title: Transforming Maternal and Neonatal Outcomes in Tertiary Hospitals in Ghana: An Integrated Approach for Systems Change.
abstract: OBJECTIVE
  In Ghana, regional referral facilities by design receive a disproportionate number of high-risk obstetric and neonatal cases and therefore have mortality rates higher than the national average. High volumes and case complexity result in these facilities experiencing unique clinical, operational, and leadership challenges. In order to improve outcomes in these settings, an integrated approach to strengthen the overall system is needed.
  
  
  METHODS
  Clinical skills strengthening, quality improvement training, and leadership skill building have all been used to improve maternal and neonatal outcomes with some degree of success. We present here a customized model tailored to the particular context of tertiary referral hospitals that develops these three skills simultaneously, so that the complex interaction between clinical conditions, resource constraints, and organizational issues that affect the lives of mothers and babies can be considered together. This model uses local data to identify the drivers of poor maternal and neonatal outcomes and creates an integrated training package to focus on approaches to addressing these drivers. Based on this training, quality improvement projects are introduced to change the appropriate clinical or operational processes, or to strengthen organizational leadership.
  
  
  RESULTS
  In testing in one of the largest referral hospitals in Ghana, the model has been well received and has improved performance in several cross-cutting areas affecting the quality of maternal and neonatal care, such as triage, patient flow, and NICU hand hygiene.
  
  
  CONCLUSIONS
  An integrated approach to systems strengthening in referral hospitals holds much promise for improving outcomes for mothers with high-risk pregnancies and babies in Ghana and in other low-resource settings.
authors.affiliation: University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill NC.
authors.forename: Rohit
authors.initials: R
authors.lastname: Ramaswamy
authors.affiliation: University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill NC.
authors.forename: Sarah
authors.initials: S
authors.lastname: Iracane
authors.affiliation: Department of Obstetrics and Gynecology, Ridge Regional Hospital, Accra, Ghana.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Srofenyoh
authors.affiliation: Department of Obstetrics and Gynaecology, South Tees National Health Service Trust, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Bryce
authors.affiliation: Department of Obstetrics and Gynaecology, South Tees National Health Service Trust, UK.
authors.forename: Liz
authors.initials: L
authors.lastname: Floyd
authors.affiliation: Kybele, Inc., Winston-Salem, NC.
authors.forename: Brianne
authors.initials: B
authors.lastname: Kallam
authors.affiliation: Department of Anesthesiology, Duke University Medical Center, Durham NC.
authors.forename: Adeyemi
authors.initials: A
authors.lastname: Olufolabi
authors.affiliation: Leadership Consultant, Berlin, Germany.
authors.forename: Romeck
authors.initials: R
authors.lastname: Van Zeyl
authors.affiliation: Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem NC.
authors.forename: Medge
authors.initials: M
authors.lastname: Owen
mesh_terms: D000328:Adult; D005260:Female; D005869:Ghana; D006801:Humans; D007231:Infant, Newborn; D000068101:Maternal-Child Health Services / Q000592:standards*; D011247:Pregnancy; D011256:Pregnancy Outcome; D058996:Quality Improvement; D062606:Tertiary Care Centers / Q000592:standards*
keywords: Ghana; low income settings; maternal and neonatal mortality; quality improvement; systems strengthening; tertiary hospital