facilitator’s guide - national aids control...

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THE UNITED REPUBIC OF TANZANIA

MINISTRY OF HEALTH AND SOCIAL WELFARE

TRAINING PACKAGE QUALITY IMPROVEMENT OF HIV AND AIDS SERVICES

BASIC QUALITY IMPROVEMENT FOR HIV AND AIDS SERVICES

FACILITATOR’S GUIDE

September 2011

Final Draft

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TRAINING PACKAGE QUALITY IMPROVEMENT OF HIV AND AIDS SERVICES

BASIC QUALITY IMPROVEMENT FOR HIV AND AIDS SERVICES

FACILITATOR’S GUIDE

MINISTRY OF HEALTH AND SOCIAL WELFARENational Aids Control ProgrammeP.O. BOX 9O83DAR ES SALAAM

Final draftExtracts from this book may be reproduced with acknowledgement to the Ministry of Health and Social Welfare (MOHSW)

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CONTENTS

ABREVIATIONS AND ACRONYMS

FOREWORD

ACKNOWLEDGEMENT

INTRODUCTION Welcome and overview of the training

UNIT 1: Background to Quality Improvement in Tanzania SESSION 1.1: Introduction to QI in Tanzania SESSION 1.2. Introduction to concepts of quality in health Care SESSION 1.3: Dimensions of quality

UNIT 2: Quality Improvement and its principlesSESSION 2.1: QI definedSESSION 2.2: Principles of QI: Focus on client needs, expectations,

communication and gaining feedback SESSION 2.3: Principles of QI: Focus on team work SESSION 2.4: Principles of QI: Focus on measurements SESSION 2.5: Principles of QI: Focus on systems and processes

UNIT 3: Quality Improvement model, approaches and implementationPART 3.1: QI model and approachesSESSION 3.1.1: Steps in QI and the improvement model SESSION 3.1.2: Five S (5S) and improvement collaborativeSESSION 3.1.3: Roles and responsibilities of QI implementation at different levelsPART 3.2: Implementation of QI activitiesSESSION 3.2.1: Preparation to practical assignmentSESSION 3.2.2: Practicum, feedback and next steps

Evaluation of training

ANNEXESANNEX 1: Checklist for instructional materials and supplies ANNEX 2: Case Study Mrs. KwanguANNEX 3: Systems and process flow chartsANNEX 4: Role play script: Session 2.3, Principles of QI: Focus on team workANNEX 5: Tanzania HIV and AIDS patient care and treatment indicators ANNEX 6: Format of matrix of tested changes based on identified problemsANNEX 7: Course evaluation formANNEX 8: Schedule/agenda for basic QI training

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ACRONYMS

AIDS - Acquired Immune Deficiency SyndromeANCs - Antenatal ClinicsART - Anti Retroviral TherapyARVs Antiretroviral drugsCBOs - Community Based OrganizationsCCHPs - Comprehensive Council Health PlansCD4 - Cluster of Differentiation 4 CHMT - Council Health Management TeamCQI - Continuous Quality ImprovementCQIT - Council Quality Improvement TeamCQI-TQM - Continuous Quality Improvement -Total Quality ManagementCRHPs - Comprehensive Regional Health PlansDACC - District AIDS Control CoordinatorDMO - District Medical Officer EPI - Expanded Program on ImmunizationFBOs - Faith Based OrganizationsGPA - Global Program on AIDSHBC - Home Based CareHBCT - Home Based Counselling and Testing HF - Health FacilityHIV - Human Immunodeficiency VirusHSHAS - Health Sector HIV and AIDS Strategy for TanzaniaHSHSP - Health Sector HIV AIDS Strategic PlanHTC - HIV Testing and Counselling IEC - Information Education and CommunicationIPOs - Implementing Partner OrganizationsLGA - Local Government AuthorityM&E - Monitoring and EvaluationMOHSW - Ministry of Health and Social WelfareMTP - Medium Term PlanNACP - National AIDS Control ProgramNCTP - National Care and Treatment PlanNEHSHIP - National Essential Health Sector HIV Intervention PackageNGO - Non Governmental OrganizationNMSF - National Multi-sectoral Strategic FrameworkNQIT - National Quality Improvement TeamOIs - Opportunistic InfectionsPDSA - Plan Do Study ActPITC - Provider Initiated Testing and Counselling PLHIV - People Living with HIV PMTCT - Prevention of Mather To Child TransmissionQA - Quality AssuranceQI - Quality ImprovementRACC - Regional AIDS Control CoordinatorRCHS - Reproductive and Child Health Service

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RHMTs - Regional Health Management TeamsRIP - Regional Implementing PartnerRMO - Regional Medical OfficerRQIT - Regional Quality Improvement TeamSTIs - Sexually Transmitted InfectionsTACAIDS - Tanzania Commission for AIDSTB - TuberculosisTQIF - Tanzania Quality Improvement FrameworkTQM - Total Quality ManagementTWG - Technical Working GroupVCT - Voluntary Counselling and TestingZTCs - Zonal Training CentresAIDS - Acquired Immune Deficiency SyndromeANCs - Antenatal ClinicsART - Anti Retroviral Therapy

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FOREWORD

In 1993 the Ministry of Health (MoH) embarked on Health Sector Reforms (HSRs) aiming at improving the quality of the services provided at Health facilities and developed the Tanzania Quality Improvement Framework (TQIF) as a guiding document for quality improvement in health service provision. In recognition of the need to improve the quality of services many stakeholders have been undertaking initiatives geared towards improving quality of services at facility level. Much of the impetus for this initiative has focused on improving the HIV and AIDS services in the country. However, these QI initiatives have so far used different approaches in design, process, monitoring and reporting structure. In this context, the Ministry of Health and Social Welfare (MOHSW) developed an HIV and AIDS QI guideline based on strategies and actions stipulated in the TQIF to ensure that QI in HIV and AIDS interventions are implemented in a harmonized way.

Following the approval by the Ministry of Health and Social welfare of the National Guidelines for Quality Improvement of HIV and AIDS Services, November 2010, the need emerged to develop the training package for Quality Improvement. Its goal is to enable the service providers to plan, conduct, monitor and evaluate improvement of quality of HIV and AIDS services in accordance with the National Quality Improvement Guidelines for HIV and AIDS Services. At the end of the training the service providers are expected to:

Explain the concepts of Quality in health care settings Identify the principles of quality improvement Explain roles and responsibilities of different levels of the health system in sustaining

implementation of Quality Improvement activities at health facility level Describe the Quality Improvement model Plan, implement and sustain activities to improve quality of HIV and AIDS services

The QI training package for HIV and AIDS services is aimed to be used in training health care providers country-wide and is arranged into three units. The first unit provides background information regarding QI in Tanzania and is subdivided in three sessions touching upon QI in Tanzania, the concepts of quality in health care and the dimensions of quality. The second unit presents QI and its principles and is subdivided in four sessions including: focus on client needs, expectations, communication and gaining feedback, focus on team work, on measurements and on systems and processes. Unit 3 is divided into four sessions. The first two sessions take the participants through the various steps and approaches in QI. The third session covers roles and responsibilities of different levels of the health care system in supporting implementation of QI activities whereas the fourth session is a practicum on planning and implementing QI at health facility level.

The facilitation training package features the learning and teaching methods. Firstly, it is based on adult learning principles, which means that it is interactive, relevant and practical. Moreover, it requires that the trainer facilitates the learning experience rather than serving the more traditional role of a teacher or lecturer. Secondly, it involves the use of behavior modeling to facilitate learning a standardized way of performing a skill or activity. Thirdly, it is competency-based. Through structured exercises and mini-lectures providing the need-to-know facts, the training package is meant to help users to reflect routine health care delivery processes in their local settings and stimulate innovations and creativity as they think how to design strategies to improve care.

The MOHSW urges all stakeholders providing HIV and AIDS services to use this QI training package for HIV and AIDS services consistently and offer critical comments for improving future editions of this document.

Blandina S. J. Nyoni

Permanent SecretaryMinistry of Health and Social Welfare

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ACKNOWLEDGEMENTS

Following the development of the National Guidelines for Quality Improvement of HIV and AIDS Services, November 2010, there was a need for a training package to facilitate and harmonize the training of health care providers at all levels of the health system to enable them to follow the Guidelines to implement and sustainQuality Improvement activities at health facility level country-wide. This training package that consists of a Facilitators Guide and Participants Manual is intended to serve as a guide for trainers with or without prior quality improvement experience in enabling trainees to acquire appropriate knowledge and skills in the implementation of Quality Improvement activities at the respective level of health care delivery.

The training package was developed based on the Tanzania Framework for Quality Improvement (TQIF) as well the National Guidelines for Quality Improvement of HIV and AIDS Services. In addition, the training package has been customized to the Tanzanian situation as it has drawn lessons from experience gained during the field implementation of quality improvement for HIV and AIDS services, piloted in collaboration with RHMT, CHMTand selected health facilities providing Care and Treatment and PMTCT services in Tanga, Morogoro, Mtwara and Lindi regions.

The process of developing the training package for HIV and AIDS service has been coordinated by the National Aids Control Program (NACP), in collaboration with key stakeholders who provided technical and financial support to ensure successful completion of the package. The Ministry of Health and Social Welfare would like to thank PharmAccess International (PAI) and University Research Company (URC) for the overall technical and financial support leading to finalization of this training package. Our appreciation also goes to the Regional and Council Health Management Teams (R/CHMT), Health Facility staffs, World Health Organization (WHO), AIDS Relief Consortium, Family Health International (FHI), Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Clinton HIV/AIDS Initiative (CHAI), Regional Implementing Partners, who participated in the development and series of reviews of the drafts of the package.

The Ministry of Health and Social Welfare would like to recognize the efforts from all Heads of Units at the NACP for their active participation in the review process and for their valuable contributions. Special gratitude goes to the Technical Working Group that worked tirelessly from initial drafting and subsequent reviews leading to finalization of this document. The following individuals deserve a special mention for the efforts they put in developing the QI training package for HIV and AIDS service:

Dr. Rowland. O. Swai MOHSW-NACP Dr. Jan van den Hombergh PharmAccess Dr. Bennett Fimbo MOHSW- NACP Dr. Davis Rumisha URCDr. H.A Ngonyani MOHSW- HSIU Dr. Hobokela Stephen URCDr. Robert Josiah MOHSW -NACP Dr. Peter Risha PharmAccessDr. Gissenge J.I.Lija MOHSW- NACP Dr. Stella Kasindi NACP/WHO Ms. Lilian Chovenye MOHSW -NACP Dr. Peter Mgosha MOHSW-NACP Mr. Jared Mussanga URCMs. Joan Kimirei PharmAccess Ms. Farida Mgunda URCDr. Elizabeth Hiza URC Ms. Suzanne Spierings PharmAccessMr. Daniel K. Kayanda PharmAccess Ms. Monica Ngonyani URCDr Yohana Mkiramweni CHAI Mr. Ivan Teri EGPAFDr. Benedicta Masanja FHI/TUNAJALI Ms. Michele Mshiu PharmAccess Dr. Otilia Gowele MOHSW-Kilosa COTC

Since it is not possible to mention everyone by name, the MOHSW also would like to thank all who contributed in one way or another in the preparation of the package.

Dr. Deo M. Mtasiwa

CHIEF MEDICAL OFFICERMinistry of Health and Social Welfare

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INTRODUCTION

This facilitator’s guide is intended to be one of the tools to guide trainers in enabling trainees to acquire appropriate knowledge and skills in the implementation of Quality Improvement activities at the respective level of health care delivery.

Following the development of the National Guidelines for Quality Improvement of HIV and AIDS Services, November 2010, there was a need for developing the training package for Quality Improvement.

Health services in Tanzania are organized in four levels: national, regional, district and facility level. National and regional levels are involved in policy, coordination and guidance, while district and facility levels are responsible for direct implementation of the QI strategy. Each level has a critical role in ensuring efficient and effective running of the QI program.1. National level

The MOHSW aims at rapid rollout of Care and Treatment services hand in hand with ensuring quality services to those in need. As more implementing partners are introducing QI approaches for HIV and AIDS services, coordination becomes important to ensure uniformity, which calls for formulation of national policy guidelines.

2. Regional levelAt the regional level, the RHMT and HIV and AIDS Implementing Partner Organizations (IPOs) will work together on QI activities in their Region. The RHMT, being the Government arm, will provide leadership to all stakeholders in QI activities connected to policy, coordination, advocacy and communication.

3. District levelImplementation of the health care policy has been decentralized to Local Government Authorities (LGAs). The day to day implementation of health services including QI is therefore the responsibility of CHMTs. In this regard, Councils have responsibility of ensuring availability of adequate resources for provision of quality health services.

4. Health Facility Level (Other Hospitals and Primary Health Facilities)The roles and responsibilities of health facilities have been broadly described in intervention specific guidelines.

Aim of the facilitator guideThe main aim of this guide is to enable the trainers, the trainee and supervisors of QI to implement effectively and standardize the HIV and AIDS services delivery. The trainer will use this guide in orienting himself/herself before and during the actual training.

Goal and objectives of the facilitator guideThe goal is to enable the service providers to plan, conduct, monitor and evaluate the HIV and AIDS services in accordance with the National Quality Improvement Guidelines for Quality Improvement of HIV and AIDS Services.

General objectivesAt the end of the training the service providers are expected to:• Explain the concepts of quality in the health care setting• Identify the principles of QI• Explain roles and responsibilities of a leader in QI• Describe the QI model

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Course organization

Course duration:

The course will be of four (5) days for both theory and practical. Facilitators will have to come one (1) day before the training in order to arrange the workshop and they shall leave one (1) day after for planning and report writing.

Time allocation:Theory 25 hoursPractical 08 hoursTotal 33 hours

Characteristics of trainees:Trainees will be health management teams such as RHMTs, CHMT and HMT. Also health care providers working with public and private health facilities, e.g. Registered Nurses, Enrolled Nurses, Clinical Officers, Clinical Assistants, Pharmacists, Pharmaceutical Technicians, Laboratory Technicians, Medical Officers, Assistant Medical Officers, Health Officers and support staff.

Characteristics of trainers:The trainers are expected to be health care providers working in public or private health facilities. They may be Medical Officers, Pharmacists, Registered and Enrolled Nurses, Clinical Officers, Health Officers, support staff and other co-opted persons who have undergone a full course on the basic for QI training and Training of Trainers (TOT).

Teaching methods and materialsIn the guide a number of teaching methods have been suggested for use by the trainer and trainee. They include: Brainstorming Lecture- discussion Small or large group discussion Individual assignments Role plays Buzzing Demonstration Case studies

Practicum assignments

Practicum objectivesDuring practicum training, trainees will be guided to perform procedures following objectives: Identify problems for HIV and AIDS services Analyse problems Develop and document changes Test and implement change, all as guided by the Standard Evaluation System (SES) Fill in a matrix the tested changes Provide feedback for the tested changes

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Facilitator techniques for some of the methods

A. Techniques for motivating participants encourage interaction1. During the first day, you will talk individually with each participant several times. If

you are friendly and helpful during these first interactions, it is likely that the participants:a) Will overcome their shynessb) Will realize that you want to talk with themc) Will interact with you more openly and productively throughout the course

2. Look carefully at each participant's work. Check to see if participants are having any problems, even if they do not ask for help. If you show interest and give each participant undivided attention, the participants will feel more compelled to do the work. Also, if the participants know that someone is interested in what they are doing, they are more likely to ask for help when they need it.

B. To be available to the participants at all timesKeep participants involved in discussions1. Frequently ask questions of participants to check their understanding and to keep

them actively thinking and participating. Questions that begin with "what," "why, " or "how" require more than just a few words to answer. Avoid questions that can be answered with a simple "yes" or "no."

2. After asking a question, PAUSE. Give participants time to think and volunteer a response. A common mistake is to ask a question and then answer it yourself. If no one answers your question, rephrasing it can help to break the tension of silence. But do not do this repeatedly. Some silence is productive.

3. Acknowledge all participants' responses with a comment, a "thank you" or a definite nod. This will make the participants feel valued and encourage participation. If you think a participant has missed the point, ask for clarification, or ask if another participant has a suggestion. If a participant feels his comment is ridiculed or ignored, he may withdraw from the discussion entirely or not speak voluntarily again.

4. Answer participants' questions willingly, and encourage participants to ask questions when they have them rather than to hold the questions until a later time.

5. Do not feel compelled to answer every question yourself. Depending on the situation, you may turn the question back to the participant or invite other participants to respond. You may need to discuss the question with the Course Director or another facilitator before answering. Be prepared to say "I don't know but I'll try to find out.”

6. Use names when you call on participants to speak, and when you give them credit or thanks. Use the speaker's name when you refer back to a previous comment.

7. Always maintain eye contact with the participants so everyone feels included. Be careful not to always look at the same participants. Looking at a participant for a few seconds will often prompt a reply, even from a shy participant,

Keep the session focused and lively1. Keep your presentations lively:

- Present information conversationally rather than read it aloud- Speak clearly. Vary the pitch and speed of your voice- Use examples from your own experience, and ask participants for examples from

their experience2. Write key ideas on a flipchart as they are offered. This is a good way to acknowledge

responses. The speaker will know his suggestion has been heard and will appreciate having it recorded for the entire group to see. When recording ideas on a flipchart,

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use the participant's own words if possible. If you must be briefer, paraphrase the idea and check it with the participant before writing it. You want to be sure the participant feels you understood and recorded his idea accurately.

