/facility/month and 118 tested QI change ideas. HCWs reported a reduction in barriers to quality care delivery related to training (p = 0.018); increased QI capacity (knowledge 37 to 89%, p < 0.001); confidence (47 to 89%, p < 0.001), QI leadership (59 to 91%, p < 0.001); and peer-to-peer learning (37 to 66%, p = 0.024). The final change package included 46 change ideas. Themes associated with higher impact changes included provision of mentorship and facility readiness support through equipment provision.ConclusionsABC provides a feasible model of an integrated approach to QI in rural Rwanda. This model resulted in increases in HCW and facility capacity to design and implement effective QI projects and facilitated peer-to-peer learning. ABC and the change package are being scaled to accelerate improvement in neonatal outcomes.

The All Babies Count Initiative: Impact of a Health System Improvement Approach on Neonatal Care and Outcomes in Rwanda

“…Facilities received an average of 0.68 visits/month, and a change package of 46 successful change ideas was developed by the endpoint to facilitate spread. 16 ABC adaptation informed by quarterly implementation data was undertaken to increase acceptability and adoption. For example, initially LSs were planned quarterly to complete the collaborative within 1 year.…”

“…MNH quality gaps that require multilevel solutions, such as infrastructure, referral systems, and data quality, were tackled in improvement projects. 16 …”

“…We saw reduced discrepancies in the HMIS of neonatal deaths over time, indicating some degree of success of these efforts. 16 , 24 …”

“…District mentors grounded QI coaching and built trust with providers through clinical observation and support. 16 A qualitative study of participating QI teams found that the nontraditional collaborative components—equipment and clinical support and the combined mentorship approach—were factors related to high impact QI initiatives. 16 Many improvement programs focus on narrow interventions, without taking a comprehensive view of the mortality drivers of MNH care quality across a health system.…”

Optimizing the development and evaluation of complex interventions: lessons learned from the BetterBirth Program and associated trial

“…Therefore, the absence of an effect on the primary health outcomes in the BetterBirth Trial suggests that the intervention may not have been sufficiently optimized to address the specific contextual barriers to maternal and neonatal health in Uttar Pradesh [ 83 ]. Because the BetterBirth Trial was a high-profile, large-scale study conducted by a team with previous experience implementing behavioral change interventions [ 20 , 21 , 84 , 85 ], it provides a realistic example of how complex interventions are currently developed and evaluated. The lessons learned from this case study are likely applicable to other teams developing and evaluating complex interventions.…”