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Standards Based Management and
Recognition Approach To Quality
Improvement
By
Prof. Emmanuel Oladipo Otolorin,
FMCOG, FWACS, FICS, FRCOG
Country Director, ACCESS/JHPIEGO
Learning Objectives
Define Quality of Care
List a variety of quality improvement
approaches
Describe the Standards Based
Management and Recognition (SBM-R)
model
Describe lessons learnt so far in
Nigeria
2
What does “Quality of Care” mean?
Illustrative definitions:
“Doing the right things right”
“Meeting minimal standards for adequate
care”
“Offering the greatest health benefits,
with the least health risks, to the greatest
number of people, given the available
resources”
3
World Health Organization’s
Definition Of “Quality Of Care”
“The proper performance, according to
standards, of interventions that are
known to be safe, that are affordable to
the society in question, and that have
the ability to produce an impact on
mortality, morbidity, disability and
malnutrition”
4
Different Perceptions of Quality
Social-cultural
Client
Civil
Society Q State/
USAID
Provider
Context
5
Criteria of good quality maternal health
services
Accessible and available
Acceptable to potential users/responsive to
local cultural and social norms (e.g. privacy,
confidentiality, quick, care by female health
workers
Adequacy of essential supplies and
equipment
Provides comprehensive care and linkages to
other RH services
Provides for continuity of care and follow-up
6
Criteria of good quality maternal health
services continued
Staffed by technically competent health care
providers who rely of clear guidelines and protocols
for treatment
Staffed by workers who provide respectful and non-
judgmental care
Service site provides information and counseling
for clients on their health and health needs
Involves clients in decision-making
Offers economic and social support to health care
providers to motivate them to do the best job they can
7
Why is Quality of Care important?
Quality of care is important because
good quality services:
are cost-efficient
are equitable
are effective
improve staff morale
save women’s lives
8
Sample list of Quality Improvement Methods
Quality assurance
Total Quality Management
Continuous Quality Improvement
Performance Improvement
Supportive/Facilitative supervision
Standard-Based Management and
Recognition (SBM-R) Approach
12
What is SBM-R?
Practical management approach for
improving performance and quality of health
services
Based on use of operational, observable
performance standards for on-site
assessment
Must be tied to reward or incentive
program
Consists of four basic steps
13
The Four Steps of SBM-R
14
Step One:
Set the Performance Standards
15
Steps to Setting Standards
Identify area of services to be improved
Define core support and supply processes to
provide these services
Develop performance standards based on
international guidelines, national policies or
guidelines, and site-specific requirements
Consider providers’ input and clients’
preferences
16
“Operationalization” of Standards
National Guidelines
(“Reference” standards)
Assessment tool
(“Operational” standards plus
indicators)
17
Performance Standards
The standards tell
providers not only
what to do but
also how to do it
18
Sample Performance
Assessment Tool (1)
Area: Pregnancy Care
Perf. Standard Verification Criteria Y, N, NA Comments
1. The facility Observe in the reception area or
conducts a waiting room if the person who
receives the pregnant woman:
routine rapid
assessment of • Asks if she has or has had:
pregnant - Vaginal bleeding
women - Headache or visual changes
- Breathing difficulty
- Severe abdominal pain
- Fever
• Immediately notifies the health
provider if any of these
conditions are present
See other examples in Nigerian Standards
19
Assessment tool areas for EMNOC:
Nigerian Hospitals
AREAS STANDARDS
1. Focused Antenatal Care 16
2. Pregnancy Complications 25
3. Labor, Delivery, Postpartum, and Newborn Care 27
4. Postnatal Care for Mother and Newborn 23
5. Support Services 24
6. Information, Education, and Communication 10
7. Human, Physical, and Material Resources 26
8. Management Systems 14
9. Infection Prevention 34
Total 199
See Page v of Nigerian Standards 20
Assessment tool areas for EMNOC:
Nigerian PHCs
AREAS STANDARDS
1. Focused Antenatal Care 16
2. Pregnancy Complications 20
3. Labor, Delivery, Postpartum, and Newborn Care 27
4. Postnatal Care for Mother and Newborn 23
5. Support Services 13
6. Information, Education, and Communication 10
7. Human, Physical, and Material Resources 25
8. Management Systems 14
9. Infection Prevention 25
Total 173
21
Step Two:
Implement the Standards
22
Steps to Implement Standards
Do baseline assessment
Identify performance gaps
Identify causes of gaps and interventions to
correct them
Implement interventions
Begin and support change process
23
Implementation Cycle
Desired
performance
Gap Cause
analysis
Actual
performance
Intervention
identification &
implementation
Model Adapted from the International Society for Performance Improvement
24
Baseline Assessment
Determines actual level of performance
using the performance assessment tool
Helps to identify performance gaps
Once gaps are identified, identifies their
causes
25
Baseline SBM-R Scores in Kano and Zamfara Hospitals: Aug. 2007
30
25
20
H1
15
H2
H3
10
5
0
Kano Hospitals Zamfara Hospitals
26
Baseline SBM-R Scores in Kano and Zamfara PHCs: Aug. 2007
30
25
20
PHC1
15 PHC2
PHC3
10 PHC4
5
0
Kano PHCs Zamfara PHCs
27
Defining the performance gap:
Example
100% of pregnant women attending
the ANC deliver with a skilled birth
attendant Define the
performance
58% of pregnant women
gap for each
Gap attending the ANC did NOT
task (in
deliver with a SBA
quantitative or
42% of pregnant women attending qualitative terms)
the ANC deliver with a skilled birth
attendant
28
In order to perform, a performer needs to:
Know how to do
+
Be enabled to do
+
Want to do
29
Capability Knowledge, skills,
(Know how to do) information
Opportunity Resources, tools,
(Be enabled to do) capacity
Motivation Inner drive,
(Want to do) incentives
30
Intervention Identification and
Implementation
Once gaps are identified, do root cause
analysis to identify corrective interventions
Interventions should match the root cause
of the gap
Implement selected interventions
31
Pareto Graph for “Reasons for Not
A. Food not
culturally
Delivering in the Hospital” (Uganda)
appropriate 160 150
148 149
144 146 100%
B. Husband
objects 140 134
122
C. Rude staff 89%
120
107 75%
D. Afraid 81%
E. Language 100 90 71%
differences
80 60%
F. Lack of 70
47%
50%
privacy
60
G. Lack of 42 28%
knowledge
40 28
H. Hospital too 20 25%
far
20 17 15
12 10 2 2
I. Dirty 1 1
hospital 0
C F H J D A E K G I B
J. Long
waiting
K. Too
crowded 32
Intervention Identification
Type of problem Type of solution
MOTIVATION INCENTIVES
Strengthening of
Resources, Capacity Management Systems,
Provision of Resources
Knowledge,
Training, Information
Skills, Information
33
“If all you have is a HAMMER…
everything looks like a NAIL.”