3. Do not turn your back to the group for long periods as you write. At the beginning of a discussion, write the main question on the flipchart. This will help participants stay on the subject.a. When needed, walk to the flipchart and point to the question. Paraphrase and

summarize frequently to keep participants focusedb. Ask participants for clarification of statements as needed. Also, encourage other

participants to ask a speaker to repeat or clarify his statement. Restate the original question to the group to get them focused on the main issue again

c. If you feel someone will resist getting back on track, first pause to get the group's attention, tell them they have gone astray, and then restate the original question. Do not let several participants talk at once

d. When this occurs, stop the talkers and assign an order for speaking. People usually will not interrupt if they know they will have a turn to talk

4. Thank participants whose comments are brief and to the point. Try to encourage quieter participants to talk. Ask to hear from a participant in the group who has not spoken before, or walk toward someone to focus attention on him and make him feel he is being asked to talk

Management of the groupDuring the training the facilitators can experience some difficulties with the participation of individuals or groups which might disrupt the conducive learning environment, e.g. making phone calls, talking, sleeping, being resistant to the subject which is taught. Identify any problem you encounter during the training and manage them accordingly. Please find hereunder an example how you can handle a situation where some participants may talk too much:a. Do not call on this person first after asking a questionb. After a participant has gone on for some time say, "You have had an opportunity to

express your views. Let's hear what some of the other participants have to say on this point”. Then rephrase the question and invite other participants to respond, or call on someone else immediately by saying, “Dr. Sam, you had your hand up a few minutes ago”

c. When the participant pauses, break in quickly and ask to hear from another member of the group or ask a question of the group, such as, "What do the rest of you think about this point?"

d. Record the participant's main idea on the flipchart. As he continues to talk about the idea, point to it on the flipchart and say, "Thank you, we have already covered your suggestion. Then ask the group for another idea.

e. Do not ask the talkative participant any more questions. If he answers all the questions directed to the group, ask for an answer from another individual specifically or from a specific subgroup. (For example, ask, "Does anyone on this side of the table have an idea?")

f. Try to identify participants who have difficulty understanding or speaking the Course language. Speak slowly and distinctly so you can be more easily understood and encourage the participant in his efforts to communicate.

Reinforce participant’s efforts1. As a facilitator, you will have your own style of interacting with participants. However, a

few techniques for reinforcing participants' efforts include:

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Avoiding use of facial expressions or comments that could cause participants to feel embarrassed

Sitting or bending down to be on the same level as the participant when talking to him

Answering questions thoughtfully, rather than hurriedly, encouraging participants to speak to you by allowing them time, appearing interested, saying "That's a good question/suggestion.”

2. Reinforce participants who: Try hard Ask for an explanation of a confusing point Do a good job on an exercise Participate in group discussions Help other participants (without distracting them by talking at length about

irrelevant matters).

C. Techniques for assisting co-facilitator(s)1. Spend some time with the co-facilitator when assignments are first made. Exchange

information about prior teaching experiences and individual strengths, weaknesses and preferences. Agree on roles and responsibilities and how you can work together as a team.

2. Assist one another in providing feedback and conducting group discussions. For example, one facilitator may lead a group discussion, and the other may record the important ideas on the flipchart. The second facilitator could also cheek the Facilitator Guide and add any points that have been omitted.

3. Each day, review the teaching activities that will occur the next day (such as role plays and demonstrations), and agree who will prepare the demonstration, play each role, collect the supplies).

4. Work together on each unit/session rather than taking turns having sole responsibility for a unit.

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D. When participants are working1. Look available, interested and ready to help.2. Watch the participants as they work, and offer individual help if you see a participant

looking troubled, staring into space, or not writing answers, These are clues that the participant may need help.

3. Encourage participants to ask you question whenever they would like some help.4. If important issues or questions arise when you are talking with an individual, make

note of them to discuss later with the entire group.5. If a question arise which you feel you cannot answer adequately, obtain assistance as

soon as possible from another facilitator or a specific reference (if any).6. Review the points in this Facilitator Guide so you will be prepared to discuss the next

exercise with the participants.

E. When leading a group discussion1. Plan to conduct the group discussion at a time when you are sure that all participants

will have completed the preceding work. Wait to announce this time until most participants are ready, so that others will not hurry.

2. Before beginning the discussion, refer to the appropriate notes in this guide to remind yourself of the purpose of the discussion and the major points to make.

3. Always begin the group discussion by telling the participants the, purpose of the discussion.

4. Often there is no single correct answer that needs to be agreed on in a discussion.5. Just be sure the conclusions of the group are reasonable and that all participants

understand how the conclusions were reached.6. Try to get most of the group members involved in the discussion. Record key ideas

on a flipchart as they are offered. Keep your participation to a minimum, but ask questions to keep the discussion active and on track.

7. Always summarize, or ask a participant to summarize, what was discussed in the exercise. Give participants a copy of the answer sheet, if one is provided.

8. Reinforce the participants for their good work by (for example): Praising them for the list they compiled Commenting on their understanding of the exercise Commenting on their creative or useful suggestions for using the skills on the job Praising them for their ability to work together as a group

F. When coordinating a role play1. Before the role play, refer to the appropriate notes in this guide to remind yourself of

the purpose of the role play, roles to be assigned, background information, and major points to make in the group discussion afterwards.

2. As participants come to you for instructions before the role play, Assign roles. At first, select individuals who are outgoing rather than shy, perhaps

by Asking for volunteers If necessary, a facilitator may be a model for the group by acting in an early role

play3. Give role play participants any props needed, for example, a baby doll, drugs.4. Give role play participants any background information needed. There is usually

some information for the "players" which can be photocopied or clipped from this guide.)

5. Suggest that role play participants speak loudly.6. Allow preparation time for role play participants.

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7. When everyone is ready, arrange seating/placement of individuals involved, Have the "Players" stand or sit apart from the rest of the group, where everyone can see them.

8. Begin by introducing the players in their roles and stating the purpose or situation. For example, you may need to describe the age of the child, assessment results, and any treatment already given.

9. Interrupt if the players are having tremendous difficulty or have strayed from the purpose of the role play.

10.When the role play is finished, thank the players. Ensure that feedback offered by the rest of the group is supportive. First discuss things done well. Then discuss things that could be improved.

11.Try to get all group members involved in discussion after the role play. In many cases, there are questions given in the module to help structure the discussion.

12.Ask participants to summarize what they learned from the role play.

G. When facilitating a brainstorming session1. Establish ground rules – all ideas will be accepted – they will be written on the

flipchart – at no time we will discuss or criticize any idea – later after we have a list of suggestions we will go back and discuss each

2. Announce the topic or problem – During few minutes we will brainstorm following our usual rules – our topic is “Principles of Quality Improvement – I would like each of you to think of at least one principle – John will write these on the board so that we can discuss them later – who would like to be the first

3. Maintain a written record on a flipchart or written board of the ideas and suggestions. This will prevent repetition and keep participants focused on the topic.

4. Involve participants and provide positive feedback in order to encourage more inputs.5. Review written ideas and suggestions periodically to stimulate additional ideas.6. Conclude brainstorming by reviewing all suggestions.

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H. Facilitating a case study1. After participants have read the case study either individually or in small groups, they

should be given opportunity to react to it: Ask trainees to analyze the situation presented and determine the source of the

problem. Examples of questions that can be asked:o Focused questions – What are three observations suggesting that the client

was not counselled properly?o Open-ended questions – What are some of the consequences of failing to

counsel a client properly prior to testing for HIV?o Problem solution – How could this problem have been avoided?

2. Give trainees opportunity to share their reactions. This sharing may take the form of one or more of the following: Reports from individuals or small groups Responses to case study questions Role plays presented by individuals or small groups Recommendations from individuals or small groups

3. Summarize the results of the case study activity before moving on the next topic

Pre and post knowledge assessmentVarious methods will be used to evaluate the training. These include continuous assessment through questions and answers, pre and post knowledge assessment results and individual / group presentation of assignments.

Grading systemThe following is a system for grading performance in knowledge and skills assessments, exercises and tests.

The score will be taken for the post test done by participantsNumerical value Descriptive term Letter grade Grade Point

80 - 100 % Excellent A 465 - 79 % Very good B 350 – 64% Good C 240 - 49 % Poor D 1

0 -39% Fail F 0

The pass mark is C and aboveHowever the candidate who fails will be allowed to provide services under close supervision.

CertificationAward –All participants attending the workshop shall be awarded a certificate of attendance to the training.Note: During each QI training facilitators shall identify participants who are potential facilitators and shall recommend them for next Training of Trainers course (TOT).

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Preparation for trainingMembers of the training team must hold consultative meetings to identify issues and share strategies and alternatives before training course. The trainees must be informed well in advance before the training course. The trainers and trainees must confirm their commitment before and during entire training course. Refer to annex 3 for the Checklist of Instructional Materials and Supplies needed for the Training.

Summary of sessions for the training

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Welcome and overview of the training

Total session time: 1 hour 30 minutes

AimTo provide overview of the of the QI training and create conducive learning environment.

Resources needed Flip charts, marker pens, and masking tape/ LCD machine/laptop Black/white board and chalk/whiteboard markers

Overview

Steps Time Activity/Method Content

1 15 minutes Presentation Welcome and opening remarks

2 15 minutes Presentation Participants/facilitators introduction

4 30 minutes Individual exercise Expectations, norms and logistics

5 15 minutes Presentation Pre - test

6 15 minutes Presentation Training objectives, output and course schedule

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SESSION CONTENTSl

ide

1

Welcome and overview of the Quality Improvement training

READ the session title to participants

CLARIFY any issues raised

Slid

e 2

Introduction

• Introduction of participants/facilitators and organizers:–Name–Job title/position–Workplace–Additional information you would like

to share

INVITE guest of honour to give the welcome remarks and officiate the opening of the training for 15 minutes.

Display slide 2 and ask the participants to introduce themselves.

The facilitator can choose any of the two approaches for the introduction of the participants:1. Sit in pairs and introduce each other

for 5 minutes; by name, title, workplace and working experiences.

2. Self Introduction in a large group (10 minutes).

PROVIDE cards for participants to write names and tag on their tables/desks.

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Slid

e 3

Norms, expectations, leadership and logistics

• Expectations • Norms• Selection of chairperson, secretariat

and time keeper• Logistics

LET participants mention norms and their expectations and write them on the flipchart.

SUMMARIZE the expectations and norms of the training:Possible expectations are: Capacity to identify areas for

improvement and ways to strengthen the services

Understand indicators To be QI educators at the workplace Integrate QI concepts to improve

general services Improve quality of services at

workplace How to link QI indicators in health

centre delivery systemPossible norms are: Active participation Share experience and opinions Respect each other’s ideas/opinion Punctuality No sub-sessions Flexibility Respect Phone on silence

LEAD the participants to select the chairperson, secretariat, rapporteurs and the time keeper (see roles hereunder)

Chairperson Manage the flow of the training Representative for the facilitator and

participants (ideas, problems etc.) Assign an order for speaking during

discussion or Questions and Answers(Q&A)

Ensure that norms are followed Select people to lead energizersSecretariat Acting chairperson Assist in organizing the classroom Organize social activities (if any)RapporteurSummarizes the day and provide

feedback the following morningTime keeper– Keeps the time of all the sessions– Informs in between how much time is

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Slid

e 4

Pre-test

Please take 30 minutes time to fill out the pre-test related to Quality Improvement in HIV and AIDS Care and Treatment

DISTRIBUTE scripts of pre-test to participants

TELL them to write their names in the scripts and answer the questions.

COLLECT the scripts after 30 minutes

MARK scripts and keep results until the end of the course.

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e 5

QI training objectives (1)

By the end of this 4 days training,participants should be able to:• Explain the concepts of quality in the health

care setting of Tanzania• Explain roles and responsibilities of a leader

in QI• Identify the principles of QI

QI training objectives (2)• Describe the QI model• Identify the national essential health sector

HIV and AIDS interventions indicators• Identify roles and responsibilities of the

national, regional, district and health facility in QI

• Develop QI work plan for implementation of QI activities at respective working places

INFORM participants that this course is one of the two(2) modules in the National Quality Improvement Training package

These modules are; Basic Quality Improvement training Comprehensive Supportive

Supervision and Mentoring of HIV and AIDS services training.

INFORM participants that they will be oriented to the National Essential Health Sector HIV and AIDS Interventions package during the course.

READ or ASK participants to read the objectives.

CLARIFY the objectives accordingly

Slid

e 6

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Slid

e 7

Training output• Increased knowledge of QI principles and

approaches • Increased knowledge on establishing of

QI teams at national, regional, districts and facility level to implement QI activities

• Developed feasible work plan for implementation of QI activities in their workplace

INFORM participants that it is important for each level to formulate a QI team that will oversee the implementation of QI activities to improve services to the agreed standards.

TELL participants that they will learn how to develop QI work plans during this training and implement them immediately at their workplaces.

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Training content overview

UNIT 1: Background information to QI in Tanzania

UNIT 2: QI and its principles

UNIT 3: QI model, approaches and implementation

* See annex 7 for course overview

TELL participants to open annex 5 and LEAD them through the detailed course schedule

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Training methodologies

• Lectures• Group discussions• Case studies• Demonstrations• Role plays• Practical

EXPLAIN to the participants that the course methodologies will includeamongst others: Lectures Group discussions Case studies Demonstrations Role plays Practical

22

Unit 1: Background to QI in Tanzania

Total unit time: 3 hours 30 minutes

AimThis unit familiarizes the participants with the background of quality of care in relation tothe national response to the HIV and AIDS epidemic in Tanzania.

Unit objectivesBy the end of this unit, participants will be able to: Explain milestones of the national response to the HIV and AIDS epidemic in

Tanzania in relation to the QI efforts Describe the concept of quality Describe the dimensions of quality

Unit overviewSession Time Title

1 60 minutes Introduction to QI in Tanzania

2 60 minutes Introduction to concepts of quality in health care

3 90 minutes Dimensions of quality

23

Session 1.1: Introduction to QI in Tanzania

Total session time: 1 hour

Session objectivesBy the end of this session, participants will be able to: Explain the milestones for national HIV and AIDS response Describe the background of QI in Tanzania Describe the rationale for QI in health care

Resources needed Flip charts, marker pens, and masking tape/ LCD machine/laptop Black/white board and chalk/whiteboard markers National Guidelines for QI of HIV and AIDS Services Tanzania Quality Improvement Framework National Essential Health Sector HIV and AIDS Interventions Package

Session overviewStep Time Activity/method Content

1 5 minutes Presentation Introduction to session title and objectives

2 15 minutes Presentation Milestones for the national HIV and AIDS response

3 15 minutes Presentation Background information of QI in Tanzania

4 10 minutes Presentation Application of TQIF, NEHSHIP and the QI guidelines

5 5 minutes PresentationBrainstorming

Rationale for QI in health care

6 5 minutes Presentation Key points

7 5 minutes Questions and answers Evaluation

24

SESSION CONTENTSl

ide

1

Session 1.1: Introduction to QI in Tanzania



Slid

e 2

Session objectives

By the end of this session, participants will be able to:• Explain the milestones for National HIV

and AIDS response • Describe the background of QI in

Tanzania • Describe the rationale for QI in health care



Slid

e 3 Milestones in the National HIV and AIDS

response

• First AIDS case detected in 1983• In 1985 MOHSW established a task force to

implement a Short Term Plan in response to the epidemic

• In 1988 the MOHSW established the NACP to coordinate programme planning, implementation and monitoring

• Since then MOHSW has developed several plans and initiatives based on prevailing program needs, scientific and technological advances

PRESENT the background information of QI in the health sector in Tanzania.

25

Slid

e 4

Milestones for National HIV and AIDS response EXPLAIN to participants the history of the HIV and AIDS National Response in Tanzania (1983 to date)

TAKE them through the diagram and clarify as needed

Slid

e 5

QI in Tanzania• In ensuring access to health care services of

acceptable quality to all Tanzanians, the MOHSW has designed a defined health system for implementation of QI described in the Health Policy and accompanying reforms

• To further respond to growing challenges of health care provision, MoHSW developed TQIF which:– Provides framework for QI of Health services– Encourages Intervention specific approach to QI– Outlines level specific responsibilities for QI

Slid

e 6

National health policies on improving HIV and AIDS servicesThe policy has been translated into the following plans and guidelines:

• HSSP III (2009 -2015)– QI one of crosscutting issue in the plan which overall objective is to

provide quality health services

• HSHSP II (2008 -2012)– One of the goals of this plan is to improve the quality of HIV and

AIDS interventions to the general public, PLHIV, health care providers and other vulnerable populations

• National Guidelines for Quality Improvement of HIV and AIDS Services– Provides guidance on how to improve quality of HIV and AIDS

services in the health sector

26

Slid

e 7

1 2 3

DISPLAY slide number 7 and ASK participants whether they have seen these three documents before

GIVE time for three to five participants to respond and share with others where they have seen or used the documents for.

SUMMARIZE the discussion by telling the participants that the documents from left to right are the:1. Tanzania Quality Improvement

Framework (reprint 2010) 2. National Essential Health Sector

HIV and AIDS Intervention Package (draft), and

3. National Guidelines for Quality Improvement of HIV and AIDS Services.

Slid

e 8

CHALLENGES

• HIV and AIDS being among the chronic illness, HCWs are compelled to adopt the chronic care model while continuing to provide the comprehensive health care services to the populations they serve.

• Inefficient recruitment and retention of human resource for Health in the country.

• Unskilled HCWs to whom the technical care of HIV patients is task-shifted to, are struggling without appropriate technical follow-ups.

EXPLAIN to participants that HIV and AIDS services have experienced many challenges

TELL them that the rationale to develop QI documents with training package was based on the experienced challenges

27

• In efforts to improve quality of HIV&AIDS services stakeholders and most implementing partners have had their own initiatives to improve quality of services in the areas they work

BUT• There was no national framework for implementing and

monitoring HIV and AIDS QI activities at all levels of health care delivery system– QI initiative introduced by partners including regional

implementing partners uses different approaches.– Supervision for HIV and AIDS services has generally

been erratic, vertical and unlinked.

– Mentorship practiced by partners for HIV care and treatment services were not harmonized and with limited coverage

09/09/20119

Raising to the challenges….

