Table 1

Plan-Do-Study-Act (PDSA) cycles

2 January 2019–4 January 2019
OPD doctors to identify HRP in ANC visits and to write HRP number with red colour in their ANC cards.
To note the HRP number with diagnosis in the HRP register in all four OPD rooms.
To explain the PW and their relatives about associated high-risk and the purpose of giving an HRP number.
Two ANC OPDs as planned.This change idea worked partially. It helped in the identification of HRP and in generating information about HRP status to the PW but led to the duplication of HRP numbers as the doctors gave the numbers in all four OPD rooms on the same day.Identification of HRP and giving an HRP number was important to highlight an HRP in LR. Hence this change idea was adapted with partial modification as PDSA-2.
7 January 2019)
To keep one common HRP register in one OPD room (room no. 212) for HRP number and to send all identified HRP from other rooms to room no. 212.One ANC OPD as planned.This new intervention led to the confusion among high-risk PW to go to another OPD room again to get an HRP number. Doctors from other OPD rooms also felt that this was increasing the visiting time of a PW.Team decided to involve one nursing orderly (NO) in the process.
9 January 2019
The team explained the new intervention to the NO and instructed her to help the high-risk PW to get the HRP number from room no. 212.One ANC OPDThe NO from the team assisted the high-risk PW to get HRP number without much difficulty. The process was not taking much time either as the OPD rooms are adjacent to each other.The idea worked well and was adopted as it is. Other NOs posted in OPD were also explained about the new process and involved. The team recorded all HRP identified in OPD in one HRP register thereafter.
7 January 2019–13 January 2019
Doctor/ Staff Nurse on-duty in LR to look for HRP numbers in the ANC cards. They had to attend such PW on priority and mark them as HRP in their case sheet.
Staff nurse to note down the HRP number in the admission and birth register.
One week in LRWith preidentification of HRP in OPD and HRP number mentioned in ANC card, the LR team found it easy to attend HRP on priority and to manage them in LR during observation and childbirth. They highlighted HRPs in LR and were prepared for any anticipated complications. SN recorded details of HRPs in the registers.
LR team helped each other to successfully carry on the new processes.
The change idea worked well and was adopted as it is. The same process was continued. However, till the end of the first 4 weeks, the team could not achieve its target. The team evaluated the reasons for unidentified HRP in the next 4 weeks and found the reasons as- unbooked HRP coming directly to LR for admission, late-onset HRP among booked PW, and missed HRP in OPD. The team decided to give HRP number in LR to unidentified HRPs and conducted PDSA cycle-5.
1 March 2019–7 March 2019
To identify and highlight HRP in unbooked PW and in a booked PW coming with late-onset HRP at the time of admission in LR.
To give HRP number in LR as HRP-LR and in OPD as HRP-OPD.
One week in LRThe QI team observed that among the unidentified HRP, some were missed out in OPD but the majority were unbooked HRP or with delayed onset HRP in booked PW.This intervention helped the team to achieve its aim and to admit more than 80% HRP in LR with preidentification. However, in subsequent weeks the team members from LR observed that the number of preidentified HRP in LR is increasing and some of them do not require urgent attention. The QI team decided to categorise HRP in PDSA-6.
6 May 2019–8 May 2019
The team planned to colour code the ANC card with yellow and red stickers to mark them as pregnancy with moderate and severe HRP respectively. They developed a list to categorise all HRP into two categories and procured one-inch round stickers online. Stickers and a list of HRP for putting yellow/red stickers kept in all OPD rooms and LR to maintain uniformity in colour coding the ANC cards.
To give priority to HRPs with red stickers.
As planned in two ANC OPDPutting a sticker on the ANC cards of some selected PW led to questions about it. However, when explained properly it helped in bringing awareness among patients and their relatives about HRP.
The process of procurement of stickers was easy and cost-effective.
The change idea worked well and adopted as it is. HRP with red stickers were given priority in the LR.
During data analysis the team observed that a good number of deliveries in LR are HRPs and required additional help.
1 July 2019–7 July 2019)
To post one additional senior resident (SR) to support the LR team in conducting CS delivery and other emergency surgical procedures between 14:00 and 21:00 hours and to assist the LR team as and when required.
To observe the effect of posting one additional SR in LR duty on other routine works.
One weekThis change idea gave very good results. The SR on duty in LR had not to leave the LR for operative procedures and was present full time to monitor the labouring patient in LR and to conduct and supervise PW undergoing vaginal birth. JR and SN in LR also felt supported. The additional SR focused on surgical procedures properly. The other routine services were managed despite posting one SR for LR duty.This idea helped the team to utilise the human resources more judiciously. LR services were well monitored and supervised now.
The team adopted this change idea and started posting an SR on 14:00–21:00 hours duty routinely to support the LR team.
  • ANC, antenatal care; HRP, high risk pregnancy; JR, junior resident; LR, labour room; NO, nursing orderly; OPD, outpatient department; PW, pregnant women; QI, quality improvement; SN, staff nurse; SR, senior resident.