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research paper

Indian Pediatr 2021;58:338-344

Catalytic Support for Improving Clinical Care in Special Newborn Care Units (SNCU) Through Composite SNCU Quality of Care Index (SQCI)

 

Harish Kumar,1 Rajat Khanna,2 Varun Alwadhi,3 Ashfaq Ahmed Bhat,2 Sutapa B Neogi,4
Pradeep Choudhry2, Prasant Kumar Saboth1 and Ajay Khera5

From 1VRIDDHI, IPE Global Ltd.; 2Norway India Partnership Initiative; 3Department of Pediatrics, Kalawati Saran Children’s Hospital; 4International Institute of Health Management Research; and 5Ministry of Health and Family Welfare, Government of India; New Delhi, India.

Correspondence to: Dr Ashfaq Ahmed Bhat, Norway India Partnership Initiative, New Delhi, India.
Email: [email protected]

Received: April 30, 2020;
Initial review: June 29, 2020;
Accepted: November 17, 2020.

 

Objective: To develop a composite index that serves as a proxy marker of quality of clinical service and pilot test its use in 11 special neonatal care units (SNCUs) across two states in India.

Design: Secondary data from SNCU webportal.

Settings: Special new-born care units in Rajasthan and Orissa.

Intervention: We developed a composite SNCU Quality of care Index (SQCI) based on seven indices from SNCU online database. These included rational admission index, index for rational use of antibiotics, inborn birth asphyxia index, index for mortality in normal weight babies, low birth weight admission index, low birth weight survival index, and optimal bed utilization index.

Outcome: Based on the SQCI score, the performance of SNCUs was labelled as good (SQCI 0.71- 1.0), satisfactory (SQCI 0.4- 0.7) or unsatisfactory (SQCI <0.4).

Results: The mean difference in SQCI between Jan-Mar 2016 and 2017 was 0.20 (95% CI 0.13- 0.28; P<0.001). Similar results were obtained for rational admission index, rational use of antibiotics, mortality in normal weight babies, low birth weight survival and optimal bed utilization. A significant improvement in the overall composite score was noted in Odisha (Mean difference 0.22, 95% CI 0.11-0.33, P=0.003) and Rajasthan (Mean difference 0.17, 95% CI 0.05- 0.3, P=0.002). Conclusion: QI approach using SQCI tool is a useful and replicable intervention. Preliminary results show that it does lead to strengthening of implementation of the programs at SNCUs based on the comprehensive scores generated as part of routine system.

Keywords: District hospital, Health programs, Health system, Quality improvement.


I
ndia has experienced a rapid expansion of Facility Based Newborn Care (FBNC) at various levels in the health system in the last decade. The services provided at each level is a product of infrastructure, availability of skilled manpower, capacity of the institution and referral mechanisms available. The facilities have been classified as newborn care corners (NBCC) at every point of child birth, newborn stabilization units (NBSUs) at first referral units (FRUs) and special newborn care units (SNCUs) at district hospitals [1]. Ministry of Health and Family Welfare (MoHFW), Government of India (GoI) under National Health Mission (NHM) has ensured functional SNCUs, in most of the District Hospitals in the country and has plans to further strengthen these units [2,3].

The SNCUs are equipped to manage small and sick neonates except those who need mechanical ventilation and surgical care. These units have admission and discharge criteria for optimal utilization of services and bed strength and services [4]. SNCUs have resulted in improvement in case fatality among newborns admitted to hospitals [5]. However, there are challenges in infrastructure, manpower and care practices [6]. There is a need to assess the performance of SNCUs with respect to quality of patient care, organization and process to support improvement and enhance accountability [5,7-9].

Experiences from QI programs on FBNC are also limited [10-13]. Reports have uncovered the insuffi-ciencies of data management systems to monitor key indicators. To address this gap, GoI with support from UNICEF and Norway India Partnership Initiative (NIPI) established a web-based data management and tracking system, ‘SNCU online’ in the year 2011, to be used across all the SNCUs in India. Between April, 2016 and March, 2017, SNCU online was functional in 571 SNCUs across 27 states with data available for more than 700,000 infants.

Measurement of quality of clinical services rendered in the SNCUs is essential for feedback and improvement. The objective of this study was to develop a composite index that serves as a proxy marker of quality of clinical service and pilot test its use in SNCUs in India.

METHODS

This study was conducted in two stages/phases viz., development of a composite index (SNCU Quality of Care Index or SQCI), and pilot testing the tool for feasibility and applicability in SNCUs.

Development of SQCI: A team consisting of six experts from national and state NIPI team developed a comprehensive tool drawing relevant indicators from SNCU online web portal. The process, spanning over a four month period, involved field visits and observations by pediatricians and statisticians. While defining the indices, due considerations were given on whether those were in accordance with global norms and standards for measuring quality of clinical care, user-friendliness, access to available data, ability to do self-assessment, and utility to Government for providing timely feedback. The focus was to have a dynamic model that could assess the optimal utilization of services, identify gaps in skills and clinical practices that influence the case fatality in every SNCU. For each of these objectives, most appropriate indicators were identified and put into a statistical model to arrive at a composite index. This was then piloted in one SNCU to test for its reliability, feasibility and usefulness in public health settings.

