Open access Quality improvement report

Sustaining extended Kangaroo mother

BMJ Open Quality: first published as 10.1136/bmjoq-2023-002307 on 20 October 2023. Downloaded from https://bmjopenquality.bmj.com on 28 January 2025 by guest. All rights, including for text and data
care in stable low birthweight babies in
NICU: a quality improvement
collaborative of six centres of Karnataka
Raksha Murthy,1 Anil Kallesh,2 Abhishek Somasekhara Aradhya ‍ ‍,3
Shruthi K Bharadwaj,4 Praveen Venkatagiri,5 Meena Jagadish,1
Poornachandra Rao,3 Divya Chandramouli,6 Doddarangaiah Hema,5 S N Chaithra,2
Hellan Glory,6 Jayashree Purkayastha,4 KMC QI Collaboration of Karnataka

To cite: Murthy R, Kallesh A, ABSTRACT

Somasekhara Aradhya A, WHAT IS ALREADY KNOWN ON THIS TOPIC
Background Kangaroo mother care (KMC) is a proven
et al. Sustaining extended ⇒ Evidence from systematic reviews has shown that
intervention for intact survival in preterms. Despite
Kangaroo mother care in stable Kangaroo mother care (KMC) improves surviv-
evidence, its adoption has been low. We used a point of
low birthweight babies in al, breastfeeding rates, reduces hypothermia and
NICU: a quality improvement care quality improvement (QI) approach to implement
and sustain KMC in stable low birthweight babies from a nosocomial infections in the short-­term and long-­
collaborative of six centres of
Karnataka. BMJ Open Quality baseline of 1.5 hours/baby/day to above 4 hours/baby/day lasting positive effects on behaviour up to 20 years.
2023;12:e002307. doi:10.1136/ through a series of plan-­do-­study-­act (PDSA) cycles over a Many quality improvement (QI) initiatives have been

mining, AI training, and similar technologies, are reserved.

bmjoq-2023-002307 period of 53 weeks. undertaken to sustain increased KMC duration in
Methods All babies with birth weight <2000 g not on their individual units. These studies have tested var-
► Additional supplemental ious interventions such as awareness of staff and
any respiratory support or phototherapy and or umbilical
material is published online only. parents, foster KMC, simpler KMC documentation,
lines were eligible. The key quantitative outcome was KMC
To view, please visit the journal increasing resources like KMC chairs and provision
online (http://​dx.​doi.​org/​10.​ hours/baby/day. A QI collaborative was formed between six
centres of Karnataka mentored by a team with a previous of beds to mothers, rewarding staff and parents
1136/​bmjoq-​2023-​002307).
QI experience on KMC. The potential barriers for extended sequentially.
KMC were evaluated using fishbone analysis. Baseline
Received 8 February 2023
WHAT THIS STUDY ADDS
data were collected over 3 weeks. A bundled approach
Accepted 21 September 2023 consisting of a variety of parent centric measures (such as ⇒ Using a bundled approach encompassing parent-­
staff awareness, making KMC an integral part of treatment centric strategies aids in quick implementation
order, foster KMC, awareness sessions to parents weekly, of KMC. The collaborative model helped mutual
recognising KMC champions) was employed in multiple learning between centres, served as a platform for
PDSA cycles. The data were aggregated biweekly and the sharing innovative ideas and helped scale up the
teams shared their implementation experiences monthly. intervention in multiple centres despite varied sick-
Results A total of 1443 parent–baby dyads were enrolled. ness and limitations in resources.
The majority barriers were similar across the centres. HOW THIS STUDY MIGHT AFFECT RESEARCH,
Bundled approach incorporating foster KMC helped in the PRACTICE OR POLICY
quick implementation of KMC even in outborns. Parental
⇒ Bundled approach could be used to increase KMC
involvement and empowering nurses helped in sustaining
KMC. Two centres had KMC rates above 10 hours/baby/ duration in future QI initiatives to reduce implemen-
day, while remaining four centres had KMC rates sustained tation time. This collaborative initiative provides
above 6 hours/baby/day. Cross-­learnings from team a framework for scaling up KMC in larger state or
meetings helped to sustain efforts. Extended KMC could be nationwide collaborations without any additional
implemented and sustained by low intensity training and need for resources and can be replicated in similar
QI collaboration. contexts across the developing world.
© Author(s) (or their
employer(s)) 2023. Re-­use Conclusions Formation of a QI collaborative with
permitted under CC BY-­NC. No mentoring helped in scaling implementation of extended
commercial re-­use. See rights KMC. Extended KMC could be implemented by parent
and permissions. Published by pass away.1 As per UNICEF, more than 35%
centric best practices in all the centres without any
BMJ. of all neonatal deaths are caused by compli-
additional need of resources.
For numbered affiliations see cations from preterm birth.2 Many preterm
end of article. infants who live experience sensory, cognitive
INTRODUCTION and language impairments as a result of their
Correspondence to
Dr Abhishek Somasekhara Problem description early birth.3 India is accountable for about
Aradhya; Nearly 15 million preterm neonates are born 25% of preterm births and 42% of low birth-
​abhishekaradhyas@​gmail.​com each year, and more than 1 million of them weight (LBW) infants worldwide.4 Kangaroo