• Clearly define minimum package of HIV and AIDS health services at each level of the health systems in order to assist various levels to plan and avoid duplication of efforts and overload;

• Provide Framework for harmonizing implementation and monitoring of QI strategies related to HIV and AIDS

• Improve supportive supervision to comprehensively cover HIV and AIDS health services; and

• Standardise and set up national mentoring system for HIV and AIDS services

09/09/2011 10

MOHSW/NACP had to

1. National Essential Health Sector HIV and AIDS Interventions Package (MOHSW, 2010)

2. National Guidelines for Quality Improvement of HIV and AIDS Services (MOHSW, 2010)

3. A Manual for Comprehensive supportive Supervision and Mentoring on HIV and AIDS Health Services (MOHSW, 2010)

09/09/2011 11

MOHSW/NACP developed:

28

Slid

e 9

Rationale for QI in HIV and AIDS services

• Emergence of new interventions • Scaling up HIV and AIDS services,

while improving and maintaining Quality • Lack of QI teams at various levels of

implementation

READ the rationale of QI in health care

ALLOW participants to ask questions where necessary

CLARRIFY as needed

Slid

e 10

Key points

This session focused on:• The milestones in the National HIV and

AIDS response • Background of QI in Tanzania • Rationale for QI in health care

Slid

e 11

Evaluation

• What is the rationale for improving HIV and AIDS services

• Mention challenges in provision of HIV and AIDS services

29

Session 1.2: Introduction to concepts of quality in health care


Session objectivesBy the end of this session, participants will be able to: Define quality and quality of care Define standards and guidelines

Resources needed Flip charts, marker pens, and masking tape/ LCD machine/laptop Black/white board and chalk/whiteboard markers Participant manuals National guidelines for QI of HIV and AIDS Services Tanzania Quality Improvement Framework National Essential Health Sector HIV and AIDS Interventions Package Different items with varying qualities (pens, exercise books, BP machines etc)

Session overview

Step Time Activity/method Content


2 25 minutes Presentation and brainstorming Define quality and quality of care

3 20 minutes Presentation Define standards and guidelines


5 5 minutes Questions and answers

Evaluation

30

SESSION CONTENTSl

ide

1

Session 1.2: Introduction to concepts of quality in health care



Slid

e 2

Session objective

By the end of this session, participants will be able to:• Define quality and quality of care• Define standards and guidelines



EXPLAIN to participants that the basic concepts of quality include the following terms are: quality, standards, quality assurance and QI.

TELL them that these terms are of great importance for health workers to understand before getting on the process of improving the quality of services.

31

Slid

e 3

Activity: brainstorming

Source: MOHSW Health Facility: Photo taken during Quality Improvement Training: Anonymous Photographer

ASK participants the following questions1. What do you see?2. Has any of you come across such

situations at your place of work?3. Do you think this is the expected

performance?

Possible responses:Question 1 Disorganized room Sheets not folded and put in a

carriage trolley for laundry Wheelchair used as carriage trolley for

the sheets Equipments (kidney dishes, jug and

bed pan) are not in the right places The wheelchair is not easy accessible

in case neededQuestion 2: Various answersQuestion 3: Preferable answer is: No this is not the expected performance

Slid

e 4

Activity: brainstorming ASK participants the following:1. What do they see2. Has any of you come across such

situations at your place of work?3. Do you think this is the expected

performance

Possible responsesQuestion 1: Organized room Sheets, blankets are neatly folded and

stored The cupboards are labelled The nurse is neatly dressedQuestion 2: Various answersQuestion 3: Preferred answer is YES

32

Slid

e 5

What is QUALITY?

ASK participants to define quality in daily practice

LET them buzz in 5 minutes and write their responses in a piece of paper

When they are ready ask one pair to WRITE on the flip chart the definition ofthe term quality.

LET others who have a different definition read and the facilitator to write on a flip chart

While the definitions are written on the flip chart MARK the key words that a definition of quality should have.

Slid

e 6

Quality is associated with:• Excellent• Superior• High Caliber• Best

SUMMARIZE the discussion by linking quality with words displayed on slide 6

Slid

e 7

Quality is…

Performance according to standards/specifications

EMPHASIZE that quality is realized by performing according to set standards /specifications

33

Slid

e 8

Quality in health care

• Accessible and effective care delivered in compliance with evidence-based standards and meets clients’ needs– E.g. high immunization coverage delivered

at appropriate schedule and age leading to control of immunizable diseases

DISPLAY slide 8 and ASK one participant to read aloud the definition of quality of care

EMPHASIZE key words in the definition i.e. accessibility, effectiveness, standard and clients’ needs using the example on immunization

Slid

e 9

Quality in health care

Quality means doing the right things the right way, otherwise there is no quality

– Doing “right things” means applying correct interventions to meet customer needs.

– Doing “right way” means applying correct processes, efficiently and on time (using set standards).

REMIND participants that quality is all about doing the right things the right way

CLARIFY what is meant by right things and right way as shown in the slide

Slid

e 10

RIGHT WRONG

Quality grid

RIGHT THINGS RIGHT

RIGHT THINGS WRONG

WRONG THINGS RIGHT

WRONG THINGS WRONGS

+ How you do it –

–H

ow y

ou d

o it

+W

RO

NG

RIG

HT

DESCRIBE the grid in slide 10 and clarify accordingly

EMPHASIZE that quality is attained when we do right things right (the upper left box)

34

Slid

e 11 Quality grid as applied in lab testing

Right things right

Filled out correct lab form and provided accurate information Conducted lab test as requested on schedule and conducted correctly

Right things wrong

Filled out correct form, but provided inaccurate information Completed lab test as requested on schedule, but conducted it incorrectly

Wrong things right

Filled out incorrect form, but provided accurate information Conducted wrong lab test, but conducted it correctly

Wrong things wrong

Filled out incorrect form, and provided inaccurate information. Conducted wrong lab test, and incorrectly

EXPLAIN example of:

RIGHT THINGS RIGHT is:1. Collect blood sample appropriately2. Put it in the right container3. Label it correctly4. Submit to lab on time5. The lab test will be conducted as

requested in a correct way6. The results will be recorded and report

written7. Report send to the clinic

RIGHT THINGS WRONG:1. Collect blood sample appropriately2. Put it in the right container3. Label it correctly4. BUT left it on the table till next day5. Filled out correct form6. But provided inaccurate information

WRONG THINGS RIGHT:1. Conducted wrong lab test2. BUT conducted it correctly3. Filled out incorrect form4. BUT provided accurate information

WRONG THINGS WRONG:1. Conducted wrong lab test2. Conducted it incorrectly3. Filled out incorrect form4. Provided inaccurate information

Slid

e 12

Quality is built on

• Guidelines• Standards

EXPLAIN to participants that quality can be attained by performing tasks in accordance to established standards and guidelines

35

Slid

e 13 Guidelines

Refers to a set of standards according towhich certain services should be provided in order to obtain the expected results

Examples:•National Guidelines for the Clinical Management of HIV and AIDS•National Guidelines for Quality Improvement of HIV and AIDS Services

EXPLAIN the meaning of guidelines by reading the definition and clarify accordingly using examples provided

DISPLAY available copies of the guidelines to participants

Slid

e 14

StandardsRefers to a statement of “desired”/ “achievable”performance of health care intervention which serves as a reference point for evaluation

Examples:•All HIV exposed infants should be initiated on CTX at the age of 4 weeks•Wearing of gloves when drawing blood

Standards are usually set by professional societies, health care organizations, panels of experts or governments

EXPLAIN the meaning of standards by reading the definition and clarify accordingly using examples provided

ASK participants to provide examples of standards they are familiar with from a health care setting

Slid

e 15 Key Points

This session focused on:• Defining quality and quality of care• Defining standards and guidelines• Defining QI and quality assurance • The principles of QI

36

Slid

e 16 Evaluation

• What is quality?

• What do these statements imply– Initiate ART to any HIV patient with CD4 cells

less than 200 per micro litre (μL)

– Counselling and testing for HIV to all pregnant mothers at ANC

• Mention principles of QI

DISPLAY the slide to participants

ALLOW participants to discuss in buzz groups for 5 minutes

37

Session 1.3: Dimensions of quality


Session objectivesBy the end of this session, participants will be able to: Define the dimensions of quality Describe the dimensions of quality and cite examples of quality for each dimension Link the dimension of quality to service delivery

Resources needed Flip charts, marker pens, and masking tape/ LCD machine/laptop Black/white board and chalk/whiteboard markers Participant manuals National Guidelines for Quality Improvement of HIV and AIDS Services Tanzania Quality Improvement Framework National Essential Health Sector HIV and AIDS Interventions Package Photographs or posters on actual services at facility or community level

Session overview

Step Time Activity/method Content

1 5 minutes Presentation Presentation of session title and session objectives

2 10 minutes Presentation Definition of dimensions of quality

3 35 minutes Presentation andbrainstorm

Description of dimensions of quality and their examples

4 5 minutes Presentation Linkage of the dimension of quality to service delivery


6 10 minutes Question and Answers Evaluation

38

SESSION CONTENTSl

ide

1

Session 1.3: Dimensions of quality



Slid

e 2

Session objectives

By the end of the session, participants will be able to:• Define the dimensions of quality• Describe the dimensions of quality and

cite examples of quality for each dimension

• Link the dimensions of quality to service delivery

READ or ASK participants to readthe objectives.

Clarify the objectives accordingly

Slid

e 3

Dimensions of quality

Dimensions of quality are aspects of care or service provided to clients (internal and external), which should be considered for provision of quality services

PRESENT the definition of dimensions of quality

EXPLAIN that dimension refers to Scope Extent Magnitude Proportions Size

39

Slid

e 4

Dimensions of quality1. Technical performance2. Effectiveness of care3. Efficiency of service delivery4. Safety5. Access to services6. Interpersonal relations7. Continuity of services8. Physical infrastructure and comfort9. Choice of services

ASK participants to READ the 9 dimensions of quality.

TELL them that each of the dimensions will be explained in the slides that follow.

Slid

e 5

1.Technical performance

The degree to which the tasks carried out by health workers and facilities meet the expectations of technical quality in compliance with the set standards.

Example:• Counseling and testing of pregnant women attending

ANC clinic and providing correct PMTCT interventions

EXPLAIN technical performance with various examples of HIV andAIDS services provided in the health system

40

Slid

e 6

2. Effectiveness of care

The degree to which desired results (outcomes) of care are achieved through appropriate diagnosis and treatment.

Example:• Reduction of episodes of pneumonia in an HIV

exposed child following regular cotrimoxazoleprophylaxis.

• A child with persistent fever after initial anti-malaria treatment has a blood smear to confirm the continued presence of malaria parasites.

EXPLAIN that success of the service delivery will be measured based on the required outcome

Slid

e 7

What will happen next !!

ASK participants to relate effectiveness of communication to the picture on the slide

Possible responses Cannot hear any of the calls Cannot send correct message to

the other end Purpose of communication not

accomplished

Slid

e 8

3. Efficiency of service delivery

Using minimum resources to achieve desired results.

Example:• Providing HIV services for mother and child at RCH

instead of referring to CTC.• Organize records for easy retrieval, use and re-

filing.

ASK participants to give examples of efficient HIV and AIDS services

Possible responses Providing same day HIV test

result Integration of HIV/TB/STI/FP

services Integrating HIV screening

services with routine hospital services

The supply officer uses FEFO methods (first expiry, first out) to avoid wasting drugs because they are past expiry date.

Organize records for easy retrieval, use and re-filing

41

Slid

e 9

Source: Implementation for 5S-CQI-TQM approaches, MOHSW:2009

DISPLAY slide 9 and then slide 10concurrently and ASK participants to explain what they observe from the two photos

TELL participants to summarize the photos in relation to effectiveness of care

Possible responses Records are poorly arranged The service provider will use too

much time to retrieve the files Possibility of misplacing/losing

files

Slid

e 10 TELL participants to summarize the

photos in relation to effectiveness of care

Possible responses Files are properly arranged The service provider uses less

time to retrieve files Less likely to misplace/lose files

Slid

e 11

4. Safety

The degree to which the risks of injury, infection or other harmful side effects are minimized

Example:• Wear Personal Protective Equipment (PPE) including

gloves, masks, gowns, boots, caps goggles and aprons• Safe disposal of infectious material to protect those who

handle them and prevent injury or spread to the community as well as appropriate handling and disposal of sharps e.g. needless and surgical instruments

EXPLAIN to participants the safety precautions for different hazardous wastes

42

Slid

e 12 DISPLAY slide 12 and ASK

participants the following question:

Is this a safe way of disposing sharps?

ALLOW about 3 to 4 participants to respond

SUMMARISE by explaining it is dangerous to dispose sharps as shown in the picture

Slid

e 13

5. Access to services

The degree to which healthcare services are accessible, not restricted by geographic, economic, social, organizational or linguistic barriers

Example:• The hospital ward has ramps for person in

wheelchairs to enter• The faith-based health facilities provide services to

the entire population regardless of religious affiliation

DISPLAY slide 13

EXPLAIN that access may be affected by: Physical access: distance, roads,

security situation etc Cost of travelling from a village to

the district hospital Attitude of service providers Organizational problems Cost of services Beliefs

Slid

e 14 ASK participants the following

question: What does this picture tell you about access?

ALLOW about 3 to 4 participants to respond and SUMMARIZE as follows: This patient does not have

reliable means of transport to access the health facility.

In situations where people in the community do not have access to health facilities, serious consequences might occur including death

43

Slid

e 15

6. Interpersonal relations

Interpersonal relations are enhanced when confidentiality, trust, respect, responsiveness, empathy, effective communication between providers and clients are observed.

Example:• A health worker is not judgmental when speaking with a patient

about his or her illness• “… when I entered the doctor’s room he was in a bad mood

and did not explain anything to me. I left confused…” (quote from a patient)

EXPLAIN that good interpersonal relationship between client and provider has a role towards proper service provision.

Use the quote from the patient in the example given to emphasize the importance of good interpersonal relations

Slid

e 16 ASK participant to describe the

picture of a health worker in a room providing counselling

ASK participants to tell whatfeatures they see in the picture

Possible explanation A health worker sitting at the

same level with the clients Happy/satisfied clients Verbal and non-verbal

communication observed

Slid

e 17

7. Continuity

Ensure uninterrupted and consistent services are provided to the population / community

Example:• Availability of supplies and trained staff• Functional referral and record keeping systems• Functional social supporting networks

EXPLAIN to participants the importance of ensuring continuity of service using examples provided in the slide

ASK participants what will happen if health services are interrupted

Possible answers Jeopardize life Out of stock of supplies Link between community and

hospital is weakened

44

Slid

e18

8. Physical infrastructure and comfort

• The physical appearance of the facility– Clean and well ventilated building– Availability of toilets according to guidelines– Infrastructure in favor for disabled persons

• Provision for privacy during consultation– Adequate rooms and screens

• Other aspects– Reading material and TV in waiting area– Benches/chairs provided in waiting and consultation

rooms

EXPLAIN to participants the importance of: Keeping a clean hospital

environment Privacy during consultations Other amenities such as TV

Possible benefits include Attracting and keeping clients Clients feeling comfortable Clients feel they receive quality

service

Slid

e 19 ASK participants to describe the

environment of one health facility in Tanzania

Possible answers The resting benches are shaded

for patients and visitors Short grass, trees are green and

clean environment. Paved and roofed corridor

connecting buildings (Good shelter)

Slid

e 20

9. Choice of services

The client can decide which facility to attend, time to seek health care and treatment plan

Example:– Having options to run HIV and AIDS care and treatment

services on weekends – Family planning; provide different choices on contraceptive

methods (long and short term)– Clinician can choose from a range of effective antibiotics to treat

a respiratory infection

EXPLAIN to participants that clients have the right to choose the type and place to access the service and involvement in the treatment plan he/she needs

ILLUSTRATE further using examples provided in the slide

45

Slid

e 21

Activity

Read Mrs. Kwangu case study on Page 81

REFER participants to page 81 in the participant manual to read the case study of Mrs. Kwangu. Three participants should read the case study aloud while the rest follow attentively

After reading the case study, DIVIDE participants in small groups of 4 – 5 people.

Slid

e 22

Group workRelated to the case study of Mrs. Kwangu1. Do you think that Mrs. Kwangu’s case

study has reflected the dimensions that we have discussed? If yes, mention the dimensions and explain how they are reflected.

2. What is your opinion about the quality of care provided to Mrs. Kwangu?

TELL them to answer question 1 and 2 in slide 22 and write their responses on a flip chart. Make sure that answers reflect all the dimensions of quality.

Possible responsesTechnical performance Counselled and tested Effectiveness of care Given referral (by mouth)Efficiency of service delivery ANC and PMTCT offered under

one roofSafety Nurse was not aware of Mrs.

Kwangu’s HIV statusAccess to service Distance to district hospital is

longInterpersonal relations Not given proper directives by

health care providerContinuity of services Mrs. Kwangu did not get CD4

count

46

Slid

e 23 Key points

This session focused on:• The dimensions of quality• Examples of quality for each dimension• Reflecting the dimensions of quality

related to service delivery scenario in the case study

SUMMARIZE the session by reading the key points based on the session content.

Slid

e 24

Evaluation

• Mention nine dimensions of quality

ASK participants to answer the question

ANSWERThe nine dimensions of quality are1. Technical performance2. Effectiveness of care3. Efficiency of service delivery4. Safety5. Access to services6. Interpersonal relations7. Continuity of services8. Physical infrastructure and

comfort9. Choice of services

47

UNIT 2 QI and its principles


AimThe aim of this unit is to introduce participants to the concepts of quality, standards, quality assurance and QI in health care. The unit will also describe the dimensions and principles of quality.