Initially, six indices were selected for SQCI, which also included an index on total deaths in the SNCU. Since this index was not able to measure the specific quality of care issues in the SNCU, it was replaced with mortality in normal weight babies (³2500 gram). Additionally, one more indicator was added on inborn birth asphyxia index, to measure whether asphyxia was managed adequately in the labour room, and its subsequent load and implication on SNCUs in terms of bed occupation.

SQCI is a composite index of seven indices, each having a range from 0.01 to 1 (Table I and Web Table I): rational admission index, index for rational use of antibiotics, inborn birth asphyxia index, index for mortality in normal weight babies, low birth weight admission index, low birth weight survival index, optimal bed utilization index. Since the indices are comparing different items and each item has multiple properties, we have taken the geometric mean to calculate the final score. Based on the SQCI score, the performance of SNCUs was assessed as a Likert scale and labelled as good (SQCI 0.71- 1.0), satisfactory (SQCI 0.4- 0.7) and unsatisfactory (SQCI <0.4) [14].

Table I Special Newborn Care Unit (SNCU) Quality of Care Index (SQCI) Calculations

Data collection: The SQCI tool was used in the states of Rajasthan and Odisha. All the parameters were retrieved in each quarter of the year, recorded in a predesigned excel database and SQCI score calculated by the program team. The indices were calculated for every month and then compiled for each quarter of the year. Each index was color coded (red for unsatisfactory, yellow for satisfactory and green for good) for better understanding. No additional data were collected for the purpose of the study.

Overall feedback, with particular emphasis on the two worst indicators, was provided to the districts. This facilitated improvement in the performance of the SNCUs.

Permission and approvals were obtained from concerned authorities (MoHFW, State governments) for retrieval and analysis of data from SNCU database. Anonymity and rights of patients and doctors were respected and therefore we did not consider individual level data in our analysis.

The data for SQCI computation was taken from an ongoing program and hence no ethical issues were involved. Since this was a program evaluation based on routinely collected data, no additional data was collected.

Data of five quarters starting from Jan- Mar 2016 to Jan- Mar 2017 were compared to assess the change in the quality of services. Paired t test was done to explore the statistical significance of the difference over a period of one year (from Jan-Mar, 2016 to Jan-Mar, 2017).

RESULTS

We present the results as composite scores aggregated from the SNCUs for the two states. In the pilot phase, data from 11 SNCUs out of total 92 SNCUs in the states of Rajasthan (n=59) and Odisha (n=33) were analyzed. The SQCI for Odisha increased from 0.44 to 0.57 over a period of one year while that of Rajasthan showed a marginal increase. (Table II, Fig. 1). Overall, the mean difference of the differences in the composite index of each unit between January to March, 2016 and same period in 2017 was 0.20 (95% CI 0.13- 0.28; P<0.001). Similar results were obtained for other indices. A significant improvement in the overall composite score was noted in Odisha [MD (95% CI) 0.22, (0.11-0.33) P=0.003] and Rajasthan [MD (95% CI) 0.17, (0.05-0.3) P=0.002] (data not shown).

Fig. 1 Comparison of select indices of SQCI model across different SNCUs in selected districts of two states in India in 2016-2017.

We analyzed the key indices that are most amenable to improvement within the limited period of intervention. Those indices were index for rational use of antibiotics, index for mortality in normal weight babies and low birth weight survival index. An analysis of every unit for the difference in these indices for the same time periods showed a significant improvement. A positive effect in terms of an improvement in the overall composite score was observed one year after the initiation of the QI model (data available at https://sncuindiaonline.org).

Table II Indices to Measure Quality of Care in SNCUs in India Based on SQCI Model
Time period SQCI Rational Index for Inborn birth Index for Low birth Low birth Optimal
admission rational use asphyxia mortality in weight weight bed
index of antibiotics index normal weight admission survival utilization 
babies index index index
Odisha (7 SNCUs combined)                 
I qtr 2016 0.44 0.91 0.34 0.70 0.40 0.27 0.66 0.20
II qtr 2016 0.28 0.95 0.01 0.64 0.44 0.26 0.71 0.28
III qtr 2016 0.46 0.95 0.41 0.62 0.17 0.33 0.65 0.47
IV qtr 2016 0.44 0.94 0.42 0.62 0.09 0.34 0.66 0.63
I qtr 2017 0.57 0.99 0.50 0.69 0.36 0.27 0.81 0.74
Rajasthan (4 SNCUs combined)                 
I qtr 2016 0.50 0.74 0.55 0.79 0.71 0.19 0.67 0.27
II qtr 2016 0.40 0.76 0.11 0.90 0.87 0.18 0.71 0.20
III qtr 2016 0.40 0.73 0.12 0.89 0.69 0.19 0.76 0.20
IV qtr 2016 0.49 0.78 0.29 0.89 0.71 0.21 0.70 0.35
I qtr 2017 0.52 0.80 0.51 0.82 0.67 0.20 0.62 0.39
 MD (95% CI) a 0.20 0.07 0.28 -0.01 -0.33 0.008 0.01 0.14
(0.13-0.28)b (0.03-0.11)b (0.16-0.41)c (-0.05-0.03) (-0.52,-0.14)b  (-0.02--0.03) (-0.09-0.12)b (0.007- 0.27)b
aMean difference in scores in each unit in first quarter of 2016 and 2017; bP<0.05; #P<0,001, SNCU: Special newborn care unit; SQCU: SNCU quality of care index; ^I quarter: January-March, II quarter: April-June, III quarter: July-September, IV quarter: October-December. 