Murthy R, et al. BMJ Open Quality 2023;12:e002307. doi:10.1136/bmjoq-2023-002307 1

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mother care (KMC) is a simple, cost-­effective and proven Available knowledge and rationale

BMJ Open Quality: first published as 10.1136/bmjoq-2023-002307 on 20 October 2023. Downloaded from https://bmjopenquality.bmj.com on 28 January 2025 by guest. All rights, including for text and data
intervention for both survival and improved neurobehav- Evidence from systematic reviews has shown that
ioural outcomes of preterms.5–7 The important compo- KMC improves survival, breastfeeding rates, reduces
nent of KMC involves continuous and prolonged skin-­to-­ hypothermia and nosocomial infections in the short
skin contact between the caregiver, especially the mother term.8 13 The KMC done in the initial few days can
and the baby. Although the effectiveness of KMC has been have long-­lasting positive effects on behaviour even
well documented, there is a huge knowledge-­practice gap up to 20 years with less hyperactivity, school absen-
and poor implementation of the intervention in many teeism, etc.7 Many QI initiatives have been undertaken
units.8 The common challenges for KMC implementa- to implement and sustain increased KMC duration in
tion are low healthcare staff awareness, non-­availability
their individual units. These QI initiatives have imple-
of mothers in the initial few days both in postcaesarean
mented KMC ranging from 2 months to 9 months.
delivery and outborn settings, resistance to foster KMC
These studies have tested various interventions such
(KMC by a family member), and lack of a structured
policy.8–10 as awareness of staff and parents, foster KMC, simpler
Quality improvement (QI) collaboratives help KMC documentation, increasing resources such as
organisations identify and target implementation KMC chairs and provision of bed to mother, rewarding
barriers by training them in QI processes, providing staff and parents sequentially. 14–19
an infrastructure for addressing common barriers Either supervision or high intensity training (>5 days
(provider concerns, leadership support, logistics, training combined with >1 interactive method) alone
structural challenges), and developing an interorgan- or even in combination is unable to bring greater
isational support network from which participating changes in quality care. While low intensity training
centres can learn from each other’s successes and combined with QI collaborative has a greater impact
challenges.11 12 Most of the challenges for implemen- on improving quality care in low-­income and middle-­
tation of KMC are similar and possibly the solutions income countries.12 With one of the centres already

mining, AI training, and similar technologies, are reserved.

too. Collaborations between organisations is the need having a prior experience of QI in KMC,16 we decided
of the hour to help scale up KMC to improve preterm to form a QI collaboration to implement extended
quality care. KMC across different centres.
Setting
A KMC QI collaboration was formed between six centres Aim
of Karnataka, India. All these six centres were tertiary We aimed to implement extended KMC for eligible
care neonatal intensive care units (NICUs) with annual babies (babies with no respiratory support/need of
admission load ranging from 250 to 1200. All the centres phototherapy/no umbilical central lines) admitted in
admitted both inborn and outborn neonates with majority the NICU of collaborative centres from a baseline of
centres catering to the outborn population. The relevant 1.5 hours (range) (40 min to 2.7 hours) per baby per
information of the participating centres has been summa- day to above 4 hours per baby per day over a period
rised in table 1. of 8 weeks.