Unit objectivesBy the end of this unit, participants will be able to: QI definition Describe principles of QI Apply principles of QI at health care settings

Resources needed Flip charts, marker pens, and masking tape/ LCD machine/laptop Black/white board and chalk/whiteboard markers Participant manuals Cards for participants to write needs and expectations Printed text of Mrs. Kwangu case

Unit overviewStep Time Activity/method Content

1 15 minutes Presentation QI definition

2 90 minutes Presentation

Principles of QI: Focus on client needs, expectations, communication and gaining feedback

3 90 minutes Presentation and discussion

Principles of QI: Focus on team work

4 120 minutesPresentation and small

group discussion Principles of QI: Focus on measurements

5 120 minutes PresentationPrinciples of QI: Focus on systems and processes

48

Session 2.1 QI definition

Total session time: 15 minutes

By the end of this unit, participants will be able to: Define QI


1 15 Presentation QI definition

Session content

Slid

e 1

Session 2.1: QI definition


Slid

e 2

Session objective

By the end of this session, participants will be able to:• Define QI



49

Slid

e 3

QI

Systematic process of assessing performance of a health system and its services, identifying gaps and causes, and introducing measures to improve quality and monitoring the impact

ASK one participant to read the definition aloud

EXPLAIN to participants the meaning of QI by clarifying key words in the definition i.e. Systematic Assessment to identify gaps Measures to improve Monitoring

Slid

e 4

The difference between the actual and the desired state

Standard of performance is defined for measurement using indicators Actual

DesiredStandards

Opportunity for improvement To 100%

From 0%

DISPLAY the figure in slide 4 and use it to emphasize the QI concept by telling them to describe one example of a quality gap using existing data (actual performance) and to come up with a quick strategy to improve (desired performance/standard)

Slid

e 5

Principles of QI

There are five principles of QI: 1. Focus on client’s needs and expectations2. Focus on communication and feedback3. Teamwork4. Measurements (data)5. Focus on Systems and Processes

DISPLAY slide 5 and ask participant to read aloud the five principles of QI

TELL participants that each of the principle will be described in detail in the coming sessions

50

Session 2.2: Principles of QI: Focus on client needs, expectations, communication and gaining feedback


Session objectivesBy the end of this session, participants will be able to: Define: client, needs and expectation Explain the importance of meeting the needs and expectations of the client Define communication and feedback Explain the levels of communication Describe importance of effective communication



2 20 minutes PresentationClient needs and expectations

3 15 minutes Activity and group discussion

Mrs. Kwangu case study

4 10 minutes Presentation The importance of meeting clients needs and expectation

5 15 minutes Presentation Communication

6 15 minutes Presentation Gaining feedback

8 5 minutes Presentation Key Points


51

SESSION CONTENTSl

ide

1

Session 2.2: Principles of QI:Focus on client needs, expectations, communication and gaining feedback


Slid

e 2

Session objectives

By the end of this session, participants will be able to:• Define client needs and expectation• Explain the importance of meeting the

needs and expectations of the client • Define communication and feedback• Explain the levels of communication • Describe importance of effective

communication and feedback


CLARIFY the objectives accordingly and TELL participants that this session is going to cover two principles which are client’s needs and expectations and communication and feedback

Slid

e 3

2.2.1 Focus on client’s needs and expectations

READ or ASK participants to read title of the session.

52

Slid

e 4

Who is a client?

A client is a person or organization using services of a professional person or organization

There are two types of clients:• External clients are individuals that come to the facility

to receive services e.g. patients• Internal clients are individuals involved in the delivery

of care e.g. doctors, nurses, administration, cleaning staff and food service personnel

READ and EXPLAIN who is a client

EMPHASISE on the QI understanding ofa client

Slid

e 5 Level of clients in service delivery

Client / Family Provider

Health CareAdministration& Management Community

EXPLAIN that the different levels are: The client The provider The health care administrators &

management The community

Slid

e 6

What are needs and expectations?

• Needs are the actual necessities or the goal that a client wants to be met from utilizing a service

• Expectations are the preconceived outcome or procedures that a client has before the actual achievement of a service

DISPLAY animated slide 6 and ASKparticipants to brainstorm on the meaning of the terms needs and expectations.

WRITE the responses on a flip chartbefore displaying the definitions of needs and expectations

SUMMARIZE participants responses on client’s expectation by linking withdescription provided in the next slide.

53

Slid

e 7

Expectations of clients ELABORATE on the client expectationsby showing how clients convene at a central point in the provision of quality services.

Slid

e 8

Activity

Based on Mrs. Kwangu case study:

• Who are possible clients in the story?• What are the needs of at least two of

the clients?• What are the expectations of at least

two of the clients?

REFER participants to case study Mrs. Kwangu on page 81 of the participant’s manual.

Based on the case study TELL participants to answer questions in slide 8 and write responses in their writing pads.

ASK 3 to 4 participants to read their responses aloud, meanwhile other participants should compare their responses

Possible answers1. Clients: Mrs Kwangu and her husband, RCH Nurse Midwife, Receptionist, the General practitioner, the lab technician, the Nurse Assistant and Paediatricdoctor2. Needs: Monitored through out her pregnancy Support from her husband3. Expectations: Right information, services and

procedures Quality care

54

Slid

e 9 Importance of meeting external

clients needs and expectationsSatisfied external clients tend to:• Comply and adhere to treatment• Often return to the health facility for additional

care• Recommend the services to others• Support resource generation for the health

facility

The opposite could apply if the clients are not satisfied

DISPLAY animated slide 9 (only the title) and ASK participants to brainstorm

ASK participants to brainstorm on what will happen when clients are not satisfied.

SUMMARIZE by displaying the rest of the information on slide 9

Slid

e 10

What was your level of satisfaction in the service you received last time you visited MoHSW headquarter?

DISPLAY the slide and TELLparticipants that the level of satisfaction by clients depends on past experiencesand expectations

ASK 2-3 participants to share their experiences last time they visited MoHSW headquarter and rank using the illustration on slide 10.

EMPHASIZE to participants that satisfaction does not apply only in hospital settings but also in markets, shops etc, as shown in the following slide

55

Slid

e 11

DISPLAY slide 11 and ASK a volunteer to explain the difference between the two food stalls at a market place.

Possible responses:Stall on the left has fewer things not well organized clothes and food

placed together Food items are dropping to the

ground Service provider looks miserable

Food stall on the right neatly organized variety of products Clients are interested with stall and

they go there even when they have to wait to be served

Service provider is friendly/welcoming

General comment is that clients willaccess your services if their expectations are met

Slid

e 12

2.2.2 Focus on communication and feedback

DISPLAY and READ the slide

EXPLAIN that, this is the second principle among the five mention principles

56

Slid

e 13

Communication

Communication is the ability to build a relationship of trust, understanding and empathy with the client and to show sensitivity and responsiveness

ASK one of the participants to read the definition

Slid

e 14 Levels of communication

Communication related to health care needs occurs at different levels between:• Client and family / friends• Client and spiritual leaders • Client and service provider • Health system and community• Provider and management• Between providers within the health care

system

EXPLAIN to the participants that communication occurs at several levels

ASK participants to mention messages that could be communicated at some of the levels

Possible answers: Client and family/friends e.g. test

results given at facility Provider – Client, e.g. instruction

about use of medication, interaction between clinician and client, registration at reception

HF Management – Provider: daily clinical meetings

HF – Community: Health education District Authority – HF: regular

monthly meeting or reports and supportive supervision

Slid

e 15

Effective Communication

Effective communication is essential for ensuring quality services and client satisfaction

For communication to be effective the following principles should be observed:

– Listen attentively– Two way communication– Affirm and acknowledge results

ASK a volunteer to read aloud and elaborate the terms

57

Slid

e 16

Barriers to communication

Barriers in communication can be caused by:• Language used used not understandable • Inappropriate channel used to convey

message • Message content not clear

Communication barriers can severely affect the quality of service

DISPLAY the animated heading of slide 16 and ASK participants to explain what they understand by barriers to communication

WRITE the responses on a flip chart

SUMMARIZE by displaying the barriers shown in slide 16 and compare with responses given on flip chart

Slid

e 17

Feedback

Feedback is information given in response to a product, service or a person’s performance of a task or service

READ the definition of feedback and clarify accordingly

Slid

e 18

Importance of feedback

Providing feedback is important in fostering communication and clients satisfaction

After obtaining suggestions for improvement ensure feedback by either:• Implementing suggested changes OR• Informing clients what action will be taken

DISPLAY the animated heading of this slide and ASK a volunteer to mention the importance of feedback

SUMMARIZE by displaying slide 18

58

Slid

e 19

Gaining clients’ feedback

Feedback can be gained through:

• Questionnaires• Interviews • Focus group discussions• Meetings

ELABORATE the means through which feedback can be obtained

ASK participants for any question or point of clarification

Slid

e 20

Key points

This session focused on:• Defining clients’ needs and expectations• The importance of meeting clients’ needs

and expectations • Defining communication and feedback• Levels of communication • The importance of effective

communication and feedback

READ through the key points

Slid

e 21

Evaluation

• How can you improve communication in a health care setting?

• How could facilities obtain feedback from clients?

ASK participants to buzz for 2 – 3 minutes on the questions based on the learning objectives and ASK one volunteer to respond

THANK the participants for their attention and participation

59

Session 2.3: Principles of QI: Focus on team work

Total session time: 1 hours 30 minutes

Session objectivesBy the end of this session, participants will be able to: Define concepts: team, work and team work Describe stages of team formation Explain the characteristics of an effective team

Resources needed Flip charts, flip chart stand, marker pens, LCD projector Facilitator and participant manuals Role Play Script_ Session 2.3_Principles of QI: Team Work

Preparations needed Select the players before the session Distribute the scripts for them to read

Session overviewStep Time Activity/Method Content

1 5 minutes Presentation Presentation of session title and objectives

2 30 minutes Presentation and role play

Role play about team work: game of 10 chairs

3 15 minutes Presentation Team and team work

4 20 minutes Presentation Stages of team development

5 10 minutes Presentation QI team composition



60

SESSION CONTENTSl

ide

1

Session 2.3: Principles of QI: Focus on team work


Slid

e 2

Session objectives

By the end of this session, participants will be able to:• Define concepts: team, work and team

work• Describe stages of team formation • Explain the characteristics of an effective

team



Slid

e 3

Activity

The game of 10 chairs!

READ and follow instruction provided in annex 4 page 140 of the facilitators manual

Total time: 30 minutes

61

Slid

e 4

Team and team work

• Team is a group of people working together to achieve a common goal for which they share responsibility

• Team work is solving problems together whereby all members have the ability to influence decisions and apply their strengths effectively

READ or ASK volunteers to read the definitions.

CLARIFY accordingly

Slid

e 5

Why team work?

• Teams can build a more complete picture of a process or situation to be improved

• Mutual support and cooperation lead to increased commitment to quality improvement

• Team accomplishment builds confidence of individual members

• When people help design a solution they embrace rather than resist it

• Reduces complexities regarding hierarchy

DISPLAY slide 5 and READ

SUMMARIZE by stressing the importance of teamwork

Slid

e 6

Teamwork is not…

• A group of people and one ‘STAR’ who does all of the work

• A group of people and a leader dictating to them what to do

ELABORATE that in a group peopleshould agree on issues that they want to accomplish as a team

ASSOCIATE the elaboration in this slide with the picture in slide 7

62

Slid

e 7

9

STRESS that in a group peopleshould agree on issues that they want to accomplish as a team.

ASK participants what they see in the picture

Possible responsesArgument between the foremen of the teams on the misaligned railway line. The other workers (team members) are merely observers.

Slid

e 8

Stages of team development

1. Forming2. Storming3. Norming4. Performing5. Closing

DISPLAY the slide and read stages of team development

EXPLAIN to the participants that each team develops in its own way. A team may reach the performing stage by going through all the stages sequentially others may developerratically – skipping some aspects of a stage, and then returning to it later.

Changes in the membership or leadership of a team, or in goals or tasks, will tend to pull the team back toward Stage 1 (forming).

TELL participants that each of the stages will be explained in detail in the next slides

Slid

e 9

Stage 1 - Forming

When a team is forming:• Members cautiously explore acceptable group

behavior• People’s roles change from “individual” to

“member”• Members may challenge the authority of the

leader/coach BUT also tend to depend on them for orientation and direction

This stage is complete when members begin to think of themselves as part of the team.

DISPLAY the slide and EXPLAIN accordingly

EMPHASIZE that in this stage members can experience excitement and pride in being involved in a particular task

63

Slid

e 10

Stage 2 - Storming

Storming is critical to effective group development• Tasks ahead may seem harder than expected• Some team members may become impatient,

argumentative and resist collaborating with each other

• This stage provides the opportunity for individuals to establish their own expertise within the group

• They will forge ways of working together and respect each other’s point of view

This stage is complete when there is a relatively clear hierarchy of leadership within the group


EMPHASIZE that in this stage members can experience positive or negative feelings about the team, the team members, and the project’s chance of success

Slid

e 11

Stage 3 - Norming• During this stage members realize their:

– Common goals– Begin to accept the team – Roles and the individuality of fellow

membersAs a result conflicts are minimal and there is more cooperation

This stage is complete when the group structure becomes established and the team develops a shared understanding of how a team member should behave.


EMPHASIZE that in this stage there is acceptance of membership in the team and relief that everything is going to work out

Slid

e 12

Stage 4 - Performing

• During this stage:– The team starts identifying, solving problems, choosing and implementing changes– Members accept each other’s strengths, weaknesses, and know their own roles

It is during this stage that the team performs at its best.


EMPHASIZE that in this stage risk-taking, creativity, and learning of new skills/roles is exhibited. The team also shows commitment to process and goals.

64

Slid

e 13

Stage 5 - Closing

The work of a problem-solving or quality improvement team is intended to end when process improvements are in place• The team must deal with either the success or

failure of their efforts and the dissolution of the team

• The team should identify lessons learned and plan how they will be communicated

The leader and team celebrate their successes and provide support if the project has not been successful


Slid

e 14

What makes effective teams?

Clear roles and responsibilities to each team member

Awareness of each other’s need Appreciation and recognition of individual

efforts/contribution Recognition of the QI team at all levels Trusting team climate Effective communication among team

members

EXPLAIN what makes effective teamsbased on the information on the slide

Slid

e 1

5

Team composition

• Team leader• Recorder or Secretary• Members from units involved in

QI activities

EXPLAIN that the composition of a team depends on the task to be accomplished in an organization or an institution such as a health facility

65

Slid

e 16

4

USE the picture in slide 16 toSUMMARIZE that by working as a team you can achieve more than working individually

Slid

e 17

Key points

This session focused on:• Defining team and team work• Characteristics of an effective team• Describing stages of team formation

READ the key points and ASKparticipants for any question for clarification

Slid

e 18

Evaluation

• What make teams effective?• What are stages of team formation?

ASK participants the following questions based on the learning objectives

THANK the participants for their attention and participation

66

Session 2.4: Principles of QI: Focus on measurements of quality in health care

Total session time: 2 hours

Session objectivesBy the end of this session, participants will be able to: Explain the importance of measuring quality of care Explain the rationale for measurement of quality Explain the methods to measuring quality Define indicators and mention their characteristics

Resources needed Flip charts, marker pens, and masking tape/ LCD machine/laptop Black/white board and chalk/whiteboard markers Participant manuals All tools available as mentioned in slide 15 Measurement tools

Session Overview

Step Time Activity/Method Content

1 20 minutes Presentation Introduction of session title and objectives

3 20 minutes Presentation and buzzing Measuring quality of care

4 20 minutes Presentation and brainstorm Rationale for measurement ofquality of care

5 25 minutes Presentation Methods of measuring quality

6 20 minutes Presentation and small group discussion

Defining indicators and sources of data



67

SESSION CONTENTSl

ide

1

Session 2.4: Principles of QI: Focus on measurements of qualityin health care


Slid

e 2

Session objectivesBy the end of this session, participants will be able to:• Explain the importance of measuring

quality of care • Explain the rationale for measurement of

quality• Explain the methods to measuring quality• Define indicators and mention their

characteristics


Clarify the objectives accordinglybefore DISPLAYING slide 3

ASK participants the following questions:1. Suppose you were asked to organize a workshop. How would you know the amount of food to prepare for attendees?Answer: find out how many people are expected to attend the workshop.2. How will you know the size of your farm? Answer: by measuring the length and width of the farm.

Slid

e 3

Introduction

• Measurement of data is key to quality improvement because it provides useful information for decision making and tells how an improvement is proceeding

• The entire process of measuring quality requires quantifying the current level of compliance with expected standards of care

READ the content of the slide to introduce the concept of measurement.

The facilitator can remind participants that they have discussed about standards in previous sessions.

68

Slid

e 4

Rationale for measuring quality of care• Compare current status versus the set standards

or guidelines• Assure quality health services are provided• Early identification of quality gaps• To measure whether change resulted into an

improvement• Raise awareness in the process of health care

delivery among health workers• Identify client needs and levels of satisfaction

EXPLAIN to participants the implications of measuring quality as detailed in slide 4

Slid

e 5

What ‘IS’ and ‘SHOULD’ be the situation at the facility

EXPLAIN to the participants that there is a difference between what ‘IS’ and what ‘SHOULD’ be the situation for level of service at the health facility.

Slid

e 6

Roles of measurement

Measurement is useful in quality improvement efforts in order to:• Identify and analyze problems• Verify possible causes of problems • Monitor change to ensure improvement is

maintained over time• Make decision based upon fact, not

opinion

EMPHASIZE that without measurement it would be impossible to determine if a change has occurred, whether or not there are problems andmake sound decisions

EXPLAIN that measurement allows us to know if there is a decrease in infant mortality, improved client satisfaction and reduced waiting time.

69

Slid

e 7

Methods of measuring quality

Quality of care can be measured on the basis of the following three aspects• Structure• Process• Outcome

READ the text in the slide and then explain that each of the three aspects of measurement will be discussed in detail in the following slides

Slid

e 8

Structure Structure refers to the different components of a system such as the healthcare system

Example• Trained and skilled health workers• Adequate equipment • Infrastructure• Organizational systems

Before DISPLAYING slide 8 ASKparticipants to give examples of components that make up the structure of the health care system.

WRITE the responses on the flip chart

SUMMARIZE the discussion by PRESENTING the remaining part of slide 8

Slid

e 9

Process

Process describes an act of taking something through an established routine or sets of procedures

Example: The process of testing a patient for HIV involves: pre test counseling, draw blood, perform the test, give results and post test counseling

ASK one volunteer to READ the definition of process

TELL participants that the series of action taken by a health care workerto test a client for HIV can bedescribed as a process.

SUMMARIZE by explaining that processes are steps or actions needed to achieve an end or determined objective.

70

Slid

e 10

Outcome

Outcome refers to the results of treatment and can represent markers of disease Progression

Example• Mortality• Re-admission of the client• Health status symptoms • Functional status of the client• Quality of life

READ the text in the slide to participants.

EXPLAIN that outcome is what happens to people, particularly in terms of their health.

EXPLAIN Outcome measures enable us to monitor the patient health status overtime (e.g. an improvement in health status symptoms or morbidity and mortality).

Slid

e 11 Sources of data for measuring

quality

Specifically designed tools are used to measure structures, processes and outcomes.

Sources of data includes:• Patient records• Survey data• Direct observations e.g. provider/client

interactions

EXPLAIN to participants that measuring quality requires specifically designed tools to measure structural, process and outcomes aspects of care

EXPLAIN to the participants that selection of sources of data depends on the purpose for which the information/data will be used.

TELL participants that obtaining data can be difficult and expensive and errors can occur at several levels.

