ImplementIng a successful qualItyImprovement program In a tB dIagnostIc facIlIty In semI-rural swazIland

Backgroundn Swaziland, situated in Southern Africa,

has a population of just over one million people and an estimated TB incidence of 1,155 per 100,000 population, making it one of the 15 countries in the world with the highest TB incidence.

n The TB/HIV co-infection rate in the country is also extremely high: 79.6% of TB patients are coinfected with HIV.

n Co-trimoxazole preventive therapy (CPT) is a simple and cost-effective intervention which can extend and improve the quality of life for people living with HIV.

n In 2007, the proportion of co-infected TB patients receiving CPT in Swaziland’s TB facilities was low: less than 25%. Failure to implement simple and cost-effective TB/HIV interventions like CPT is a serious gap in quality of care.

n Since 2007, the USAID Health Care Improvement Project (HCI) has worked with the Swaziland Ministry of Health National Tuberculosis Control Program (NTCP) to improve the quality and rapidly scale up the availability of TB/HIV services in the country’s seven hospitals and 11 health centers.

n Piggs Peak Hospital, a semi-rural facility in the Hhohho Region of Swaziland, is one of the facilities that is applying continuous quality improvement approaches to improve the quality of integrated TB/HIV care, including CPT.

noVEMBEr 2010This work was supported by the American people through the United States Agency for International Development (USAID) Health Care Improvement (HCI) Project and received funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The USAID Health Care Improvement Project is managed by University Research Co., LLC (URC) under the terms of Contract Numbers GHN-I-01-07-00003-00 and GHN-I-03-07-00003-00.

MEthodn NTCP, HCI and the Piggs Peak TB focal

person reviewed key data as part of a baseline assessment and identified key performance gaps.

n Health care staff in the TB clinic were trained on continuous quality improvement (CQI) approaches and tools.

n Facility baseline data were presented to the hospital management as part of sensitization about quality management and CQI for TB/HIV services.

n Subsequently, a TB/HIV multi-disciplinary quality improvement (QI) team of ten people was formed.

n The QI team applied the following tools and approaches to analyze and improve patient flow and care processes: QI documentation journal, fishbone diagram, QI framework for testing QI interventions, an Excel database, a QI synthesis form, and the baseline assessment findings.

n The team applied an improvement framework that included documentation of improvement actions implemented by the team using the plan-do-study-act (PDSA) cycle.

n Several performance indicators were developed to track the effects of changes made by the team in Piggs Peak. These indicators included:

– Smear not done (SND)

– Smear conversion rate (SCR)

– Treatment success rates (TSR)

HEALTH CARE IMPROVEMENTPROJECT

Members of the Piggs Peak Hospital quality improvement team during a monthly team meeting. Team members include: Ms. J. Malindzisa (TB nurse), N. Ncube (Outpatient Department), P. Dlamini (Male medical ward), H. Mkhonta (Female medical ward), Dr. B. Mpundu (ART unit), Sr. E. Nobunga (ART unit), Sr. Mahlalela (TB unit), L. Mdluli (Regional TB coordinator), C.Dladla (URC) and Dr. E. Phiri as team leader.

– HIV counseling & testing (HTC) uptake

– ART uptake rate (% of co-infected patients receiving ART)

– CPT uptake rate (% of co-infected patients receiving CPT)

figure 1: fishbone diagram of possible root causes of the low proportion of tB patients receiving co-trimoxazole preventive therapy (cpt)

ClientsHealth workers/staff

Not trained on TB/HIV management

Do not appreciate the importance of CPT

Not recording all patients receiving CPT

Not demanding CPT as part of TB/HIV care

Some think co-trimoxazole increases the pill burden

Co-trimoxazole tablets not supplied to TB clinics

TB patients required to get co-trimoxazole from the Hospital pharmacy

Procedures

Low proporation of co-infected TB patients receiving CPT

the contractor team for the usaId Health care Improvement project includes urc (prime contractor), encompass llc, family Health International, Health research Inc., Initiatives Inc., Institute for Healthcare Improvement, and Johns Hopkins university center for communication programs (ccp). for more information on HcI’s work, please visit www.hciproject.org or contact hci-info@urc-chs.com.

figure 2: cpt uptake in piggs peak government Hospital, January 2008-June 2010

25%

61%

92%97% 98% 99% 98% 99% 100% 100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan-M

ar 08

Apr-Ju

n 08

Jul-S

ept 0

8

Oct-Dec

08

Jan-M

ar 09

Apr-Ju

n 09

Jul-S

ept 0

9

Oct-Dec

09

Jan-M

ar 10

Apr-Ju

n 10

% TB-HIV co-infected patients receiving CPT

Jan 08QI team formed in Piggs Peak Hospital

Feb 08Training of TB unit staff on proper quantification and timely ordering procedures for co-trimoxazole

Feb 08Training of TB and ART unit staff in TB-HIV management

Mar 08Initiate monthly supervision and review of CPT component of TB register

Mar 08Introduction of job aid on the co-trimoxazole dosages for adults and children

Apr 08Initiate quarterly review of TB/HIV data to facility staff, including CPT data

Jun 08Initiate client education sessions on benefits of CPT

Dec 08Work with hospital pharmacist to put in place procedures to ensure availability of co-trimoxazole in the TB clinic

Jan 09National TB/HIV guidelines updated to require CPT for co-infected patients

Changes made at Piggs Peak Hospital:

figure 3: other tB-HIv performance Improvements at piggs peak Hospital

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Smear Not Done (SND)

Smear Conversion rate (SCR)

Treatment Success rates (TSR)

HIV Counseling & testing (HTC)

uptake

ART uptake rate (% of co-infected

patients receiving ART)

35%

0%

62%

84%

64%

72%

38%

89%

27%

39%

Jan-Mar 2008

Apr-Jun 2010

n The QI team decided to first address the problem of the low proportion of co-infected TB patients receiving co-trimoxazole preventive therapy. The problem was then quantified by

reference to the findings from the baseline assessment.

n A problem analysis including performance gaps and root causes was done using a fishbone diagram (see Figure 1).

n On a quarterly basis the quality improvement team members completed a synthesis form with assistance from a QI coach from HCI on improvement efforts and the results achieved. The synthesis form captured key changes and categorized them as effective or not, to facilitate the sharing of effective changes with other facilities.

RESULTSn The Piggs Peak team documented a

dramatic increase in the proportion of TB patients receiving co-trimoxazole from a baseline of 25% to almost 100% within 12 months. These positive results have been sustained for the past 18 months, as seen in Figure 2. Key changes that were introduced by the team to achieve these results are shown in the box to the right of the chart.

n The team undertook improvement activities aimed at the other indicators of TB-HIV care quality and achieved improvements in these other areas as well, as seen in Figure 3.

CONCLUSIONS AND LESSONS LEARNEDn The early success with improving

coverage of TB-HIV co-infected patients with co-trimoxazole preventive therapy was valuable for the local QI team and constituted an important incentive for sustaining and expanding the quality improvement experience.

n This experience shows that health facility staff in Swaziland—a resource-constrained setting with a serious TB-HIV epidemic—can apply QI approaches to make measurable gains in quality of care to improve the quality of life of TB-HIV co-infected patients.