Table 1 Summary of the participating centres and demographic features

Hospital ID Centre 1 Centre 2 Centre 3 Centre 4 Centre 5 Centre 6
Organisation type Public sector DNB teaching Fellowship DNB teaching Fellowship Medical
training training college
No of admissions/month 120 80 50 30 20 130
Average patient occupancy/day 25 18 8 6 6 35
Patient:nurse ratio 8:1 5:1 3:1 3:1 2:1 4:1
Entry collaboration January 2022 January 2022 January 2022 April 2022 June 2022 June 2022
Baseline KMC rate in hours/baby/day 0.6 2.9 2.7 1.6 1 2.7
No of parent baby dyads enrolled 845 187 84 51 22 254
Mean gestational age at birth (SD) 34 (2) 32 (1) 33 (2) 32 (2) 32 (1) 31 (3)
Mean birth weight (SD) 1689 (210) 1670 (275) 1554 (329) 1543(344) 1470 (290) 1450 (330)
Outborns (%) 460 (54) 51 (27) 53 (63) 11 (21) 6 (27) 37 (15)
Caesarean delivery (%) 321 (38) 153 (82) 68 (81) 46 (90) 21 (96) 162 (64)
Twin gestation (%) 66 (8) 40 (21) 3 (3) 6 (11) 3 (14) 27 (11)

DNB, Diplomate of National Board; KMC, Kangaroo mother care.

2 Murthy R, et al. BMJ Open Quality 2023;12:e002307. doi:10.1136/bmjoq-2023-002307

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METHODS (after discharge) were involved for peer counselling of

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Design new parents.
A multidisciplinary QI collaborative was formed between
6 centres of Karnataka, India. Each centre had a team of at Measurements
least two nurses and two doctors. The study was conducted The key quantitative outcome was KMC hours per baby
in the NICU and step-­down wards from January 2022 to per day. The number of hours of KMC per baby was
December 2022. Both inborn and outborn stable babies taken as a numerator. The number of eligible babies
below the birth weight of 2 kg were eligible for the study. was taken as the denominator. Twin babies were taken as
A stable baby was defined as a baby not requiring respira- two eligible babies. We also recorded the percentage of
tory support, phototherapy for jaundice and or having parents completing extended KMC as another outcome
umbilical central lines. The babies on respiratory support indicator since May 2022. Audits were done by two nurses
were also given KMC in the unit, but were not part of the and was supervised by one doctor from each centre. KMC
data collection. Extended KMC was defined as KMC hours duration was uploaded in the common Google form of
more than 4 hours per baby per day as per the national the collaboration on a daily basis. The number of KMC
guidelines.20 We used a point of care QI approach to hours was calculated from 08:00 the previous day to 07:59
implement KMC in stable LBW babies through a series of the next day. Descriptive statistics were used to describe
plan-­do-­study-­act (PDSA) cycles. the demographic variables. We obtained 2–3 weeks of
All teams of centres except centre 6 were trained baseline data to calculate the median. Monthly compli-
together at a QI Workshop held at Bangalore which ance rates were collected thereafter and displayed using
helped to form the collaboration. The six collabora- run charts from Microsoft Excel software. We defined a
tive centres were enrolled sequentially. Mentoring unit shift according to evidence-­based rules.21 When we iden-
(centre 3) enrolled centre 1 and 2 first in January 2022. tified a shift, we recalculated the new median using the
After implementation of extended KMC in the first two points that made up the shift and compared new data to
centres, centre 4 was enrolled in April 2022. Centres 5 this new median. We followed the Standards for Quality

mining, AI training, and similar technologies, are reserved.