Slid

e 12

Display of data: run chartIndicator 2: Proportion of exposed children under 18 months receiving daily Cotrimoxazole

prophylaxis each month

0

10

20

30

40

50

60

70

80

90

100

PER

CEN

TAG

E

ALL SITES AGGREGATE 0 4 3 4 6 9 10 12 19 16 12 12 31 36 41 45 49 50 54 57

MEDIAN 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14

# of sites reporting 5 7 8 8 8 8 8 8 8 8 8 8 8 8 7 7 7 8 8 8 0 0 0 0

DENOM 273 480 508 492 511 502 497 488 488 523 487 479 880 877 832 832 832 877 877 877 0 0 0 0

J F M A M J J A S O N D J F M A M J J A S O N D

2008 2009

Numerator:# of HIV exposed infants that started receiving cotrim oxazole within 2 m onths of age Data Source: CTC 2 card, PMTCT RegDenominator: The estim ated # of H IV exposed infan ts born in the preceeding 12 months

EXPLAIN to participants that visual display of data of used for QI in health care settings is shown by the run chart, whereby data is plotted over time

71

Slid

e13

Indicators

DISPLAY slide 13 and explain to participants that the following slides will focus on indicators

Slid

e 14

Definition of Indicators

Indicators are quantitative measures used to monitor and evaluate the quality of important governance, management, clinical, and support functions that affect patient outcomes.

ASK a volunteer to READ the definition of indicators

72

Slid

e 15

Characteristics of indicators

• S – Specific• M – Measurable• A – Achievable• R – Realistic• T – Time bound

DISPLAY slide 15 and explain the meaning of each characteristic using descriptions provided below

Specific means the indicator measures what it is intended to measure with highest degree of accuracy/precision

Measurable means the indicator can be quantified/assessed using appropriate measurement scales

Achievable impliesfeasibility/attainability of a particular issue that the indicator is targeting

Realistic meanspracticability/rationality of the issue which the indicator is addressing

Time bound implies that the indicator has a specified time to be realized

ASK participants to give examples for each characteristic

E.g. Increase enrolment of HIV Positive Pregnant mothers from RCH and Labour ward to CTC at Bombo Hospital from 20 percent to 35 percent by December 2010

73

Slid

e 16

Components of indicators• A numerator

– the part of a common fraction appearing above the

line, representing the number of parts of the whole

that are being considered

• A denominator

– the number below the line in a simple fraction, which

indicates the number of parts making up the whole

• Time over which the event may take place

PRESENT the slide to participants.

Use the flipchart andDEMONSTRATE how to calculate a percentage by using numerator and denominator through the following example:

What is the percentage of the participants wearing spectacles?

Steps 1. Count the number of participants

e.g. 20. (denominator)2. Count how many participants wear

spectacles e.g. 5. (numerator)3. Illustrate with this information what

the numerator and denominator is

Answer:Numerator: the number of people wearing spectaclesDenominator: Total number of participants

To calculate percentageNumerator x100 = % Denominator

5 out of the 20 participants wear spectacles

5 x 100 = 25%20

25% of the participants wear spectacles

74

Slid

e 17

Examples of indicators (1)

• Numerator: number men accompanying their partners to ANC in a given month

• Denominator: total number of women attending ANC in the same month

Indicator: proportion of men accompanying their partner to ANC per month

DISPLAY the first part of animated slide 17 (indicator)

ASK participants to state the numerator and denominator for the indicator.

SUMMARIZE by displaying the animated numerator and denominator for the indicator

Slid

e 18

Examples of indicators (2)

• Numerator: number of HIV patients both in general care and on ART seen at the clinic in the past six months who had a CD4 test in a particular month

• Denominator: total number of HIV patients in general care and on ART seen at the clinic in the past 6 months

Indicator: % of HIV patients from CTC receiving CD4 test once every 6 months

DISPLAY the first part of animated slide 18 (indicator)

ASK participants to state the numerator and denominator for the indicator.

SUMMARIZE by displaying the animated numerator and denominatorfor the indicator

75

Slid

e 19

Exercise on indicators

1. Indicator: Proportion of pregnant women testing for HIV at RCH clinic every monthNumerator: Denominator:

2. Indicator: Proportion of Tuberculosis patients tested for HIV in a month Numerator: Denominator:

DISPLAY slide 19

ASK participants write answers toquestions 1 and 2 in their notepads.

TELL participants to exchange their notepads with their neighbors and ask 5 participants to read out the answers.

SUMMARISE the discussion by writing the correct answers on a flip chart.

1. Indicator: Proportion of pregnant women testing for HIV at RCH clinic every month.Answer is:Numerator: number of pregnant women tested for HIV in a month at RCH clinicDenominator: total number of pregnant women attending RCH clinic in a particular month.

2. Indicator: Proportion of Tuberculosis patients screened for HIV every month. Answer is:Numerator: number of TB patients tested for HIV per month.Denominator: total number of TB patients seen per month.

Slid

e 20

Role of indicators

• Document the quality of care• Make comparisons “what IS” and “what

SHOULD” be• Set priorities (e.g. organizing medical care)• Support improvement• Monitoring and evaluation• Support patient choice of providers

READ the information on the slide and explain accordingly

76

Slid

e 21

Types of indicators

DISPLAY slide 21 and tell participants that the slides that follow will describe types of indicators

Slid

e 22

1. Structural indicators

• Structural indicators describe the type and amount of resources used by a health system or organization to deliver programs and services

• Relate to the presence or number of staff, clients, money, beds, supplies, and buildings

DISPLAY the heading of slide 22 and read the definition of structural indicators

PROVIDE examples of structural indicators e.g. 1. Proportion of staff trained in HIV

clinical management in 20102. Proportion of functional CD4

machines in the region in a month3. Proportion of days in a month with

stock out of ARV

Slid

e 23

2. Process indicators

Process indicators assess what the provider did for the patient and how well it was done

DISPLAY slide 23 and read the definition of process indicators

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Slid

e 24

Examples of process indicators

• Proportion of patients seen by a doctor at CTC within 4 hours

• Proportion of patients treated according to clinical guidelines

• Proportion of HIV patients who undergo CD4 testing after every six months

DISPLAY the examples of process indicators shown on slide 24 and clarify accordingly

Slid

e 25

3. Outcome indicators

Outcome indicators attempt to describe

the effects of care on the health status

of patients and populations

DISPLAY slide 25 and read the definition of outcome indicators

Slid

e 26

Examples of outcome indicators

• Intermediate outcome– Clinical improvement among HIV patients

receiving ARVs– Increase in CD4 counts among HIV patients

receiving ARVs

• End result– Mortality– Morbidity– Functional status– Patient satisfaction

DISPLAY the examples of outcome indicators shown on slide 26 and clarify accordingly

78

Slid

e 27

Key points

This session focused on:• The importance of measuring quality of

care • The rationale for measurement of

quality• Methods for measuring quality• Indicators and their characteristics

READ through the key points and respond to any questions that may be raised by participants

Slid

e 28

Evaluation

• Cite three examples for each type of indicator:– Structural/Input indicator– Process indicator– Outcome indicator

ASK participants to respond to the evaluation question on slide 28

79

Session 2.5: Principles of QI: Focus on systems and processes


Session objectivesBy the end of this session, participants will be able to: Define what is meant by a system and its components Explain the concept of “system’’ Explain the concept of “process” Differentiate between a process and a system Carry out process analysis and re-design the process

Resources needed Flip charts, flip chart stand, marker pens, LCD projector Posters of digestive, respiratory, hospital system


1 5 minutes Presentation Presentation of session title and objectives

2 10 minutes Presentation Definition of a system and its components

3 15 minutes Presentation and discussion The concept of a system

4 15 minutes Presentation and discussion The concept of a process

5 15 minutesPresentation Interrelation between a system

and process

6 50 minutes Presentation and group work

Process analysis and re-design



80

SESSION CONTENTSl

ide

1

Session 2.5: Principles of QI: Focus on systems and processes


Slid

e 2

Session objectivesBy the end of this session, participants will be able to:• Define what is meant by a system and its

components• Explain the concept of “system’’• Explain the concept of “process”• Differentiate between a process and a system• Carry out process analysis and re-design the

process



Slid

e 3

33

ASK participants to describe what they see

Possible answers: Internal parts of human body Respiratory system consisting of

nose, air way and lungs

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Slid

e 4

The hospital system

OPD RCH clinic Labor ward

Pharmacy

CTC

HBC X-ray department

Laboratory

ASK participants to describe what they see

Possible answer: Different areas of service delivery

in a hospital as shown in slide 4 Map of a hospital

Slid

e 5

Definition of a system

A system is a set of interacting andinterdependent parts and processes

Example• Health care facility e.g. reception, outpatient,

inpatient, CTC, pharmacy, laboratory etc• Human body e.g. nose, lungs, intestines• Computer system e.g. monitor, keyboard,

processor

DISPLAY the animated heading of slide 5

ASK participants to define a system and to give examples. Allow a few responses.

LEAD participants through the slide(E.g. health care facility, human body, computer system).

EXPLAIN that systems can be small or large, simple or complex, and they can comprise few or many parts.

Slid

e 6 A system is made up of the

following components• Input:

– Components/items which are a needed before starting any activity, e.g. buildings for service provision, qualified and skilled staff, plan, equipments, budget, logistics etc.

• Process– Series of steps needed to perform a task or

accomplish a goal, e.g. drawing blood for CD4 count, registering HIV positive women to CTC

• Output– The immediate results of a process

LEAD participants through slide 6 and elaborate on the meaning of each of the components of a system using examples provided

82

Slid

e 7

Clients

Vaccines/ diluents

Trained personnelBudget

Standards

Refrigerator

Purchasing

Patient registration

ExaminationCalculating dose

Injection

Inventory

Recording

Immunized clients

Example of immunization system

PROCESSES OUTPUTINPUT

DISPLAY slide 7 and ELABORATEthe relationships between components of a system

Slid

e 8

“ … Every system is perfectly designed to get exactly the results it gets …”

By Paul Batalden

DISPLAY the quote by Paul Bataldenand EMPHASIZE that system design determines the results it produces.

If different results are desired from a system then a change in the system is necessary

Slid

e 9

Qualityfails when

Systemfails

ASK participants to discuss/ buzz on this statement for 2 to 3 minutes.

After the discussions TELLparticipants that when there is a breakage in the system or when the system does not work there will be no quality in that service.

83

Slid

e 10 Why focus on systems and

processes• In most situation processes, not people, are

at the root of most quality problems

• In order to improve quality, providers must understand and be able to analyze processes through which services are provided

• Processes might need to be changed, (or added/reduced) to improve quality.

DISPLAY slide 10 and EXPLAIN to participants that the majority of quality problems are in poorly designed processes and that improvement will depend on how we understand process analysis and process re-design

Slid

e 11

Process analysis

DISPLAY slide 11 and EXPLAIN to participants that the rest of the session will focus on process analysis

Slid

e 12

What is process analysis?

To gain deeper understanding of a potential problem in a series of steps in an activity to identify areas for improvement

DISPLAY the heading of slide 12 and let participants brainstorm what is meant by process analysis.

SUMMARIZE by displaying the definition of process analysis provided in the slide

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Slid

e 13

Why process analysis?

• To identify and understand problems and underlying causes

• To provide clear framework for identifying part of the process that requires change

• To enable teams to communicate to others what they are doing and why

DISPLAY slide 13 and LEAD participants and explain theimportance of process analysis

Slid

e 14

Steps in process analysis

• Decide what process you want to work on

• Collect performance data on current situation

(baseline data)

• Analyze the data and current process

• Describe the current process using a process flow chart

• Identify weak or redundant steps

LEAD participants through slide 14and

EXPLAIN the importance of different steps in process analysis

CLARIFY the steps outlined in the slide

Slid

e 15

Guide to process analysis (1)

• List every step in the process

• Identify who does what

• Identify where the action takes place

• Determine if steps consist of sub-

steps

DISPLAY the slide and clarify the guide to process analysis accordingly

85

Slid

e 16 Example of a process flow chart at RCH clinic DISPLAY slide 16 and refer

participants to annex 2 page 93 of their manual

GO through the process map and mention the steps taken in the following two scenarios:1. Mother who is HIV negative2. Mother who is HIV positive.

ELABORATE to participants that this is how a process map is done

Slid

e 17

Guide to process analysis (2)

A process flow chart describes the current situation and identifies steps that are:• Unclear• Inefficient• Leaves room for error• Unnecessary• Inconsistent

Display slide 17 and ASK participants to identify steps that are unclear, inefficient, unnecessary, inconsistentor which leave room for errors in the example given in the process map.

Slid

er 1

8

Steps in improving a process (1)

Identifying improvement areas • Steps where time could be used more efficiently?

• Steps where two tasks could be accomplished in a single step, or could be done parallel?

• Steps where a task could be shifted to a less-qualified staff member?

• What is the longest step?

• Why does it take that long?

DISPLAY slide 18 and EXPLAIN to participants that redesigning of a process map starts by askingourselves questions displayed in slide 18

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Slid

e 19


Identify possible changes to the process that can reduce the identified problems• CTC staff gives periodic health education at ANC in groups of

10

• Attendant to accompany woman to CTC

• Lab to stay open till 2pm

• Task shifting to a less qualified staff member

Re-write your process flow chart with new steps or new actions

DISPLAY slide 19

EXPLAIN that the team can come up with changes such as those displayed on slide 19

Slid

e 20 Example of a re-designed process map at

RCH clinic DISCUSS the re-designed process for improvement. Point out which steps have been merged, or left out.

EXPLAIN that instead of sending the patient to CTC and going through the whole process, the patient blood is drawn at RCH and thereafter referred to CTC.

Slid

e 21


Implementation of the re-designed process to see if it results into an improvement of the process of care at RCH• Compare your results (e.g. percentage of

pregnant women who test positive for HIV that are successfully enrolled in CTC services) before and after the changes

• Decide if the changes are making a difference and are worth making them permanent

EXPLAIN to participants that it is important to test the re-designedprocess before implementing the change

87

Slid

e 22

Activity1. Draw process flow chart to describe the

process of care that Mrs. Kwangu went through at

I. Melela Health centre II.Labour ward at Melela HCIII.District hospital

2. Identify weak or redundant steps in each of the stations above

3. Prepare an improved process flow chart to make the process work better and present this

DISPLAY slide 22 and DIVIDEparticipants in groups of 4/5 persons read the case study of Mrs. Kwangu and answer the following questions

ALLOCATE 1 process to each group and give 20 minutes for them to do a process analysis and redesign.

TELL each group to identify weak or redundant steps in each of the stations above.

Let participants present their process maps by doing “gallery walk”,

SUMMARIZE group presentations

Slid

e 23 Key points

This session focused on:• Defining what is meant by a system and its

components

• Explaining the concept of system and process

• Conducting process analysis and re-design using process flow charts

SUMMARISE the session using the slide 23.

ASK participants if they have any questions and CLARIFY accordingly.

Slid

e 24

Evaluation

• Mention components of a system

• Give examples of a system and its components

ASK participants the questions on slide 24 to determine if they have understood the session

88

Unit 3: QI Model, approaches and implementation


AimTo train participants on the QI model and approaches in order to acquire knowledge that will enable them to implement and monitor QI activities at health facility level.

Unit objectivesBy the end of this unit, participants will be able to: Describe the overview of the QI model and approaches Explain the application of the Plan Do Study Act cycle ( PDSA) in the model to bring

about change Describe the QI approaches Carry out a practicum on QI in a hospital setting


1 90 minutes QI improvement model

2 60 minutes QI approach: 5S

3 60 minutes QI approach: improvement collaborative

4 500 minutes Practicum implementing QI activities

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Part 1: QI model and approaches

Session 3.1.1: Steps in QI and the improvement model


Session objectivesBy the end of this session, participants will be able to: Describe the four steps of QI Apply the PDSA cycle in planning QI activities Use the improvement model in relation to the principles of QI to reduce quality gaps in

HIV and AIDS services

Resources needed Flip charts Marker pens LCD projector Chalk board Case study (Mrs. Kwangu)


1. 5 minutes Presentation Recap on definition of QI

2. 5 minutes Presentation Introduction to session objectives

3. 5 minutes Presentation Steps in QI

4. 25 minutesPresentation,

brainstorming and small group discussion

PDSA cycle

5. 35 minutesPresentation and

discussions Application of PDSA cycle in addressing quality gaps

6. 5 minutes Presentation Key points

7. 10 minutes Presentation Evaluation

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SESSION CONTENTSl

ide

1

Session 3.1.1: Steps in QI and the improvement model

READ the session title to participantsand CLARIFY any issues raised

Slid

e 2

Recap on Quality Improvement

What is QI?

QI is a systematic process of assessing performance of a health system and its services, identify gaps and causes, and introducing measures to improve quality and monitoring the impact

Before stating the sessions REVIEWwith participants the meaning of QI.

LET participants BUZZ on the question in the slide for 2 minutes.

ALLOW 2 to 3 pairs to read their answers aloud and WRITE the responses on a flip chart.

SUMMARIZE their responses and give the correct definition of QI by clicking on the slide.

Slid

e 3

Session objectives

By the end of this session, participants will be able to:• Describe the four steps of QI• Apply the PDSA cycle in planning QI

activities• Use the improvement model in relation to

the principles of QI to reduce quality gaps in HIV and AIDS services

READ or ASK participants to read the objectives and CLARIFY the objectives accordingly

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Slid

e 4

The four steps of QI

• Identify: determine what needs to be improved

• Analyze: understand the problem• Develop: hypothesize about what

changes will improve the problem• Test/implement: test the hypothesized

solution to see if it results into improvement

LEAD participants through the slide and briefly explain on the three fundamental questions

EXPLAIN to the participants that, in order to respond to these three fundamental questions in quality improvement PDSA cycle is used.

Slid

e 5

QI model (1)The three fundamental questions when combined with the Plan, Do, Study, Act cycle (PDSA cycle) form the basis of the model for improvement in the health care settingThe three fundamental questions are:• What are we trying to accomplish?• How will we know that a change is an

improvement?• What changes can we make that will result in an

improvement?

GUIDE participants through the content on the slide

Slid

e 6

QI model (2)

What is Plan, Do, Study, Act (PDSA) cycle?

The PDSA cycle is a systemic way of implementing identified changes, measuring the effects of changes and decide whether to abandon, modify or implement the change.

