Like most of the former Soviet Union, the Tula and Tver Oblasts — administrative districts within the Russian Federation, each with a population of about two million — were left after the fall of the Soviet Union with a great deal of responsibility and little funding with which to accomplish anything. In the early 1990s, the health care system was decentralized and provided just one example of a system strapped for resources. In the Tula Oblast, that meant an inability to treat 27 percent of the adult population estimated to suffer from arterial hypertension (AH), while in Tver Oblast it meant difficulty with managing large numbers of pregnancy-induced hypertension (PIH) and neonatal respiratory distress syndrome (NRDS).
Such a scenario would seem an unlikely place to start an evidence-based quality assurance initiative, but that’s just what Dr. Rashad Massoud and the University Research Co., funded by the US Agency for International Development (USAID),
did, with what they call “groundbreaking results.” For example, hypertension-related hospitalizations are down by 85 percent in the Tula Oblast, and PIH-related hospitalizations have decreased by 61 percent in Tver Oblast.
How Did They Do It?
The improvement projects in Tula and Tver were established in 1998 as part of the Quality Assurance Project (QAP) whose goal was to adapt and implement quality improvement methodology in the Russian health care system. Working with US and Russian Federation officials and managed by the University Research Co., the QAP implemented quality improvement methods in general practitioners’ offices and hospitals, and then broadened the effort oblast-wide throughout three phases. In each phase, the project was based on four basic quality improvement principles: focus on the client, understand work as systems and processes, teamwork, and focus on the use of data. That translated into a four-step methodology: identify the problem, analyze the system of care, develop solutions, and test and implement those solutions (using PDSA cycles). The point was to avoid handing down unrealistic goals and plans — as Moscow had done for decades – that could not be implemented in the regions.
PIH, NRDS, and arterial hypertension emerged as “the problems” when the Russian and American experts analyzed data in each oblast. Experts then analyzed the health care systems to identify “all unclear steps and variations in practice” and develop indicators that, along with baseline data, would allow for comparisons before and after the system was altered. In the third step — developing solutions — experts and leaders used evidence-based medicine to reorganize the delivery of health care in the three problem areas, and published guidelines based on this approach. Finally, the implementation of the guidelines was tested.
The methodology was evidenced-based and an adaptive collaborative improvement model based on the IHI Breakthrough Series
. A US-based quality improvement expert, who provided technical assistance and managed the overall project with frequent trips to Russia, mentored a local Russian counterpart to manage the day-to-day project activities. Each oblast also hired a local project coordinator to support teams in their improvement work.
Phase I of the QAP, from 1998 to 2000, consisted of three demonstration projects. In Tver Oblast, those projects included three facilities that cared for women with PIH, and five that cared for infants with NRDS. In Tula Oblast, projects were established in five facilities that cared for patients suffering from arterial hypertension.
Phase II, from 2000 to 2002, focused on spreading the changes to improve systems of care from the pilot sites to other sites. New systems of care for patients with PIH have spread from 3 to 40 hospitals; for patients with NRDS, from 5 to 43 hospitals; and for patients with AH, from 5 to 289 clinics. This spread was spearheaded by Phase I “champions” who were committed, knowledgeable, and enthusiastic individuals working “in the background” to promote the role of Russian counterparts to the extent possible.
Phase III began in 2002 and is still underway. It is the most ambitious part of the project, and involves bringing the lessons of Tula and Tver to 23 territories of the Russian Federation and continuing to make improvements in hypertension, PIH, and NRDS. In addition, this phase will focus on improving care in other clinical areas: secondary cardiovascular disease prevention, diabetes, neonatal jaundice, tuberculosis, and depression, among other conditions.
A recent report by the QAP tells a dramatic success story for Phases I and II. The proportion of women with PIH has dropped from 43.8 percent in 1998 to 5.6 percent. And the system made better use of resources: a study in the year 2000 demonstrated an 87 percent cost savings in treating PIH with the new system of care. There has been one death from preeclampsia in Tver Oblast, but organizers say that was because one physician “refused to follow the improved system of care.”
The news is just as good for the treatment of NRDS:
- 95 percent of neonates are alive on the seventh day after initial resuscitation
- Cases of hypothermia on arrival in the NICU are now rare exceptions
- The number of NICU deaths due to RDS has dropped by 64 percent
In Tula Oblast, adults with hypertension are now more than seven times as likely to be managed in a primary care setting, rather than in a hospital, with hypertension-related hospitalizations down 85 percent and hypertensive crises down 60 percent. Almost 70 percent of patients treated in such settings having achieved stable blood pressures. The new system of care for hypertension has also resulted in cost savings:
- Hospital hypertension treatment costs have decreased 41 percent
- Primary care hypertension management costs have decreased 39 percent
- The overall cost of care for patients with hypertension has decreased 23 percent
But numbers don’t tell the whole story. An independent evaluation of the QAP by Kim Ethier, MA, found that the overall goals of the project could only be accomplished if local participants felt they played an important role. What has made the QAP successful thus far — and what will allow it to continue to build on its success — is the core strategy to empower local practitioners to make improvement. Otherwise, the project will never create long-lasting change.
“The quality improvement methodology is designed to allow people to make decisions and have control over their own work,” Ethier explained in her report. “Experts’ and consultants’ approaches to local leadership and teams included respect and appreciation for the knowledge team members bring.”
Participants in QAP described six elements of moral satisfaction that outweighed the additional work and time required by the project: closer relationship with colleagues, healthier patients, participation in research, support and mentoring, the lack of monetary incentives, and early evidence of change.
Rebuilding the Russian Federation’s health care system is a formidable task, but the QAP has clearly shown it can make great strides. “The work undertaken by QAP/Russia in conjunction with Russian counterparts has become a world-class showcase,” according to a 2003 QAP report. “It has gone far beyond ground breaking results in outcomes and cost savings. It has successfully tackled one of the most formidable problems in modern day development: scale up.”