and 6 were enrolled in June 2022. Due to lack of funding Improvement Reporting Excellence 2.0 guidelines for
and non-­availability of research staff, sequential enrol- reporting.22
ment into the collaboration was done.
Each centre had a team of 2–3 nurses and 2 doctors. Strategy
Each of the participating sites chose a nurse-­led team During the baseline period (at least 2 weeks), the two
leader. Two nurses and one doctor ensured implemen- nursing officers from individual centres collected daily
tation of the bundle approach and entered data to the data on KMC hours per baby per day from eligible infant–
common database. Other doctor was a senior consul- mother dyads on a predesigned Excel sheet. The data
tant who ensured team meetings and supervision of the were supervised by doctors from individual centres and
data. The change package (bundled approach) that was submitted to the core team of collaboration. The poten-
given to them was based on interventions that helped tial barriers for prolonged KMC were evaluated using fish-
implement KMC in the mentoring unit and the first two bone analysis. After the baseline period, we implemented
centres. Our collaborative faculty consisted of the mento- extended KMC sequentially over a period of 2 months
ring team and senior paediatricians (with prior research/ through a series of two PDSA cycles. In each phase, the
QI experience in KMC). Run charts of each centre were duration of KMC per baby per day was recorded daily and
updated once every 2 weeks in a common whatsapp displayed in the run charts every 2 weeks. The collabora-
group. Monthly meetings on a virtual platform held every tive meetings were held every 4 weeks with all the teams
4 weeks provided the teams with the opportunity for on a virtual platform which, If there was a sudden dip in
learning and served as a motivation. If there was a sudden the rate of KMC in 2-­weekly run charts, the team meetings
dip in the rate of KMC in 2-­weekly run charts, the team with individual centres were supervised by the mentoring
meetings with individual centres were held and super- team.
vised by the mentoring team. This assisted in creating a
helpful communication system for early escalation and PDSA cycles
tackling of challenges. PDSA #1 (2–4 weeks)
A change package (bundled approach) was employed in
Patients and public involvement the first PDSA based on the previous experience of centre
Patients and/or the public were not involved in the design, 3.16 The major process concerns addressed were staff
or reporting, or dissemination plans of this research. awareness, availability of mothers and hesitation for foster
However, mothers were involved indirectly during imple- KMC. The components of the bundle were staff sensiti-
mentation phase (PDSA 2) and during sustenance phase. sation, issues related to mother’s preparedness, availa-
In the implementation phase, mothers were the judges bility of KMC chairs, structured counselling, promoting
for the counselling competition for nurses. During the foster KMC, making KMC part of day to day practice and
sustenance phase, mothers were trained on KMC on a simpler KMC documentation. The staff sensitisation was
weekly basis and mothers with prior KMC experience the first component addressed by training sessions at

Murthy R, et al. BMJ Open Quality 2023;12:e002307. doi:10.1136/bmjoq-2023-002307 3

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each centre virtually through live CME by the mentoring sustenance of KMC. Parental involvement was continued

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team (https://www.youtube.com/watch?v=3Vlu76uR- by weekly sensitisation sessions (every wednesday after-
r0I&t=​36s). The session consisted of evidence, procedure noons) by nursing officers at each centre. These sessions
and monitoring of KMC. In addition, applying QI princi- were also facilitated by mothers who had previous KMC
ples for implementation of KMC was also discussed. The experience (after discharge). This peer counselling
recorded session was used to train the nurses who missed served as a platform for promoting foster KMC and
the session. Following that, the remaining components of raising awareness on KMC. Monthly celebrations by cake
the bundled approach were ensured simultaneously. cutting were also continued by nursing officers with
Available mothers were convinced that sponging should mothers at all centres. KMC continued to be prescribed
suffice instead of bath as in one of the centres bathing in treatment chart by doctors, while nurses documented
facilities were not available for mothers and in few centres in the nursing monitoring sheets, thus KMC became part
there was a cultural taboo to delay mothers’ bath in the of daily routine at all centres. One of the factors helping
initial few days. A structured counselling was followed by sustenance was a simpler data collection method of
playing a video explaining the benefits of KMC to the updating on a daily dashboard and uploading the results
parents on the first visit (https://www.youtube.com/​ on the collaboration’s common Google form (which was
watch?v=U0yBG59Afds). Foster KMC was promoted by accessible via mobile devices). Knowledge attrition was
explaining the importance of KMC in daily NICU coun- one of the concerns raised during team meetings. This
selling sessions. Entry restrictions were removed for was addressed by using a questionnaire to assess knowl-
fathers or other close family members willing to do KMC edge of the nursing officers once in 3 months. The initial
as earlier entry was there only for a fixed period of time. recorded video of KMC sensitisation was used to retrain
The visiting restriction display outside NICU was modi- staff if the scores were less than 80% on the questionnaire.
fied to allow fathers or other close family members at The nursing officers promoting maximum KMC were
any time for doing KMC. The posters encouraging foster identified as KMC champions on a monthly basis and were
KMC were placed at the counselling room. rewarded with prizes and certificates. The housekeeping

mining, AI training, and similar technologies, are reserved.