DISCUSSION

This study describes the development of a composite index and its application in two states of India. Our results showed SQCI in the SNCUs could be utilized for improving quality of services. An analysis of the SQCI over a period of one year showed a significant improvement in both the states.

Our findings demonstrate that program managers can use the tool to monitor the FBNC program. In the state of Rajasthan, the SQCI scores were utilized to initiate discussions on the challenges and discuss areas for improvement such as rational use of antibiotics, admission criteria and inpatient management of LBW newborns. Similarly, in Odisha, this model was used to identify and prioritize the shortfalls that were addressed during supportive supervision by the medical officers as part of the routine program.

Globally, it is now known that quality improvement (QI) models work in diverse cultures and locations [15]. Studies have shown that a regular system of QI intervention generally leads to improved adherence to health care delivery practices [8,12,13]. A QI project in six tertiary care hospitals in India, focused on interventions for increasing awareness on health care associated infections, improving compliance to infection control measures and monitoring rational antibiotic use reported. Periodic visits, rapid assessments and feedback, training and action at public health facilities has been reported to lead to improvement in adherence to QI guidelines in labor rooms in Rajasthan [8]. Periodic monitoring of labor rooms and newborn care facilities in Bihar also resulted in favorable outcomes [13,17]. Though on-site real time observations to assess quality of delivery of services have their own merits, yet it is a cost-and-resource intensive exercise and hence, may not be a preferred option for public health program [13].

Several QI models that have attempted to improve the quality of services have focused on babies with LBW [18-21]. The goals of these models were to identify and explain variations in clinical practices and patient outcomes from the routinely collected secondary data on newborns weighing less than 1500g [19]. Our assessment is based on the online database maintained by the health system, which is similar to those models. In our country, the purpose of setting up SNCUs was to take care of LBW babies primarily. However, reports suggest that the bulk of admissions to SNCUs are contributed by babies whose birthweights are more than 2500 [5,6]. Our approach therefore included babies of all birth weights.

An advantage of our approach is the ease with which data can be assembled and analyzed without relying on any special technical help. In our case, concurrently and routinely collected data from SNCUs were used which was independent of the process of medical records data abstraction. The indicators used to calculate SQCI are objective in nature, and less likely to be influenced by individual perceptions. Another advantage of our approach is that every SNCU in-charge in the country has access to review their own performance through the online portal, which is an advantage in terms of efficiency and feasibility.

Our limitations were that we captured only the providers’ performance and users’ perspectives were completely missed out. Although an important component in itself [22], we did not include them due to feasibility issues. Certain indices such as newborns discharged within 24 hour do not capture the reasons for admission, which is a drawback. Secondly, an independent evaluation to assess the validity of SQCI indices was not undertaken and it remains a limitation. In order to obtain some feedback on the reliability of SQCI, trained neonatologists did an independent assessment of select SNCUs, although this was not very objectively done. The overall feedback given by the experts confidentially corroborated well with the inferences drawn based on data driven QI model. Our experiences from 11 SNCUs across two states represent diverse locations lending to a possible generalizability with states with similar health indicators.

Government at both national and state levels were in support of QI initiatives using SQCI. Use of an existing mechanism of surveillance without any major external support for QI makes it more feasible as compared to the existing QI models. Implemented within the existing health systems, infrastructure and human resources, it contains a few components that can be easily added onto the existing system.

The SQCI index is a useful tool to evaluate the quality of neonatal care services in the Indian Special Newborn Care Units. The index can be used to follow a unit’s performance over time or to benchmark various units and for quality improvement.

Contributors: HK: conceptualized SQCI and provided technical oversight of the process of SQCI analysis and use; RK: developed the statistical model during conceptualization of SQCI, analyzed data, interpreted the results and contributed to writing of the manuscript. VA,AK: provided technical support during conceptualization of SQCI, monitoring indicators and reviewed the manuscript; AAB: contributed in the framing of monitoring indicators and reviewed the manuscript SBN: reviewed the literature and drafted the manuscript; PC,PKS: implemented SQCI in their respective states, reviewed manuscript and provided inputs.

Funding: This study was conducted as part of the Newborn care project supported by Norway India Partnership Initiative (NIPI); Competing interest: None stated.

WHAT IS ALREADY KNOWN?

There are multiple methods available to assess quality of services from routinely collected data.

WHAT THIS STUDY ADDS?

It is possible to calculate indices (SQCI) based on available data that serve as proxy to quality of services.

It is feasible to implement SQCI in public health settings for quality improvement.


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