Drivers of Health Facility Quality Improvement: Job Aids and Quality Improvement Support Teams

This approach has been adopted by the Zimbabwean Ministry of Health and Child Care (MOHCC) with support from the United States Agency for International Development (USAID)-funded Maternal and Child Health Integrated Program (MCHIP) Associate Award. The introduction of QISTs and job aids was aimed at addressing persistent challenges with quality in maternal and newborn health (MNH) at 36 health facilities in Manicaland Province. Despite initial improvements, MNH quality performance scores remained below standards, and maternal mortality remained unacceptably high. Research questions focused on evaluating the effect of QISTs and job aids on health facility performance scores and maternal mortality. The study design involved a before- and after-intervention approach, with QISTs and job aids established in each of the seven districts and at each health facility after basic training on supportive supervision. Health workers were trained to use job aids during labor admission and post-natal monitoring of baby and mother. Assessments were conducted at four and 14 months after the intervention. Findings revealed a marked improvement in QI performance scores, with average scores increasing from 50% to 71%. Improvements were maintained more than a year after the introduction of the interventions, with a slight decrease in performance at some sites attributed to the rotation of previously-trained staff. Maternal mortality declined during the same period, with an accelerated reduction observed. The study also found that diverse QISTs functioned better, with the best-performing district, Nyanga, having a diverse composition of clinical, technical, and management departments, as well as project sponsors. The Nyanga QIST had three Basic Emergency Obstetric and Newborn Care-trained members, whereas other QISTs had only two. Limitations of the study included the reliance on financial and technical support from USAID/MCHIP for QISTs to conduct adequate supportive supervision, and the inability to distinguish between the effects of the job aids and those of the QISTs. Implications of the study include the need for the MOHCC to ensure funds are available for regular supportive supervision by district QISTs, and the revision of MNCH tools to function as job aids, which has financial implications. The establishment of functional QISTs and the use of job aids is associated with sustained quality performance improvement and likely contributed to the progressive decline in maternal mortality at the 36 high volume health facilities in Manicaland Province. Recommendations include developing national guidelines for MNCH QI incorporating the use of job aids and the establishment of functional QISTs, revising existing MNCH tools used by health care providers to function as job aids, recognizing achievements in quality improvement, and using dashboards to track QI performance.