KMC was made part of the daily routine by prescribing staff in one of the centres (centre 1) assisted in helping
it in the treatment chart. A poster competition on KMC mothers for KMC (placing and removing) as the high
for nurses also instilled a lot of enthusiasm. patient: nurse ratio was a concern. The 2-­weekly display
Nurses recorded KMC hours in the respiratory rate of run charts of each centre in whatsapp group served
column and calculated total KMC hours at the end of the as a motivation. The centre having a sudden dip was also
day with input-­output calculations. The total KMC hours identified and a team meeting was done supervised by the
were then transferred to the daily dashboard of the unit mentoring team. The monthly team meetings were held
which served both as a visual reminder and an acknowl- on a virtual platform to assess the progress of KMC and
edgement. These data were transferred to the common discuss challenges. These meetings were chaired by senior
Google form of the collaboration every day by the nursing paediatricians (with research experience in KMC) across
officer. the country on a 3-­monthly basis. They not only moti-
PDSA # 2 (2–4 weeks) vated the teams but also guided the collaboration with
In PDSA 2, the bundled approach of the first PDSA was their experience. Two centres were given lead to present
adopted and the major process concern of parental aware- the results of collaboration at both national and interna-
ness was addressed. Hence, attempts were focused towards tional level. The rewards instilled enthusiasm among the
parental involvement. The ‘parental awareness session collaboration.
on the importance of KMC’ was conducted by doctors at Currently, extended KMC is being sustained in six
each centre once a month (all centres). A unique compe- centres. Two more new centres are in the baseline phase
tition of KMC counselling was conducted at two centres of data collection and will be part of collaboration. The
(centres 1 and 2) where nurses had to counsel a mother key interventions and drivers are summarised in figure 1.
on KMC. The judges were a panel of parents doing KMC The SOP of key steps of the collaboration is summarised
and the audience consisted of parents of admitted babies in online supplemental material.
in NICU. As KMC mothers participated in the session just
as much as the participant did, the competition served as
an interactive learning experience for them. The success RESULTS
of extended KMC was celebrated by nurses and parents A total of 1443 neonates below 2 kg were part of the QI
by cutting a cake which helped in further parental moti- initiative across 6 centres. There were a total of 145 (10%)
vation. twins and 618 (43%) were outborns. The demographic
features of enrolled neonates are summarised in table 1.
Sustenance phase The fishbone analysis revealed lack of healthcare
The bundled approach especially sensitisation, foster professional awareness, non-­availability of mothers, no
KMC and simpler data collection helped to implement formal counselling and thus lack of parental awareness as
extended KMC. Parental involvement was key in ensuring major concerns for KMC (online supplemental figure 1).

4 Murthy R, et al. BMJ Open Quality 2023;12:e002307. doi:10.1136/bmjoq-2023-002307

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mining, AI training, and similar technologies, are reserved.
Figure 1 Driver diagram depicting key drivers and interventions. CME, Continuing medical education; KMC, Kangaroo mother
care; LBW, low birth weight; LSCS, lower segment caesarean section; NICU, neonatal intensive care unit.

Figure 2 depicts the improvement of KMC rates over had done this strategy first). Centre 3 (figure 2C) was
time as run charts. centre 1 (figure 2A) had a baseline in the sustenance phase and ensured mentoring other
KMC rate of 0.6 hour/baby/day (40 min). We identified centres. Centre 4 (figure 2D) had a baseline KMC rate as
a shift of 10 data points after the baseline period. We 1.7 hours/baby/day. We identified three shifts in the run
recalculated the median based on this and found the new chart of centre 4 after the baseline period, 12 weeks and
median of 6.1. This shift suggested improvement with a 31 weeks corresponding to improvement with bundled
bundled approach. We identified an additional shift of 10 approach, improvement with sustenance phase by weekly
data points after 18 weeks. We recalculated the median parental sensitisation sessions and recognising KMC
based on this and found the new median of 10.4. This shift champions respectively. Centre 5 (figure 2E) had a base-
suggested improvement with weekly parental sensitisation line KMC rate as 0.8 hours/baby/day. We identified two
sessions. We identified an additional shift of 10 data points shifts in the run chart of centre 5 after the baseline period
after 27 weeks. We recalculated the median based on this and after 16 weeks corresponding to bundled approach
and found the new median of 14. This shift suggested and sustenance phase respectively. Centre 6 (figure 2F)
improvement with recognising and rewarding nurses as had a baseline KMC rate as 2.7 hours/baby/day. Similarly,
KMC champions. Centre 2 (figure 2B) had a baseline we identified two shifts in the run chart of centre 6 after
KMC rate of 2.9 hours/baby/day. We identified two shifts the baseline period and after 17 weeks corresponding to
in the run chart of centre 2 after baseline period and bundled approach and sustenance phase, respectively.
18 weeks, corresponding to improvement with bundled The components of the bundle and its compliance in
approach and during sustenance phase with recognising each centre are summarised as table in online supple-
and rewarding nurses as KMC champions (Centre 2 mental material.

