Background: Since October 2017, JSI Research and Training Institute Inc./ The Last Ten Kilometers (L10K) Project has been supporting the Amhara, Oromia, SNNP, and Tigray Regional Health Bureaus (RHBs) to develop the Reproductive, Maternal, Newborn, and Child Health (RMNCH) Centers of Excellence (CoE)— a functional linkage of health facilities across the continuum collaborating to pursue excellence in clinical RMNCH quality and community health and serve as an innovation hub, competency center, and learning platform— to reduce maternal and neonatal mortality and morbidity by expanding access to efficient, high-quality RMNCH services. The CoE strategy is designed to establish one demonstration zone per region in four regions (i.e., Amhara, Oromia, SNNP, and Tigray regions) where selected health care facilities— one general hospital, one primary hospital and one Primary Health Care Unit (PHCU), and all health posts under the selected PHCU— would be excellent centers in providing High-Quality Clinical Care (HQCC) to the community and act as a role model for learning to the other zones and facilities within the region in quality service provision, health service management, and community engagement. It is designed to develop capacity of facilities to mentor other facilities, implement HQCC, and create strong supportive linkages which could be a sustainable way for the health system to expand quality improvement (QI) efforts of institutionalizing quality culture and produce important systemic changes and would have the potential to reduce the maternal and neonatal deaths in target CoE facilities.

Objectives: This operation research was conducted to understand ‘what works and does not work’ to improve the implementation intensity of CoE initiative. Specifically, this research focused on 1) processes of establishing CoE and skill lab; 2) implementation strength of CoE; and 3) facilitators and barriers to the establishment of CoE and use the skill lab.

Methods: Researchers choose an implementation strength study complemented by a programmatic qualitative research design to answer the stated research questions.  In-depth interviews (IDIs) were conducted with 34 program implementers in the intervention areas.

Results: Some of the descriptive findings are presented below. The qualitative component of the study is transcribed and its synthesis is underway (which will be presented).

Functional facility linkages across the continuum: The functional facility linkage percentage scores are 91% (7.3 out of 8 points) between health centers and their satellite health posts and 89% (2.7 out of 3 points) between hospitals and health centers.

Findings from the qualitative study showed that the clinical catchment-based mentorship initiative is making a difference. Hospital and health center staff mentioned that it helped them improve referral management, create strong learning collaboration and referral linkages, and improve nursing care plans, follow-up care, and provision of all components of (e.g., partograph completeness, regular vital sign monitoring).

Establishing RMNCH skills lab, a hub for competency training: Skills labs were established in four general hospitals, two primary hospitals, and four health centers in the four regions to help health care providers retain and practice RMNCH skills. Hospitals and health centers have an average of 160m² and 30m² space area, respectively, dedicated to the skill lab with the following partitions: registration/reception, main demonstration area, store area, and audio-visual area. Facilities arrange the skill lab layout flexibly to accommodate a variety of needs depending on the skill taught, demonstrated or practiced. Facilities have different electro-medical equipment and low fidelity manikins that enable training in simultaneous or multiple skills. Most of the facilities have the following obstetric basic skill sets including management of eclampsia, shoulder dystocia, mal-presentations, giving IV and IM injections, catheterization skills, PPH management, management of labor, instrumental delivery, neonatal resuscitation, perineal repair (vaginal tears and episiotomy). It is also furnished with necessary flexible furniture such as exam tables and chairs.

Currently, in all of the 10 CoE facilities, their skill labs are functional. All facilities assigned a skill lab officer or a focal person coordinating the skill lab. Currently, the skill lab is opened for 5.4 hours, on average.  Since April 2019, an average of 11 (ranging from 1–43 sessions) training/skill practice sessions per facility (health centers/hospitals) were organized, while some facilities have provided training to HEWs at the skill labs as part of the catchment-based mentorship program in the health posts. A total of 1,833 trainees (1,195 staff and 638 students) from nine health facilities from the four regions attended the training from the skill lab. The qualitative study indicates that the training increased participant competency, especially in family planning, pre-eclampsia/eclampsia and postpartum hemorrhage management, assisted deliveries, and newborn resuscitation. According to feedback from the skill lab officers’ during our learning visits to the demo zones, facility staff are very motivated and committed to practicing what they learned in the skill lab sessions. Senior staff are interested in sharing their experiences and transferring their skills. Another encouraging result is that senior facility management have allocated budgets for consumables and staff training, and have assigned skill-slab focal persons.

Provision of client-focused high-quality clinical care: The performance of health facilities in terms of provision of basic and emergency obstetric and newborn functions in the past 3 months prior to data collection improved over time. On average 5.5 signal functions provided in April 2018 improved to 6.75 in October 2019. This means that except one health center that provided 6 of the functions, 3 of the HCs are providing all 7 signal functions and upgraded to fully functional BEmONC facilities. Likewise, all hospitals are fully functional EmONC centers. Consequently, the proportion of expected obstetric complications managed at facilities improved over time.

In each facility, multidisciplinary QI teams are formed consisting of relevant technical staff to identify critical barriers and design tailored solutions to address them. Each facility has a mean of 3 QI active projects being implemented. Project types included neonatal death, essential newborn care, compassionate and respectful care (CRC), early ANC, postnatal 24 hours stay in the facility, referral feedback to another health facility, medical records completeness.  Six of the projects focusing on improving safe childbirth checklist utilization, partograph use, outpatient waiting time, and nursing care plan are completed meeting their targets (data would be presented).

However, the perinatal mortality (stillbirth and early neonatal death) and neonatal death at NICU, as well as the average length of stay of sick neonates admitted at NICU, did not show significant improvement over time.