Lack of tools and
equipment
Lack of knowledge
and skills
Lack of motivation
Lack of data and
and incentives
information
Lack of financial
transparency
There is an epidemic of
“workshopitis” in Nigeria
34
/
Effort = Performance
Effort is NOT the same thing as
Performance
35
Change Management Strategy
Implementation of change can be difficult
(business as usual mentality is rampant)
Performance standards are a tool for
initiating and sustaining change
Important to focus on actions and
achievement of early results to help ease
the change process
Individuals can be powerful agents for or
against change
36
Change Management Strategy
The standards in the tools represent
easy and hard challenges
Changes start with the “low-hanging
fruit”
Managers and providers should start with the
easiest tasks and then move to more
difficult tasks, as they develop and increase
their change management skills
Observe change process to identify new
developments, initiatives and behaviors
37
“Multidimensional”
Supervision and Support
SBM-R process uses a variety of ways to
supervise and support change process:
Self/internal assessment
Peer/benchmarking
Supportive supervision (on demand), external
assessment
Client involvement and community participation
(e.g. HFDC with community membership)
Bottom-up approach: based on local control,
empowerment, motivation, advocacy,
resource mobilization
38
Step Three: Measure Progress
39
Steps to Measure Progress
Encourage providers to
self-assess
Measure progress
(internal monitoring)
Bring facilities together
to share challenges
and successes
40
Example: Total Results by Hospital,
Honduras
2001-2004
80
70
60
50 Baseline
1st internal
40
2nd internal
30
3rd internal
20
10
0
HRO HJMG HSMO
41
Results from Seven Hospitals in Malawi
2002 2002 2003 Ext 03-04 Ext 04
100
90
80
70
60
50
40
30
20
10
0
CDH SJH LCH MCH QECH ZCH LH
42
PROQUALI, Brazil
Compliance with standards of reproductive
health care
13th Health Center-Bahia
100
80
60
Baseline
12 Months
40 15 Months
20
0
Total Infection Infra-
Prevention structure
43
PROQUALI Brazil:
Results from Five Pilot Clinics
100
90
80
70
60
50
40
30
20
10
0
Baseline 9 months 12 months 24 months
44
Qualitative results
45
46
47
48
Step Four: Recognize
and Reward Achievements
49
Steps to Recognize Achievements
Address motivational issues
Decide upon incentives
Implement incentive programs
50
Ways to Enhance Motivation
Empowerment: Giving the tools to self-
assess and implement
Challenges: Establishing a clear goal
Achievements: Easy to show results
Healthy competition: Grouping facilities
encourages sharing of experiences and
some competition to succeed
51
Recognition methods (as an Incentive)
Feedback
(verbal, written)
Social
recognition
Material
recognition
52
53
Conferred by the
Ministry of Health to
Mzuzu Central Hospital
in recognition of the
achievement of standards
of excellence in
Infection Prevention
practices
Year 2004
____________________________
Secretary for Health
54
More sample awards
Health care quality
improvement award
for Texas State, USA
Uganda’s Yellow Star
55
Defining Leadership
Leadership: Enabling groups to
make progress in complex
conditions
Leadership is an activity that
takes place at all levels, not a
position of authority
56
We need Leaders and Change Agents!
Leaders must be:
Visionary
Committed
Courageous
Proactive
Nelson Mandela
Determined to make a
difference
Humble
Role model
Mahatma Ghandi
Persistent
Kind
Understanding Mathew Luther-King
57
Managers should think of LEGACY after office!
Tune off the
W.I.I.F.M radio
station.
Think LEGACY
58
Summary
The Standard Based Management and
Recognition Approach has been used in
different parts of the world to improve
the quality of health care services
It can be applied to a variety of technical
areas including integrated RH, IMCI,
EPI, Malaria, HIV/AIDS, Trauma, and
Management of Chronic diseases etc.
59
Summary
SBM-R is:
A four-step process
Not as complicated as it may sound
Puts the power in the hands of local
providers and managers
Requires multiple sources of
supervision and support
60
Thank You from
61