Murthy R, et al. BMJ Open Quality 2023;12:e002307. doi:10.1136/bmjoq-2023-002307 5

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Figure 2 Run chart depicting KMC rate in hours per baby per day. (A) (centre 1), (B) (centre 2), (C) (centre 3), (D) (centre 4), (E)
(centre 5), (F) (centre 6). The Oval shows a signal of shift. KMC, Kangaroo mother care; PDSA, plan-­do-­study-­act.

Lessons and limitations of LBW neonates made sure KMC is reviewed each day in

mining, AI training, and similar technologies, are reserved.

In NICUs, the healthcare professionals tend to focus the rounds, improved communication among all health-
predominantly on respiratory care and fluid manage- care professionals and ensured regular documentation
ment. Often the knowledge-­implementation gap exists in the patient case notes. The strategy of recognising
with developmentally supportive processes of stable ‘KMC champions’ monthly, made nurses feel encour-
growing LBW babies such as KMC. Poor utilisation of aged and motivated. Parental awareness was ensured by
KMC has multifactorial reasons ranging from low nurses’ weekly awareness sessions by nurses (Wednesdays). The
awareness, staff shortage and inadequate support from daily dashboards, run charts and posters in a few centres
leadership, to non-­ availability of mothers in outborn served as visual reminders. Foster KMC was exception-
units, lack of awareness, challenges of accommodation or ally successful in predominant outborn units and fathers
cultural practices from parents’ side.8–10 The QI collabo- showed equal enthusiasm for kangaroo care. Parental
ration ensured addressing these multiple problems based involvement through competitions and monthly success
on a common bundle approach across all six centres celebrations ensured integrated efforts to sustain KMC.
and also addressed few unique challenges of individual Although most of the strategies were similar across all
centres with team meetings. centres, few strategies had to be implemented based on
One of the unique strategies of the collaboration was the local context. One centre did not have access to a
employing a bundled approach for implementation of mother’s hygiene/bath. Sponging was allowed instead of
KMC. Bundle is a package of evidence-­based best prac- bathing. This strategy was also employed if there was a
tices that, when implemented collectively, improve the cultural barrier for early bathing of mothers in the first few
reliability of their delivery and maximise the patient days. One centre had issues with a higher patient to nurse
outcomes.23 Instead of the conventional approach of ratio. Housekeeping staff were motivated to drive KMC by
testing individual strategies in each PDSA cycle, bundled motivating and helping mothers in picking for KMC or
approach was tested in the first PDSA. The components of placing them back in warmer. One centre had issues with
the bundle were derived from the previous QI experience availability of KMC chairs and collaboration influence
of the mentoring team.16 The bundled approach reduced for early procurement of these special chairs was fruitful.
the implementation time across different centres from One centre had issues with hesitation by female nurses
the previous 9 months to 8 weeks. Healthcare profes- to foster KMC by fathers. Continued success of KMC and
sionals training was an easier strategy employed without peer counselling by other centres allayed the hesitation.
much need of resources. The initial training of centres The collaborative model helped mutual learning
happened on a live virtual platform. The recorded link between centres, served as a platform for sharing innova-
helped to train nurses who missed the sessions due to tive ideas and understanding different ways of improving
leave or night shifts. To assess knowledge attrition after the predefined indicators. The root of the issue that the
the training, the collaboration ensured 3-­monthly assess- collaboratives seek to address is deficiencies in the clin-
ments of nurses and retraining was done if the scores were ical processes and organisational structure of the health
less. Making KMC an integral part of daily prescriptions system. The collaborative model involves multiple sites

6 Murthy R, et al. BMJ Open Quality 2023;12:e002307. doi:10.1136/bmjoq-2023-002307

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working on the same issue concurrently, and the approach nationwide scaleup and thus resulting in achieving the

