Details of changes tested
| PDSA | Categories of changes | Plan | Do | Study | Act |
| PDSA 1 May 2019, week 1 | Patient flow management | A team of OPD doctors, nurses and counsellors developed a plan for improved patient flow during ANC that allowed the pregnant women to obtain various ANC service components sequentially. Volunteers from the Red Cross Society were engaged to support in crowd management and systematically direct the patient flow. | This ‘change’ was tested in three ANC OPDs over 3 days covering 30 ANC clients. | This change was successful, and team was able to manage crowd | This change was found feasible and was then applied to all the OPDs and adopted. |
| PDSA 2 May 2019, week 2 | Recording and verification of ANC services received | The QI team assigned a senior resident with the responsibility of verifying whether a PW received all ANC services (eg, anthropometric measurement, BP check and Hb testing) before the patient was directed to the senior faculty member/doctor for a review of the findings and an obstetric assessment. | This ‘change’ was tested in three ANC OPDs over 3 days covering 36 ANC clients. | This change was found to be effective in ensuring that pregnant women received all the available ANC services but felt difficult to write each service. | Department printed an ANC register to record all the services during the OPD and then change was adopted. |
| PDSA 3 May 2019, week 3 | Ensuring receipt of Hb test report on the same day | As per current practice, PW did not receive their Hb test results on the same day. Instead, they had to make another OPD visit so that the doctor could review and discuss their findings with them. Often PW, especially those who lived far from the hospital, did not return for this second visit, given their time and financial constraints. The QI team decided to try to make the Hb report available on the same day as it was critical for timely assessment of anaemia and treatment. | This ‘change’ was tested in three ANC OPDs over 2 days covering 19 ANC clients. | The practice was not found feasible | This change could not be applied in 100% of the cases due to the limited capacity of the in-house laboratory. This change did not work and was abandoned. |
| PDSA 4 June 2019, week 1 | Use of MCP card to record and track ANC data | 1. The QI team facilitated the availability and use of government-issued MCP cards, which record and track anthropometric measurements, clinical examination (BP) and tests (eg, blood test report for Hb, urine test for sugar and albumin). Initially, a junior resident (JR) doctor was assigned the task to enter the ANC data for each pregnant woman from the OPD slips to the MCP cards. 2. The team decided to assign the responsibility to the auxiliary nurse midwife (ANM) who worked at the adjoining family planning centre. | 1. This ‘change’ was tested in three ANC OPDs over 2 days, covering 18 ANC clients by JR. 2. Tested in three ANC OPDs over 3 days by ANM covering 35 ANC clients. | 1. The team found that this was not sustainable since the JR was also responsible for other patients in the OPD. 2. The team found that not all ANC clients reported to the ANM to get their data from the OPD slip transferred to their MCP card. Also, in some cases, the data related to weight, height and BP was not recorded on the OPD slip. | The QI team briefed and oriented the JRs and the ANM on the importance of recording these parameters in the OPD slips and the MCP cards. Hospital management made JR and ANM (rotation wise) responsible for this work and included it as one of the their key responsibility. QI team was able to obtain expected results by this change and decided to adopt the practice. |
| PDSA 5 May 2019, week 4 | Nutritional counselling | 1. The hospital did not have a dedicated nutrition counsellor and hence the HIV counsellor was assigned the additional responsibility of counselling the pregnant women on the importance of a healthy diet. 2. Additionally, a junior doctor from the OBGY department was assigned the responsibility of nutrition counselling. | 1. This ‘change’ was tested in three ANC OPDs over 3 days covering 30 ANC clients with HIV counsellor. 2. Tested three ANC OPDs over 3 days covering 36 ANC clients with junior doctor and HIV counsellor. | 1-However, due to the high patient load, this was not sustainable. Group counselling was also not a feasible option since there was not enough space in the OPD. 2. It worked well with additional junior doctor. | Women were classified based on their Hb status into normal, moderate and severely anaemic. Need-based counselling was provided to moderately and severely anaemic PW. Changes adapted, tested further and then adopted. |
| PDSA 6 May 2019, week 4 | Assessment of quality of counselling | To assess the quality of nutrition counselling and to improve counselling, the departments of OBGY and PSM developed an exit interview questionnaire for pregnant women attending OPD. | This ‘change’ was tested in one ANC OPDs over 1 day covering 12 ANC clients. | A junior resident from the department of PSM was assigned to conduct the interviews with randomly chosen patients twice a week. | The process was found to be both feasible and sustainable. Change was adopted. |
| PDSA 7 June 2019, week 2 | Developing data recording system | The QI team introduced the system of recording ANC data, including maternal nutrition services. A staff nurse assigned to record the data. | This ‘change’ was tested in two ANC OPDs over 2 days covering 22 ANC clients. | Staff nurse was able to record ANC data of maternal nutrition services provided to PW. | Based on the suggestion of the QI team, the OBGY department developed a new register to record all relevant information of services provided to pregnant women in the ANC OPD and change was adopted. |
ANC, antenatal care; BP, blood pressure; Hb, haemoglobin; MCP, mother and child protection; OBGY, obstetrics and gynaecology; OPD, outpatient department; PW, pregnant women.