LEAD participants to link the three fundamental questions and the PDSA cycle

EMPHASIZE on the cycle and arrows to assist participants to understand that improvement is a continuous process

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Slid

e 7 The improvement model

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

PlanAct

DoStudy

Step:1

Step: 2

Step: 3

Step: 4

DISPLAY slide 7 and EXPLAIN how the four steps are linked to improvement model

Steps 1 identify: what are we trying to accomplish?

Steps 2 analyze: How will we know that a change is an improvement?

Steps 3 develop: What change can we make that will result in improvement?

Step 4 test and implement: PDSA cycle.

Slid

e 8

Step 1: IDENTIFY (1)

When identifying a problem, the question to be considered is:

1. What is the problem?

REFFER participants to the case study of Mrs. Kwangu for 2 minutes on page 81 of the participants guide

GIVE participants time to read the case study

TELL them that they will be referring to the Mrs. Kwangu’s case in the next discussion about the steps in QI

ASK participants to brainstorm andidentify what was the problem in the case study?

RECORD their responses on the flip chart

SUMMARIZE by sharing with them the problems as per case study

Possible answers1. She was not registered in any of

the registered2. She was not given accurate

information at the RCH and the CTC

3. She was not given a referral letter4. No precautions taken during

delivery etc.

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Slid

e 9 QI framework for HIV and AIDS

servicesIn HIV and AIDS services and in other chronic conditions, QI efforts should gear towards addressing the following key quality frameworks:• Access

– Those who are in need of service receive the appropriate services, e.g. all who receives HT services are enrolled into care and receive appropriate care

• Retention – All those receiving the services for example ART services are

retained, e.g. there very few are lost to follow up for those on ART

• Wellness– All those receive service have better health outcomes, e.g.

patient CD4 count raises, now ambulatory, can continue with routine work

EXPLAIN to participants that by using performance indicators to assess quality gap they need to cover the key areas of QI framework

NEEDED: distribute to participants the list of indicators categorized by three framework areas which are • Access• Retention• Wellness

INSTRUCT participants to read the list provided in annex 3 page 84-87 of the participants manual

EXPLAIN to participants that these are performance measurements that form the basis of assessing quality of care

Slid

e 10

Step 1: IDENTIFY (2)

Ways to identify problems– Client might express satisfaction

• Suggestion box• Client exit interview

– An adverse effect might draw attention• Client presenting with unusual allergic reactions

– Record review

TELL participants that in the health care setting you can identify problems by asking or observing the three ways mentioned in the slide

Slid

e11

Step 2: ANALYZE (1)

When analyzing a problem, the question to be considered:

1. How do you know that it is a problem?(group work –use identified problem to analyze the process)

LEAD participants through the slide and EXPLAIN that the purpose of analysis stage is to; Understand why the process or

system produces the effect that we aim to change

Measure the performance of the process or system to obtain baseline data

Understand the existing process through use of flow charts

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Slid

e 12

Step 2: ANALYZE (2)

Gain deeper understanding of the opportunity for improvement before considering changes

• Analysis requires– Use of existing data or collecting additional

data– Drawing flow charts or process analysis

diagrams

TAKE participants back to step 1 which is identification of problem

All participants SELECT one of the identified problems from the flip chart.

DIVIDE participants into small groups of 5 to 6.

LET them use the identified problem to analyze the process.

ALLOW each group to present in plenary.

RECORD response on the flip chart

Slid

e 13 Step 3: DEVELOP (1)

• The third step begins when enough data has been collected to develop hypotheses about what changes or interventions might improve the existing problem

• Use information gathered from previous steps (identify and analyze) to explore and decide which changes would result in QI

TAKE participant through the slide content

EXPLAIN that hypothesis is an educated guess about the underlying causes of a problem.

Slid

e 14 Step 3: DEVELOP (2)

When DEVELOPING a change, the questions to be considered are:

1. How frequently does it occur, or how long has it existed?

2. What are the effects of this problem?

ASK participants (in large group) to answer the two questions

RECORD their answers on a flip chart

TELL participants: The first question can only be

answered when you have data The second question can be

solved by using flow chart

EMPHASIZE that: Data is the only objective way to

determine initial and follow up levels of performance and

Flow charts enhance understanding of a process.

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Slid

e 15

Step 4: TEST AND IMPLEMENTATION

• Not every change is an improvement

• Proposed solutions need to be tested before institutionalization to see if they lead to expected improvement

• Results will determine next step

EMPHASIZE that although changes in a process are important for QI, BUTnot every change is an improvement.

Therefore it is important to TEST the proposed solutions/ hypothesis before adopting it as a standard practice.

Slid

e 16 Standard Evaluation System

(SES)• Introduction to SES for documenting QI

work• Components of the tool are:

– Improvement objective– Indicator– Problem description– Process analysis– Tested changes– Run chart

DISTRIBUTE the SES tool to participants

EXPLAIN to participants that this tool will be used for documenting changes during the practicum

EXPLAIN the key components of the tool• SMART objectives• Indicator to be used is the one

selected by the QI team• Precisely describe the problemProcess analysis should be realistic and stepwise

Slid

e 17 The Matrix for Processing Identified Problem

Tested changes( include 1-2 sentences to briefly describe the changes)

Planned Started Date

End date if applicable

Responsible Person

Comments EXPLAIN to participants that changes identified during process analysis will be filled-in this matrix and explain how to fill other columns accordingly

DISTRIBUTE the matrix REFER to annex 4: Worksheet: Format of matrix to test changes based on identified problems page 88 of the participants manual

CLARIFY to participants that there could be more than one change to be tested per each improvement area

REMIND participants that not every change is an improvement and it is important to determine if change(s) are producing desired improvements through continuous measurement

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Slid

e 18 Example of a filled matrix for case study of

Melela Health CentreTested changes( include 1-2 sentences to briefly describe the changes)


End date if applicable

Responsible Person

Comments

•To increase the number of HIV positive pregnant women receiving CD4 count service.

1st/4/2010 30th/6/2010 CTC i/c and Laboratory technologist

•Daily review of records to be done

•To increase number of HIV + PW who return to DH or Facility receive the CD4 count test result for initiation of ART.

1st/4/2010 30th/9/2010 DACC/CTC i/cLaboratory technologist

•Daily review of records to be done

•Continuous adherence counselling to patients

TAKE them through the e.g. of filled matrix based on the previous example of Mrs. Kwangu’s case before giving them practicum instructions.

DISCUSS with them and if they have any input to share to the matrix for Melela HC

SUMMARISE the discussion

Slid

e 19 Activity: Complete the improvement model DISPLAY slide 19.

For each box ASK volunteers to fill-in the contents and LET other participant assist until the model is correctly filled-in

Slid

e 20 Application of the improvement

model …Based on Mrs. Kwangu case study

Current Practice (CD4 count service)

• Melela Health Center refers HIV+ pregnant women to District Hospital for CD4 count

• Queue for registration at district hospital

• Queue on waiting bench to see doctor

• Referred by doctor to laboratory

EXPLAIN to participants that the current practice for getting CD4 count service can be found in the case study.

TELL participants that we are going to use the current practice in the case study to identify, analyze, develop, test and implement changes which will improve service delivery

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Slid

e 21

Application of the improvement model …

Current Practice (CD4 count service)

• If clients arrives at laboratory after 12.00 pm or after 30 samples have been drawn, clients are asked to return on another day

• On return, client go through the same process of registration, seeing a doctor and being referred to the lab

Slid

e 22 Application of the improvement

model … Based on Mrs. Kwangu case study

Step 1: Identify the problem:• Problem is that HIV+ pregnant women are

not having CD4 count checked • What are we trying to accomplish?

To increase the number of HIV positive pregnant women receiving CD4 count service

TELL participants that the identified problem on the slide will be used to demonstrate the application of the improvement model

Slid

e 23 Application of the Improvement

Model …Based on Mrs. Kwangu case study

Step 2: Analyze the problem:• The analysis concludes that the client flow

system is not well structured:– Long distance from health centre to the district hospital – Limited time– Limited number of CD4 count taking per day

• How will we know that a change is an improvement?– If number of CD4 count tests to HIV+ pregnant

women goes up

BEFORE displaying this slide

ASK participants to brainstorm why the current practice for CD4 count service does not increase the number of women eligible for testing

REFER participant to page 82 process flow chart

ASSIST participants to link this exercise with the process flow chart

WRITE their responses on the flip chart.

EXPLAIN the correct possible answers given on the slide.

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Slid

e 24 Application of the improvement model …

Based on the case study of Mrs. Kwangu

Step 3: Develop:

The development is to introduce changes to the current process which will increase the number of HIV+ pregnant women receiving CD4 count services

What changes can we make that will result in an improvement based on the analysis done? • The process could be shortened, added,

removed or modified

EMPHAZISE that the first three steps should be answered in order to define step 4 the PDSA cycle to test the changes.

Slid

e 25 Application of the improvement model ...

Based on the case study of Mrs. Kwangu

Step 4: Test and implement (PDSA cycle):• Apply the agreed changes: test, implement

and monitor if they produce the intended results (increase the number of HIV+ pregnant women receiving CD4 count service)

LEAD participants through the content of the slide

Slid

e 26 Example application of 1st PDSA

CYCLEPlan• Melela Health Centre will send patients to district

hospital with direct referral to lab so patients can get sample before noon

• MHC staff will track number of HIV+ pregnant women getting CD4 count done

Do• MHC discusses approach with DMO, Hospital

Management, MO i/c and lab staff• Agree that HIV+ pregnant women go direct to lab for

CD4 count

EXPLAIN that several cycles may be needed to test the change before desired results are achieved

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Slid

e 27

1st PDSA cycle …Study• The number of HIV+ PW from the MHC getting

CD4 count done increases from 10% (before change) to 24% (after change)

• But some HIV+ PW are still asked to try again another day, but don’t return or return without success

Act• Decide to continue direct referral, but will try

more changes in 2nd cycle

The abbreviation HIV+ PW stands for HIV positive pregnant women

Slid

e 28

2nd PDSA CYCLEPlan• Lab to increase the number of samples taken per day;

instead of one batch of 30 samples increase to 2 batches of 30 samples

• Increase opening hours of the lab from morning till afternoon

Do• HC discusses suggested changes with DMO, Hospital

Management, MO i/c , lab staff. • Agree that the laboratory will run 2 batches of CD4 count

(up to 60 samples) a day• Order additional reagents and supplies• Change opening hours, e.g. from morning till afternoon

EXPLAIN that after finishing the first cycle a second cycle can be needed to continue implementing the changes as defined during the first cycle.

Slid

e 29

2nd PDSA CYCLE …Study• The number of HIV+ PW from the MHC getting

CD4 count done increases from 24% to 42% • But some HIV+ PW are still not going to the DH

for the testAct• Decide to continue direct referral to the

laboratory and 2 batches of 30 samples, but will try more changes in 3rd cycle

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Slid

e 30

3rd PDSA cycle

Plan• MHC will draw CD4 count samples once a week and send to

laboratory of DH• Results taken back from DH to MHC• Identify which HIV+ PW is eligible for ART and needs referral

to DH for treatment (MHC does not provide Care and Treatment)

Do• MHC discuss and agree suggested changes with DMO,

Hospital Management and MOIC • MHC i/c takes CD4 samples when going to DH for weekly

meeting• MHC i/c collects last week’s result to take back to MHC• Identify who is eligible for ART

DISPLAY slide 27 and EXPLAIN accordingly

Slid

e 31

3rd PDSA CYCLE …Study• The number HIV+ PW getting CD4 counts

increases from 42% to 80%. • But only small # of identified HIV+ PW

eligible for ART (according to CD4 count) are going to DH to receive them (Identification of new problem)

Act• Continue sample referral system• But now work on improving the # of HIV+ PW

actually go to DH for treatment

EXPLAIN that in the third cycle a new problem has been identified: The number of HIV+ PW eligible for

ART (according to CD4 count) are not going to DH to receive them (Identification of new problem)

The health facility has to come up with a plan how to solve the problem

Slid

e 32

Next steps

• Share successes in the increased number of HIV+ pregnant women getting CD4 count

• Share successes of increased capacity of District Hospital laboratory in performing CD4 count

• Consider PDSA cycle to address the new identified problem (small number of identified HIV+ PW eligible for ART are going to DH to receive them).

• After each cycle the QI team shares the results of the tested change to determine the level of improvement attained

EXPLAIN to participants that sharing of information (whether positive or negative) is key to continuous improvement

101

Slid

e 33

Key points

This session focused on:• Describe the four steps of QI• Apply the PDSA cycle in planning QI

activities• Use the improvement model in relation to

the principles of QI to reduce quality gaps in HIV and AIDS services

SUMMARISE the session using slides30

ASK participants for any question for clarification

Slid

e 34

Evaluation

• What are the three fundamental questions on the model for QI?

ASK volunteers to mention the three fundamental questions

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Session 3.1.2: QI approach: Five S (5S) and improvement collaborative


Session objectivesBy the end of this session, participants will be able to: Identify QI approaches used in health care settings in Tanzania Describe the steps for each of the 5S components Mention the importance of 5S List examples of 5S activities in Tanzania Define the improvement collaborative Describe the features of the improvement collaborative

Resources needed Flip charts Marker pens LCD projector Chalk board Case study (Mrs. Kwangu)


1. 5 minutes Presentation Introduction to session title and objectives

2. 5 minutes Presentation QI approaches used in Tanzania

3. 15 minutes Presentation Steps for each of 5S components

4. 5 minutes Presentation and discussion Importance of 5S

5. 10 minutes Presentation and discussion

Examples of 5S activities in Tanzania

6. 10 minutes Presentation Definition of improvement collaborative

7. 10 minutes Presentation The improvement collaborative model

8. 20 minutes Presentation Features of an improvement collaborative

9. 5 minutes Presentation Key points

10. 5 minutes Question and answers Evaluation

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SESSION CONTENTSl

ide

1

Session 3.1.2: QI approach: Five Sand improvement collaborative


Slid

e 2

Session objectivesBy the end of this session, participants will be able to:• Identify QI approaches used in health care

settings in Tanzania • Describe the steps for each of the Five S

(5S) components• Mention the importance of 5S• List examples of 5S activities in Tanzania• Define the improvement collaborative • Describe the features of the improvement

collaborative

READ or ASK participants to read the objectives and CLARIFY the objectives accordingly

Slid

e 3

QI approaches

The QI approaches used in Tanzania for improving health care services are:

• 5S

• Improvement collaborative

DISPLAY and READ the slide

EMPHASIZE that, the quality improvement approaches are the means of achieving the goals of PDSA cycle

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Slid

e 4

5S

5S is a philosophy and a way of organizing and managing the workspace and work flow with the intent to improve efficiency of work

DISPLAY the slide and read the definition and CLARIFY accordingly

Slid

e 5

Components of 5S

• 5S is a management tool, used as a systematic approach for productivity, quality and safety improvement in all types of organizations

• 5S is an abbreviation for five terms:– Sort– Set– Shine– Standardize – Sustain

BEFORE displaying slide 5

ASK participants the following question- What are the components of 5S?

RECORD response on the flip chart

SUMMARIZE their responses and display the correct answer as in the slide

EXPLAIN in brief each S as follows;• Sort to remove unused stuff from

your working place. • Set is to organize all necessary

items in proper order for easy services provision.

• Shine is to maintain high standards of cleanness.

• Standardize to set up the Sort, Set, and Shine as norms in every section of health facility.

• Sustain is to train and maintain discipline of the health care workers engaged

EMPHASIZE that 5S is conducted systematically with the full participation of all staff serving the institution

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Slid

e 6

Steps for each of 5S Component (1)

1. Sort• It is to remove unused stuff from your

working place, by:– Categorizing and color code the items – Develop inventory list for all categorized items– Remove all unnecessary items for discarding– Store (keep) “may be needed” items– Regular sorting of unused items– Develop culture of returning items to where

they belong

TAKE participants through the content of the slide

EMPHASIZE that sort is basically a cleaning up procedure

Slid

e 7


2. Set• To organize all necessary items in proper order

for easy services provision– Organize cabinets with labeling/numbering– Keep items at their respective areas and label them

accordingly– Directional arrows leading to service areas– Labeling of service rooms– Update stock/equipment inventories

• The rules and regulations must be written and well known to all staff


Slid

e 8


3. Shine• To maintain high standards of cleanness

– Routine cleaning and mass cleaning campaign

– Clean not only the place that comes into your view but also behind/under furniture or equipment

– Clean and attractive environment will be appreciated by internal & external clients


EMPHASIZE that cleaning is everyone's responsibility

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Slid

e 9


4. Standardize• To set up the Sort, Set, and Shine as norms

in every section of health facility– Work instructions– Standard Operating Procedures (SOPs)– Standards and regulations for both

administrative and technical staff

Facilitator should MENTION that the first three components, set the stage,for the facility to develop and implement standard operating procedure to maintain good working environment

Slid

e 10


5. Sustain• To train and maintain discipline of the

health workers engaged– Apply regular self assessment– Quarterly 5S audit and implementation of

improvement activities

EXPLAIN that facilities are advised to conduct self assessment and that MOHSW conducts quarterly assessment of the facilities

MENTION that there is a guideline for 5S

Slid

e 11

Importance of 5S

• The workplace gets cleaned and better organized• Hospital and office operations become easier and

safer• Results are visible to everyone; insider and

outsiders• Visible results enhance the generation of more and

new ideas• People will be proud about their clean and

organized workplace• As a result the health facilities good image

generates more business


TAKE participants through the slide and explain accordingly

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Slid

e 12

Examples of 5S activities in Tanzania (1)Medical records room

Before 5S After 5S


EXPLAIN the examples of photographs taken from different facilities in Tanzania showing the work that has been done on 5S approachslide 12 to 14

Slid

e 13 Examples of 5S Activities in Tanzania (2)

Dumping Point at a Health Facility

Before 5S After 5S


Slid

e 1

4

Examples of 5S Activities in Tanzania (2)HTC room

Before 5S

After 5S

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Slid

e 15

Improvement Collaborative

Is an organized network of sites (e.g. districts, facilities or communities) that work together for a limited period of time to rapidly achieve significant improvements in a focused topic area through shared learning and intentional spread methods

CLARIFY by giving the followingexample:In a region, all selected health facilities will work on agreed improvement areas and monitor the progress of their activities and share best practices and challenges within a given time frame

Slid

e 16 Improvement Collaborative model

Mobilise National

Leadership/stakeholders

Form Technical

Leader Group and

Collaborative Management

Structure

Select Regions and Sites

Finalise Technical Content/Change Package

Adopted from QAP

DISPLAY slide 4 and TAKE participant through the slide and explain accordingly

TELL participants that there are basically three faces of an improvement collaborative:1. The introductory phase2. Implementing phase3. Coaching and clinical mentoring

during action period

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Slid

e 17

Phase 1: Introductory phase

During the introduction phase, sessions are organized to introduce the improvement concept to regional, district and facility levels for initiating QI activities and to create ownership

TAKE participant through the slide and explain as follows. 1. The introductory phase (the

shadow boxes on the left) is the period of orientation session:

o To introduce the improvement concept to regional, district and facility level management for initiating QI activities and

o For the sustainability of the QIwork.

o Regional and district management team undergo training on QI concepts and its application

o Regional and district management team are trained on coaching and clinical mentorship skills and they will act as coaches and QI experts to the QI team at each site.