BMJ Open Quality: first published as 10.1136/bmjoq-2023-002307 on 20 October 2023. Downloaded from https://bmjopenquality.bmj.com on 28 January 2025 by guest. All rights, including for text and data
promotes learning from peers who are all experimenting goal of reducing neonatal mortality.
with various ways to enhance shared indicators.11 12
Participation in QI collaborative activities may improve
health professional’s knowledge, problem-­ solving skills CONCLUSIONS
and attitude; teamwork; shared leadership and habits for We were able to implement extended KMC across all six
improvement. Interaction across QI teams may generate centres through bundling of raising nurses’ awareness,
normative pressure and opportunities for capacity simplifying documentation, making KMC as a prescribed
building and peer recognition.24 Shared experience of
intervention and promoting foster KMC. We could
working as a part of the collaborative with regular mento-
sustain by continuous parental involvement, developing
ring seemed to improve the effective team functioning at
local champions and low intensity training. Mentoring
each centre. Constant efforts were put through regular
and regular motivation for each other through collabora-
meetings by the collaborative team members to maintain
tion served as a backbone for continuous improvement.
the teams’ motivation and to build and sustain their confi-
We believe our experience could be replicated in similar
dence. Bundled approach with regular training of nurses,
contexts across the developing world. Also, policy-­makers
staff encouragement, foster KMC and regular parental
could use this experience as a framework for larger state
involvement were key in sustaining KMC. Majority of chal-
or nationwide collaborations.
lenges faced were similar across different centres with few
differences which we were able to overcome with strat- Author affiliations
egies customised to each centre. The 2-­weekly updates 1
Pediatrics, SNR Hospital, Kolar, Karnataka, India
of run charts helped identify early dips and team meet- 2
Pediatrics, Sarji Hospital, Shimoga, Karnataka, India
3
ings led by the mentoring team helped identify sudden Pediatrics, Ovum Hospitals, Bangalore, Karnataka, India
4
Neonatology, Kasturba Medical College Manipal, Manipal, Karnataka, India
change within the team and thus ensured sustenance. The 5
Pediatrics, Chinmaya Mission Hospital, Bangalore, Karnataka, India
monthly presentation by each team helped cross learning, 6
Pediatrics, Ovum Woman & Child Speciality Hospital Banaswadi, Bangalore,

mining, AI training, and similar technologies, are reserved.

gave a sense of peer pressure and also empowered them Karnataka, India
on KMC. The collaborative features such as having a stan- Twitter Abhishek Somasekhara Aradhya @abhiaradhyas and Praveen Venkatagiri
dard change package, collaborative faculty (mentoring @drpraveen_v
team), learning sessions interaction at the start of project
at each centre, monthly conference calls, team initiated Acknowledgements Data analysis and driving QI: Team from SNR hospital-­Dr.
calls (whenever there is a sudden dip of KMC rate in Srinath CS, Dr. Kamalakar; Sarji hospital—Ms. Asmath, Dr. Prashant, Dr. Dhananjay
Sarji; Ovum woman & Child Specialty Hospital, Hoskote—Ms. Gayathri, Ms. Anusha
2-­weekly data), site visits (three centres), written progress Bai; Chinmaya Mission hospital—Dr. Sushma; Ovum Woman & Child Specialty
on monthly basis, collaborative extranet, etc were the key Hospital, Banaswadi—Dr. Nayana Singhekar, Dr. Vimal Kumar; KMC Manipal-­Mrs
components which helped in the success.25 Pratima, Mrs Dakshayani, Mrs Sujatha, Mrs. Supritha. Dr. Tanushri Sahoo, Assistant
Professor, AIIMS Bhubaneshwar and Dr. Suman Rao, Professor, St. Johns Medical
College, Bangalore for guiding the collaboration.
Limitations
Collaborators Dr. Srinath CS, Dr. Kamalakar; Sarji hospital—Ms. Asmath, Dr.
Major challenge faced by the collaborative was lack of
Prashant, Dr. Dhananjay Sarji; Ovum woman & Child Specialty Hospital, Hoskote—
funding to equip and support teams to manage data Ms. Gayathri, Ms. Anusha Bai; Chinmaya Mission hospital—Dr. Sushma; Ovum
collection and handle the challenges. With more centres Woman & Child Specialty Hospital, Banaswadi—Dr. Nayana Singhekar, Dr. Vimal
interested in joining the collaborative, designing stand- Kumar; KMC Manipal-­Mrs Pratima, Mrs Dakshayani, Mrs Sujatha, Mrs. Supritha.
ardised ways of implementation, tracking the data and Contributors RM: designed data collection tool, data collection, assisted in data
sustaining will be a greater challenge. Different centres analysis, drafted initial manuscript. AK: data collection, assisted in data analysis,
assisted in drafting the initial manuscript, critical inputs to the manuscript and
with variable patient groups, facilities, manpower and approved the final manuscript. ASA: conceptualised the study, supervised data
experiences warrant the need for innovative ideas to collection, data analysis,critical inputs to the manuscript, drafted the initial
sustain KMC over a longer period of time. The babies on manuscript and guarantor. SKB: supervised data collection, assisted in drafting the
respiratory support were also given KMC but they were initial manuscript, critical inputs to the manuscript and approved the manuscript.
PV: supervised data collection, critical inputs to the manuscript andapproved the
not part of data collection of the collaboration. Other final manuscript. DC, MJ, PR, DH, SNC, JP and HG: data collection, critical inputs to
components of KMC such as feeding and early discharge the manuscript andapproved the final manuscript.
were also ensured. But formal data collection was not part Funding Publication of this article is made open access with funding from the
of the collaboration. Nationwide Quality of Care Network.
This collaborative initiative paves way for the deter- Competing interests None declared.
mined collaborations to design methods to explore KMC Patient and public involvement Patients and/or the public were not involved in
with other aspects of neonatal care and outcomes. It the design, or conduct, or reporting, or dissemination plans of this research.
provides a great opportunity to weave KMC within the Patient consent for publication Not applicable.
existing health system, and the collaboration initiative
Ethics approval The study was approved by the Institute Review Board (IRB no.
model can be an effective method of implementation to sarjiethics/2022/004) for multicentric QI collaboration. The mothers were explained
scale up the intervention. The findings from this imple- about the QI initiative in their own understandable language and verbal consent was
mentation research project will provide inputs to policy obtained.
makers to formulate KMC QI collaboration for state or Provenance and peer review Not commissioned; externally peer reviewed.