Slid

e 18

Phase 2: Implementation phase

This phase is divided into:• Learning sessions

– Structured five days workshop every 3 months. Bring together representatives from participating sites within a region or district

• Action period– Implementation of work plans developed

during learning session – The action period ranges between 2-4 months

DISPLAY slide and TAKE participants through the content in the slide

Slid

e 19

Phase 3: Coaching and mentorship

Coaching and mentorship are performed during action period in order to:

• Assess teams functionality

• Review collected data on priority indicators

• Review progress on implementation of work plans

• Provide onsite training on formulation and testing of changes, documentation and plotting data in run charts

DISPLAY the slide and EXPLAIN to participants that during subsequent learning session participants shares experiences and enrich each other learning on improvement issues

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Slid

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Follow up learning sessionsDuring subsequent learning sessions QI teams:• Share experience, challenges and lessons

learnt as they implement quality improvement, e.g. teams can learn from each other

• Share and spread best practices with other teams

• Conduct peer to peer learning • Present realized activities and data

collected based on work plans

TAKE participants through the slidecontent

TELL participants that coaching and clinical mentoring is done by regional and district management team within their respective areas

EMPHASISE that the RHMT/CHMT are expected to identify potential people within their regions/councils and train them as coachers and mentors of others. (As per National Guideline of SSM).

Slid

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Key points

This session focused on:• Identifying quality improvement

approaches used in Tanzania• Identifying components and steps of 5S• Highlighting the importance of 5S with

examples from Tanzania• Defining the improvement collaborative

SUMMARISE the session using the slide 21


Slid

e 22

Evaluation

• What are the QI approaches used in Tanzania?

• What are the phases of an improvement collaborative?

ASK participants to write their response on their notebooks,

WALK around to check if their answers are correctPossible answersQuestion 1a. 5S b. Improvement collaborative

Question 21. The introductory or pre-work phase2. Implementing phase3. Coaching and mentoring during

action period

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Session 3.1.3: Leadership, roles and responsibilities of QI teams at different levels


Session objectivesBy the end of this session, participants will be able to: Define the concept of leadership Mention attributes of a leader Describe the roles of a leader in QI in the health care setting Identify the roles and responsibilities of QI teams at the different levels of the health

system in Tanzania

Resources needed Flip charts, marker pens, and masking tape/ LCD machine/laptop Black/white board and chalk/whiteboard markers National Guidelines for Quality Improvement of HIV and AIDS Services Tanzania Quality Improvement Framework National Essential Health Sector HIV and AIDS Interventions Package


1 5 minutes Presentation Objectives of the session

2 5 minutes Presentation Concept of leadership

3 5minutes Presentation, discussionand brainstorming

Attributes of a leader

5 15 minutes PresentationRoles of a leader in quality improvement

6 20 minutes Presentation and activityRoles and responsibilities at different level of the health sector



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SESSION CONTENTSl

ide

1

Session 3.1.3 Leadership, roles and responsibilities of QI teams at different levels


Slid

e 2

Session objectivesBy the end of this session, participants will be able to:• Define the concept of leadership • Mention attributes of a leader• Describe the roles of a leader in QI in health

care setting• Identify the roles and responsibilities of QI

teams at the different levels of the health system in Tanzania


Clarify the objectives accordingly

Slid

e 3

Definition of leadership• Leadership

is the art or process of influencing people so that they will strive willingly and enthusiastically toward the achievement of group goals

Therefore:

• A Leaderplaces him/herself before the group as they facilitate progress and inspire the group to accomplish for this case QI goals

PRESENT the definitions

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Slid

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Activity

What are the roles of a leader?

DISPLAY the slide and ASK participants to answer the question

DISTRIBUTE VIPP cards to every participant

GIVE them 10 minutes to do the activity

TELL them that each participant shall write one role of a leader on a piece of paper

When everybody is ready ASK them to move to the board and stick the paper containing the answer

SUMMARIZE the activity by organizing their responses

CLARRIFY by moving to next slide

Slid

e 5

Attributes of a leader

Some of the attributes of a leader include:• The ability to influence others• Inspire others to achieve set objectives• Have shared vision • Ability to direct

DISPLAY Slide 5 and LEAD participants through the listed attributes

LET participants buzz in pairs for 5 minutes about other attributes and qualities of a leader

ASK them to write down the qualities and attributes of a leader in a piece of paper

LET each pair to mention the qualities and attributes as they discussed

WRITE the responses on a flip chart one column list of qualities and another for lists of attributes and summarize as follows;

Possible answer is; Setting high standards Live to your standards and mentor

those who follow Create and share vision Make the hard choices when

necessary Be visible and out front Instil hope on those who follow

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Slid

e 6

Quality of a leader● Some qualities of a leader that are essential in most

leadership styles

• Truthful

• Approachable

• Patient

• Accountable

• Persuasive

• Adaptive

• Credible

• Confident

• Focussed

• Communicator

• Integrity

DISPLAY Slide 6 and LEAD participants through the listed qualities

Slid

e 7

Roles of a leader

• To guide a team of people to improve the quality of HIV and AIDS care and treatment services

• To inspire and assure cooperation among the group

• To promote individual contribution towards achieving set objectives

DISCUSS with participants for 10 minutes on how these leadership roles are related to their roles at workplaces

LET 5 to 8 participants respond by mentioning their job responsibilities and relate to these roles

WRITE their responses on a flip chart.

SUMMARIZE the responses and move to the slide

Slid

e 8 Roles of a leader in QI in the health

care setting

There are four specific roles:A Support a systematic approach to QIB Communicate prioritiesC Support team membersD Facilitate innovation and learning

EXPLAIN the specific roles of a leader in QI and relating them to the participants responses from the previous slide

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Slid

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Roles of a leader in QI (1)

A. Support a systematic approach to QI• Guidance • Participate in QI team meetings• Use data in decision-making• Support QI changes• Allocate resources to support

implementation of changes

DISPLAY slides 9 - 12 and LEAD the participants through to elaborate on thespecific roles of a leader in quality improvement

EMPHASIZE that effective leadership is leadership is key to quality services

Slid

e 10


B. Communicate priorities• Develop and reinforce a sense of

common purpose• Clarify the quality goals of the team• Guide team members through selection

of priority areas for improvement• Facilitate ongoing dialogue between

leader and team members on QI activities

Slid

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C. Supporting team members• Guidance • Re-assurance (instill hope on team

members)• Recognizing their quality efforts

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Slid

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D. Facilitate innovation and learning• QI → introducing and testing changes• Support staff as they learn new skills • Create a safe environment for learning

and for experimentation

Slid

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ACTIVITY ON ROLES AND RESPONSIBILITIES

The roles for different levels should be mixed up and participants should be asked to sort out roles for a specific level

Slid

e 14 QI teams at different levels of

the health system• National level• Regional level (RHMT)• Council level (CHMT)• Facility level

DISCUSS with participants for 10 minutes on the roles and responsibilities of QI teams at the four levels

LET 5 to 8 participants respond by mentioning the roles and responsibilities for each level or divide them into small groups and let them discus for 10 minutes then each group to present

WRITE their responses on a flip chart.

SUMMARIZE the responses and move to slide 15 – 19

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Slid

e 15 Roles and responsibilities of QI

at national level• Provide vision on policy formulation, setting standards

and coordination• Prioritizing, planning and budgeting for QI• Establish a Technical Working Group for QI• Establish national standards and monitoring indicators

for evaluation of various HIV/AIDS interventions• Develop guidelines, manuals and QI training packages• Liaise with stakeholders in rolling out QI training,

implementation and reporting• Supervise QI activities

ASK participants to come up with additional roles and responsibilities for each level

Information can be found in the participants manual and National Guidelines for Quality Improvement for HIV and AIDS Services

Slid


at regional level• Establish Regional QI Team and appoint a focal

person• Carry out regional QI activities and provide

technical support to the districts• Enforce use of QI guidelines by all stakeholders• Coordinate and monitor implementation of QI

activities• Ensure QI activities for HIV and AIDS are

incorporated into Comprehensive Regional Health Plan (CRHP)

Slid


at district level• Establish a Council QI Team and appoint a focal

person• Carry out Council QI activities and provide technical

support to the health facilities• Enforce the use of QI guidelines by all stakeholders• Coordinate and monitor implementation of QI

activities in the district• Ensure that QI activities for HIV and AIDS are

incorporated into Comprehensive Council Health Plans (CCHP)

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Slid


at health facility level (1)• Establish a facility QI Team and appoint a

focal person• Use existing data to set improvement

priorities and objectives• Ensure the use of specific guidelines for HIV

and AIDS interventions• Develop work plans, monitor indicators and

identify resources required

Slid


at health facility level (2)• Implement the work plans and collect data to

monitor improvement• Integrate QI activities into facility work plan

and budgets• Share experiences within facility, between

facilities, with CHMTs and with stakeholders.• Institutionalize best practices and lessons

learnt

Slid

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Key points

The session focused on:• Defining the concept of leadership • The attributes of a leader• Describing the roles of a leader• Roles of leaders in QI• Roles of QI teams at the different levels of

the health system

SUMMARIZE the presentation by reading the key points based on the session content

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Slid

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Evaluation

• What is leadership?

• What are your roles in QI in your workplace?

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Part 2: Implementing QI activities


Unit objectivesBy the end of this unit, participants will be able to: Practice the application of QI steps and principles in developing a QI plan for a

particular HIV and AIDS quality of care problem.

Pre-unit preparationsThe facilitator should make the following preparations a day or two before facilitating this session:- Identify health facilities where the practicum will be conducted and negotiate with

facility leadership Identify and orient focal person(s) / practical facilitator at the health facilities for each

quality of care problem that groups of participants will work on Make arrangements to enable easy access to sources of data for quality of care

problems in question Agree on timing of the practicum Prepare for other logistics (transport, SES printouts, allowances for practical

facilitator etc)


1 60 minutes Preparation to Practical Assignment

2 370 minutes Visit to the Health Facility for Practical Session

3 170 minutes Feedback Session, Discussions and Way Forward

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Session 3.2.1: Preparation to practical assignment

Total session time: 60 minutes

Session objectivesBy the end of this session, participants will be able to: Review the QI principles and steps in QI Set priorities and identify areas for improvement Practice the procedure for formation of QI teams Use standard format for documenting QI activities

Resources needed Flip charts Marker pens LCD projector Chalk board Annex 3: Tanzania HIV/AIDS patient care and treatment indicators Annex 4: Format Matrix for processing identified problems at a facility

Session overviewStep Time Activity/Method Title

1 15 minutes Presentation and group discussion Recap of QI principles and steps in QI

2 10 minutes Presentation Setting priorities / identify areas for improvement

3 20 minutes Group work Formation of QI teams

4 10 minutes Presentation and group discussion

Use standard format for documenting QI activities

5 5 minutes Presentation Key Points

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SESSION CONTENT

Slid

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Session 3.2.1: Preparation to practical assignment


CLARIFY any issues accordingly

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Session objectivesBy the end of this session, participants will be able to:• Review the QI principles and steps in QI• Set priorities and identify areas for

improvement• Practice the procedure for formation of

QI teams• Use standard format for documenting QI

activities

READ the session objectives to participants


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Slid

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Brainstorm activity

Mention the 5 QI principles

TAKE participants through the recap of the QI principles and steps for QI for 15 minutes using slide 3 to 5.

ASK participants to mention principles of Quality Improvement.

LET them brainstorm for 5 minutes

Possible answer is;Principles of Quality Improvement1. Measurement2. Systems and Processes3. Teamwork4. Addressing clients’ needs5. Communication and Feedback

SUMMARISE the discussion by emphasizing that these principles depend on each other and that to achieve continuous improvement all must be observed

TELL participants that these principles will form the basis of this session

Slid

e 4 Activity: group discussion on

model for improvement

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

PlanAct

DoStudy

DISPLAY the slide of the model for improvement diagram

ASK one participant to explain the model to the rest of the group and clarify accordingly

SUMMARIZE and clarify any issue raised

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Slid

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Brainstorm activity

Recap of QI steps

ASK participants to mention steps in Quality Improvement

ALLOW some of the participants to respond to complete all the 5 steps

When all are mentioned SUMMARISE the discussion.Possible answer is;The QI steps are;1. Identify2. Analyze3. Develop4. Test and Implement

EXPLAIN to participants that these steps will form the basis of improving healthcare service at their work place

EMPHASIZE that these principles of QI, the Model and steps for improvement will be applied during the practicum

Slid

e 6 Developing and monitoring QI

activities in health care setting• Identifying areas for improvement (step 1) by using:

– Available data on performance indicators to identify quality gaps that needs to be addressed

– Take the QI framework into consideration for HIV and AIDS services to select performance indicators related to access, retention and wellness

• Ideas from clients on areas which they think needs improvements so as to improve client satisfaction

• Formation of QI team for the identified / priority area and analyze the identified area for improvement (step 2)

• Prioritization of areas of improvement and development of proposed change(s) (step 3)

• PDSA cycle to implement the change for the identified area of improvement (step 4)

• Use the SES to document proposed change and monitor if the changes result into an improvement

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Slid

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MatrixThe following matrix is used to fill in the identified changes during the process analysis. There could be more than one change to be tested per each improvement area. Important to know that not every change is an improvement and it is important to determine if change(s) are producing desired improvements through continuous measurement

T he M at rix for P roc es s ing Iden tified Pro blemTested changes( includ e 1-2 sentences to bri efl y d escribe the chang es)


End date if appl icable

R espo nsible Person

C omments

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ACTIVITY

1. Identifying areas for improvement by using the QI framework for HIV and AIDS services related to access, retention and wellness (see annex 3)

2. Formation of QI team for the identified / priority area

3. Prioritization areas for improvement4. Fill in the identified changes in the

standard SES format (see annex 4)

ACTIVITY 1 DISTRIBUTE list of indicators from relevant documents (PMTCT, CTC or HTC etc.)

ASK each QI team to go through the list of indicators

SELECT one indicator from each category of the framework (access, retention or wellness) to which they will work on during the practicum.

2 TAKE participants through the activity of formation of QI teams for 20 minutes.

DIVIDE participants in groups based on their level of responsibilities and write the names and levels on a flip chart.

DISPLAY the flip chart and let everybody read who group members are.

GUIDE participants to form QI teams based on their roles and responsibilities at their duty stations and sit together to form a group.

FORM at least three QI teams: RHMT, CHMT and health facility teams.

3. GUIDE each QI team to prioritize one from the three indicators which they will work on during the practicum.

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Slid

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Key points• The indicators for service delivery are categorized into three

framework areas:– Access– Retention – Wellness

• The QI steps are:– Identify– Analyze– Develop– Test and implement

• The components for the SEF/S tool for documenting QI work are:– Improvement objective – Indicator – Problem description – Process analysis– Tested changes– Results eg on run charts

SUMMARISE the session using the slide 9


.

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Session 3.2.2: Practicum, feedback and next steps

Total practical time: 5 hours

Practicum objectivesBy the end of this practicum, participants will be able to: Identify problems for HIV and AIDS services Analyse problems Develop and document changes Test and implement change, all as guided by the SES Fill in a matrix the tested changes Provide feedback for the tested changes

Resources needed Flip charts Marker pens LCD projector Chalk board Annex 4: Format matrix for processing identified problems at a facility


1 10 minutes Presentation Instructions for the practicum

2 240 minutes Practicum Practical assignment (visit health facility)

3 40 minutes Presentation and group discussions Feedback session and discussions

4 10 minutes Presentation and group discussion Next steps and way forward

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SESSION CONTENTSl

ide

1

Session 3.2.2: Practicum, feedback and next steps



Slid

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Session objectivesBy the end of this practicum, participants will be able to:• Identify problems for HIV and AIDS services• Analyze problems • Develop and document changes• Test and implement change, all as guided by the

SES• Fill the tested changes in a matrix• Provide feedback for the tested changes

READ the practicum objectives to participants


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Instruction for practicum• Small group assignment to visit health facility• Facility stations/sections to visit

– RCHS– OPD– Pharmacy

• Tasks to be done– Identify problems for HIV and AIDS services – Analyze the problem – Develop and prioritize changes – Test and implement change– Document identified changes in the SES– Provide feedback to the plenary on the tested changes

Instructions for the Practicum:

INFORM participants that Teams shall VISIT selected health facility areas for 4 hours.

DISTRIBUTE the indicators (PMTCT and CTC) to different groups such as; 1. Percentage alive and on ART X

months after start of ART(X= 12, 24, 36 and 48 months) (Retention) (at the CTC)

2. Percentage of persons starting first-line ART who are still on first-line ART X months later (Retention) (at the CTC)

3. Percentage of individuals starting ART who are prescribed a standardregimen (Access) (at the CTC)

4. Percentage lost to follow-up during the 12 months after starting ART(Retention) (at the CTC)

5. Percentage of persons starting first-line ART who are still on first-line ART 12 months later (Retention) (at the CTC)

ASSIGN each group a training facilitator or group leader who shall be supervising the process in relevant groups

Participants shall SHARE the matrix to the group facilitator/leader before sharing it to the HF staffs.

ClassroomASK each team to compile and prepare a presentation (for 30 minutes) using the format (the SES matrix) provided for feedback in classroom.

GUIDE team during presentations and discussions for 30 minutes.

SUMMARIZE the session and observations from the practicum and present the way forward.

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Slid

e 4 Next steps after going back to

your workplace• Give immediate feedback to colleagues at your respective

facility and the facility management and share the QI training package manual

• Establish a site QI team and appoint a QI focal person e.g. DACC, CTC in charge etc

• Identify areas for improvement in your workplace• Carry out a process analysis for priority processes• Use PDSA cycle to test and implement change • Document identified changes in the SES (indicating objective,

responsible person and timeline)• Start implementing changes • Continues monitoring by measuring • Evaluate if the change resulted into an improvement and if so

institutionalize the change or develop and test new changes

TELL participants that we have come to the end of QI training and narrate next steps as detailed.

EXPLAIN that each region/district or council and health facility that has attended shall provide a tentative date for follow up after trainingThe follow up visit for supportive supervision and coaching by the RHMT/CMHT should be within 2-3 months after this training.

EXPLAIN what they should expect during the follow up.

INVITE another facilitator to conduct evaluation of the training course.

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Evaluation of the training

Total Session Time: 2 hours

AimEvaluation is an important aspect is training. It informs the trainers and programme manager on the extent to which the training objectives have been met. In this unit, methods of how the Basic of Quality Improvement training will be evaluated are presented including post-knowledge test and self-evaluation forms.

Session objectiveBy the end of this session, participants will be able to:1. Discuss achievements made after training3. Assess the extent to which course objectives have been met

Resources needed Flip charts, marker pens, and masking tape/ LCD machine/laptop Black/white board and chalk/whiteboard markers Post test scripts and marking scheme Evaluation forms

Session overview

Steps Time Activity/Method Content

1 05 minutes Presentation Presentation of Session Title and Objectives

2 30 minutesIndividual exercise Post test

4 35 minutes Individual exercise Evaluation of the training

5 30 minutes Presentation Feedback for Pre and Post-test

6 20 minutes Presentation Closing

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SESSION CONTENTSl

ide

1

Evaluation of the Training



Slid

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Session objectives

By the end of this session, participants will be able to:• Discuss achievements made after training• Assess the extent to which course

objectives have been met

READ or ASK participants to readthe objectives.

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Post test

Please take 30 minutes to fill in the post test related to Quality Improvement in HIV and AIDS Care and Treatment

ADMINISTER the post test and give instructions related to the test

TAKE trainees through the questions and clarify accordingly

Participants will do the test for 30 minutes

MARK the test for 30 minuteswhile participants are filling in Evaluation forms

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Slid

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Evaluation of training

DISTRIBUTE to participants the evaluation forms

TELL them they will use 30 minutes at most to do the evaluation

COLLECT the evaluation forms and summarise them after the closing for future improvement of the courses

REVIEW the workshop expectations to see if they are met

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Feedback for pre and post test

AFTER correction of all the post test scripts take 30 minutes for feedback

PREPARE a summary of knowledge gain for the participants using graph or table

DISTRIBUTE to participants the pre and post test scripts done

DISPLAY the results in a slide or flip chart without participant names

SUMMARISE the discussion andCOLLECT all the scripts from participants.

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CLOSING

INVITE responsible person from the region for a closing session for 20 minutes.

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Annex 1: Checklist of instructional materials and supplies needed for the training

Item Needed Number NeededFacilitator Guide 1 For Each FacilitatorParticipants Manual 1for Each ParticipantParticipants Handout 1 For Each ParticipantLaptop Computer 1LCD Projector 1 Screen For Projector/ Or Suitable Wall 1Flip Charts 5 RollsFlip Chart Stand 1Marker Pens 5 BoxesPens 1 BoxPencils 2 DozensEraser 1 Per ParticipantWriting Pads (A4) 1 Per ParticipantPrinted Pre and Post Test 2 Per ParticipantPrinted Checklists For Practicum 1 Per ParticipantPrinted Time Tables/Course Schedule 1 Copy Per ParticipantFolder 1 Per Participant

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Annex 2: CASE STUDY Mrs. Kwangu IntroductionMelela Health Centre (MHC) provides comprehensive antenatal services including Prevention of Mother to Child Transmission of HIV (PMTCT) and delivery. Melela Health Center does not provide care and treatment services. Patients who require care and treatment services are referred to the district hospital for further management.

Part 1: First RCHC visitMrs. Kwangu is a primigravida who attends RCHC clinic at Melela Health Center. During a health education session, Mrs. Kwangu was convinced to undergo counselling and testing for HIV. The HIV test results are positive, and since she was 30 weeks pregnant the RCH nurse midwife gives her Nevirapine and instructions on how and when to use. But while that process what taking place she was not registered in the PMTCT register nor in the RCH 4 card. She is then referred (without referral form) to CTC at the district hospital, about 80 kilometers from Melela Health Centre. She is afraid of disclosing to her husband, fearing that he would chase her away.

Part 2: Mrs. Kwangu at the District HospitalMrs. Kwangu organizes herself and on Monday leaves for the district hospital for CD4 count test as instructed by the counsellor. Because she did not have a referral slip, on her arrival at district hospital (around 9am), she was not sure where to go. She first went to the general reception, were she got registered and asked to sit at the waiting bench. She lines up at the queue and waits for 3 hours before seeing a clinician. After consultation she was directed to go to the laboratory for CD4 testing. She arrives at the laboratory few minutes after 12 noon. The Laboratory technician tells her she was late and that he had already reached his maximum number of 30 samples for CD4 testing for the day. She was given an appointment to come the following Thursday.

Part 3: Follow - upOn Thursday Mrs. Kwangu finds that she has no money for bus fare and no other means of transport therefore she fails to go to the district hospital.

Part 4: Next RCHC Visits at MHCShe continued attending the RCHC as scheduled. When labour started she reported in time at the health facility where she was received by a Nurse Midwife. She was examined and given instructions to go to the labour ward. At the second stage of labour which was an hour later Mrs Kwangu through the assistance of Nurse Assistant delivered a beautiful baby weighing 3.5 kg.

The following morning, she receives general health education about breastfeeding and care of the baby before she was discharged. She went home with her husband happily.

Part 5: Twelve months laterMrs Kwangu was admitted at the district hospital Paediatric ward. Her beautiful baby was having recurrent pneumonia. The Doctor ordered several investigations including HIV testing which revealed that the baby was HIV positive.

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Annex 3: System and process flow chart

Identified steps that are; unclear, inefficient, inconsistent and unnecessary

Simplified flow chart after analysis and recommended changes for improvement

Re – designing the process

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Annex 4 Role Play Script_ Session 2.3_Principles of QI: Team work

NeededAsk three volunteers from the group8-10 chairs (depends on availability of chairs and space)

Total time: 30 minutes

FIRST PART

Instructions to the three volunteers by the lead facilitator

1. The lead facilitator will take the three volunteers outside of the classroom2. The three volunteers are not allowed to communicate or interact with each other3. The facilitator will instruct each volunteer on an individual basis:

a. 1st participant: arrange the chairs facing the back of the roomb. 2nd participant: arrange the chairs facing the front of the classc. 3rd participant: arrange the chairs in two rows facing each other

NOTE: volunteers are not allowed to talk to each other about their assignment

Instructions to participants in the classroom by the co-facilitator1. The co-facilitator first arranges the 8-10 chairs in front of the classroom in a

un-organized way2. Instruct the participants in the classroom to observe the role play and write

down their findings on a piece of paper.

SECOND PARTAfter the instructions the lead facilitator takes the three person back into the classroom where they will be asked to execute the assignment they were given without communicating to one another in 2 minutes.

Instructions to the three volunteers by the lead facilitator1. After the two minutes the lead facilitator will take the three persons outside the

classroom.2. The facilitator outside is asking them why they didn’t succeeded in achieving their

assignment.3. Discuss what they can do as a team to fulfil the assignment successfully. 4. They have 2 minutes to discuss and come up with a plan to try it for the second

time5. Thereafter they will go back to the classroom for the second role play

NOTE: during the second role play they are allowed to communicate to each other

Instructions to participants in the classroom by the co-facilitator1. The co-facilitator will ask the observers to share their finding in the group and

write the answers on a flip chart. What did they observe? Why didn’t they succeed in carrying out their assignment? What was the problem?

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THIRD PARTThe three people will enter the classroom again and the lead facilitator will explain to the rest of the group that they will conduct another role play to carry out the assignment they have been given for 2-3 minutes.

Thereafter a group discussion is convened whereby everyone can share their input on what they have seen in the first and second role play and describe the difference they observed.

What improvement was seen in the 2nd role play compared to the first one? Why did the individual assignment fail in the first role play and why did they

succeeded in the second one?

The facilitators should use the group discussion to lead all the participants to the subject of the next session, being TEAMWORK. Ask them to share experience about teamwork in their work environment – positive and negative.

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Annex 5: Handout 1_Tanzania HIV/AIDS Patient Care and Treatment Indicators

sn Indicators or other aggregated data

Rationale Reporting Obligation

1 Percentage alive and on ART X months after start of ART(X= 12,24,36 and 48 months) (Retention)

Assesses progress in providing ART to every person with advanced HIV infection. Monitors trends in coverage

National, UNGASS, UA , EWI

2 Percentage of persons starting first-line ART who are still on first-line ART X months later (Retention)

Early warning indicator for HIV drug resistance

National EWI

3 Number enrolled in HIV care: (a)new and (b)cumulative ever at the facility by age and sex (Access)

Identifies gross numbers of patients enrolling in HIV care, contributing to national targets and progress of scale-up

National

4 Number started on ART: (a)new and (b)cumulative ever started at the facility by age, sex and pregnancy status (Access)

Identifies gross numbers of patients starting on ART, contributing to national targets and progress of scale-up

National

5 Number receiving HIV care during period by age and sex (Access)

Identifies reach and accessibility of HIV care during scale-up, informs facility-level planning

National Global fund

6 Number currently on ART at the facility by age, sex and 1st-line or 2nd-line regimen (Numerator for UNGASS and National Core 7)(Access)

Assesses progress in providing ART to every person with advanced HIV infection

National Global Fund

7 Number medically eligible for ART but not yet started by age and sex. (Access)

Identifies reach and accessibility of ART during scale-up

National

8 Number currently enrolled in care receiving Cotrimoxazole (Access)

Allows monitoring of Cotrimoxazole use, drug supply management.

National

9 Number currently on ART receiving Cotrimoxazole

Allows monitoring of Cotrimoxazole use

National

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(Access)

10 Percentage patients currently on ART who status is (working, ambulatory, bedridden)(wellness)

Patient productivity, quality of life, and therefore ART success

National

11 Percentage of health facilities that offer ART (UA) (Access)

Measures access to Care and Treatment services

UNGASS

12 Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy. (Access)

The indicator measures coverage of ART among those who need it.

UNGASS

13 Percentage of individuals starting ART who are prescribed a standard regimen.(Access)

Numerator: Number of individuals initiating first-line ART at the site who are prescribed an appropriate first-line regimen during the selected time periodDenominator: Number of individuals starting ART during the selected time period Set target: 100%

National EWI

14 Percentage lost to follow-up during the 12 months after starting ART.

(Retention)

*"Lost to follow up" is defined as having missed three consecutive months of drug pick-ups and clinical appointments.Numerator: Number of individuals starting ART during a selected period of time in the previous year who were subsequently classified as "LOST TO FOLLOW UP"* during the first 12 months of ARTDenominator: Number of individuals starting ART during the selected time period in the previous year Set target: < 20%

National EWI

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15 Percentage of persons starting first-line ART who are still on first-line ART 12 months later. (Retention)

Numerator: Number of individuals starting ART during a selected period of time in the previous year who are (12 months from ART start) still on first-line ART (this includes substitutions of one standard first-line regimen for another).Denominator: Total Number of individuals starting ART during a selected time period in the previous year ,minus the number of individuals starting ART in that time period who were transferred out during the 12 months after starting ART. However, individuals who died, stopped ART, switched to second-line ART, or were lost to follow-up must be included in the denominator. Set target: > 70%

National EWI

16 Percentage of persons who attended all appointments during a year. (Retention)

Numerator: number of individuals who were on ART at the end of the previous year or who started ART at some time during the present year who kept all appointments on time in the year up until the time they were classified as lost to follow-up, dead, transferred out, or stopped ARTDenominator: number of individuals who were on ART at the end of the previous year or who started ART at some time during the present yearSet target: 80%

National EWI

17 Percentage of HIV positive patient who were screened for TB in HIV Care or Treatment setting (Access)

Numerator Denominator

New national indicator for TB/HIV collaborative activities

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18 Percent of HIV positive patient in HIV Care or Treatment ( pre ART or ART) who started TB treatment (access)

Numerator Denominator

New national indicator for TB/HIV collaborative activities

19 Number of HIV positive clinically malnourished who received therapeutic and or supplementary food (wellness)

Nutritional support New national indicator

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Annex 6: Standard Format for Documentation of Quality Improvement work

Site Name: _________________________

Part A: Planning worksheet

Improvement Objective: To

Indicator:

Description of Problem:Briefly describe the problem being addressed and gaps between the current situation and your improvement objective.

Process Analysis:Which steps in the process of care are currently problematic?

Part B: Changes Worksheet

In the table below, please list all the changes you will introduce Tested Changes: Use 1-2 sentences to briefly describe the tested change

Planned Start Date:

End Date (if applicable)

Responsible person

Comments: Note here any evidence that the change took place; and potential reasons why it was or was not effective such as key barriers or important enabling factors.

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Part C: Graph: Describe the indicator(s) you have used, including the value of the numerator and denominator. Annotate your graph based on the time the change was introduced or ended. You may use the change’s number (from the table above) to annotate.Name of the indicator:Definition of the numerator: definition of the denominator:

0 1 2 3 4 5 6 7 8 9 10 11 12 ________ _________ _________ _________ _________ _________ _________ _________ _________ _________ __________ __________ _______

Indicator #1 ( )Numerator

Denominator

%

Time (Months)

IndicatorValue

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ANNEX 7: COURSE EVALUATION FORM END OF WORKSHOP EVALUATION

Instructions:* Feel free to write your name

Name: _________________________

* For any of your response give justification in the space provided

1. This workshop has been very beneficial.Agree: ……………………Disagree:………………………….......................………Comments:……………………………………………………………………………

2. The workshop objectives have been adequately covered:Agree: ……………………….. Disagree: …………………………………Comments:……………………………………………………………………………

3. The methodologies used were relevant to meet the objectives of the workshopAgree: ……………………….. Disagree: …………………………………Comments:……………………………………………………………………………

4. The facilitators for this workshop have assisted in meeting objectives of the workshop.Agree: ……………………….. Disagree: …………………………………Comments:……………………………………………………………………………

5. The time for this workshop was adequate:Agree: ……………………….. Disagree: …………………………………Comments:……………………………………………………………………………

6. The logistical arrangements (accommodation, food, etc) were satisfactory.Agree: ……………………….. Disagree: …………………………………Comments:……………………………………………………………………………

7. Other comments

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Annex 8: Course Schedule for Basic Quality Improvement Training

Day 1Time Activity Responsible 08.00 - 08.15 Registration08.15 - 08.30 Participants Introductions,08.30 - 09.00 Expectations, Norms and Logistics09.00 - 09.30 Welcome and opening Remarks09.30 - 10.00 Pre- course questionair10.00 - 10.30 TEA BREAK10.30 - 10.45 Training Objectives, Output and course

Schedule10.45 - 12.45 Introduction to Quality Improvement in Tanzania 12.45 – 13.45 Introductions to Concepts of Quality in Health

Care13.45 – 14.45 LUNCH BREAK14.45– 16.45 Dimensions of Quality16.45 – 17.00 COFFEE BREAK17.00 – 17.30 End of the day 1: Facilitators meeting

Day 2Time Activity Responsible 08.00 - 08.15 Recap day 108.15 - 08.30 Secretariat Report day 108.30 - 09.30 Define quality improvement

Principle of Quality :Focus on Clients Needs and Expectations

09.30 –10.30 Principles of Quality: Focus oncommunication and feedback

10.30 –11.00

TEA BREAK

11.00 - 13.30 Principles of Quality: Focus on Team work13.30 – 4.30 LUNCH BREAK14.30 – 7.00 Principles of Quality: Focus on

Measurements 17.00-17.15 Evaluation of day two

17.15 –17.30 COFFEE BREAK17.00 –18.00 End of the day 2: Facilitators meeting

Day 3Time Activity Responsible 08.00 - 08.15 Recap day 208.15 - 08.30 Secretariat Report day 208.30 - 10.30 Principles of Quality: Focus on Systems and

Processes10.30 –11.00 TEA BREAK

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11.00 - 13.00 Principles of Quality: Focus on Systems and processes (continues)

13.00 –14.00 LUNCH BREAK14.00 - 16.00 Steps in Quality Improvement and

Improvement Model (PDSA Cycle)

16.00 –16.20 Evaluation of day three16.20 –16.40 COFFEE BREAK16.40 –17.20 End of the day 3: Facilitators meeting

Day 4Time Activity Responsible 08.00 - 08.15 Recap day 308.15 - 08.30 Secretariat Report day 308.30 – 10.30 Quality Improvement Approaches:

5S and Improvement Collaborative

10.30 – 11.00 TEA BREAK11.00 – 14.00 Leadership in Quality Improvement

Roles and responsibilities of QI implementation at different levels

14.00 – 14.45 LUNCH BREAK14.45 – 15.30 Discovering and managing change and ToT

Guide15.30-16.00 Preparation to Practical Assignment16.00- 16.20 Evaluation of day four16.20 – 16.40 COFFEE BREAK

16.40- 17 20 End of the day 4: Facilitators meeting

Day 5Time Activity Responsible 08.00 - 08.15 Recap day 408.15 - 08.45 TEA BREAK9.45 – 12.30 Practicum: Visit to the Health Facility for

Practical Session12.30-13.30 Practicum: Summarize the problem

identification/analysis and provide feedback to facility

13.30-14.30 LUNCH BREAK14.30 – 15.30 Classroom: Feedback session and next

Steps (work plan)15.30 – 16.00 Evaluation of Training:- Post – Course

Evaluation16.00 – 16.20 Evaluation of Training:- Filling Course

Evaluation forms

149

16.20- 16.40 Evaluation of Training:- Feedback to Pre-and Post – Course Questionnaires

16.40- 17.00 Closing and Refreshments

17.00-17.30 End of the day 5: Facilitators meeting

facilitator’s guide - national aids control...

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