Murthy R, et al. BMJ Open Quality 2023;12:e002307. doi:10.1136/bmjoq-2023-002307 7

 Open access

Data availability statement All data relevant to the study are included in the 10 Mathias CT, Mianda S, Ginindza TG. Facilitating factors and barriers

BMJ Open Quality: first published as 10.1136/bmjoq-2023-002307 on 20 October 2023. Downloaded from https://bmjopenquality.bmj.com on 28 January 2025 by guest. All rights, including for text and data
article or uploaded as online supplemental information. to accessibility and utilization of Kangaroo mother care service
among parents of low birth weight infants in Mangochi district,
Supplemental material This content has been supplied by the author(s). It has Malawi: a qualitative study. BMC Pediatr 2020;20:355.
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been 11 Nadeem E, Olin SS, Hill LC, et al. Understanding the components of
peer-­reviewed. Any opinions or recommendations discussed are solely those quality improvement collaboratives: a systematic literature review.
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and Milbank Q 2013;91:354–94.
responsibility arising from any reliance placed on the content. Where the content 12 Garcia-­Elorrio E, Rowe SY, Teijeiro ME, et al. The effectiveness of
includes any translated material, BMJ does not warrant the accuracy and reliability the quality improvement collaborative strategy in low- and middle-­
income countries: a systematic review and meta-­analysis. PLoS One
of the translations (including but not limited to local regulations, clinical guidelines,
2019;14:e0221919.
terminology, drug names and drug dosages), and is not responsible for any error 13 Sharma D, Farahbakhsh N, Sharma S, et al. Role of Kangaroo mother
and/or omissions arising from translation and adaptation or otherwise. care in growth and breastfeeding rates in very low birth weight
Open access This is an open access article distributed in accordance with the (VLBW) neonates: a systematic review. J Matern Fetal Neonatal Med
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which 2019;32:129–42.
14 Joshi M, Sahoo T, Thukral A, et al. Improving duration of Kangaroo
permits others to distribute, remix, adapt, build upon this work non-­commercially,
mother care in a tertiary-­care neonatal unit: a quality improvement
and license their derivative works on different terms, provided the original work is initiative. Indian Pediatr 2018;55:744–7.
properly cited, appropriate credit is given, any changes made indicated, and the use 15 Arora P, Kommalur A, Devadas S, et al. Quality improvement initiative
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. to improve the duration of Kangaroo mother care for twin preterm
neonates born at a tertiary care hospital in resource-­limited settings.
ORCID iD J Paediatr Child Health 2021;57:1082–8.
Abhishek Somasekhara Aradhya http://orcid.org/0000-0003-3524-0939 16 Ramachandrappa G, Somasekhara Aradhya A, Mercy L, et al.
Sustaining prolonged Kangaroo mother care in stable low birthweight
babies over 2 years in a predominant outborn unit: a quality
improvement approach. BMJ Open Qual 2022;11:e001771.
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8 Murthy R, et al. BMJ Open Quality 2023;12:e002307. doi:10.1136/bmjoq-2023-002307