KABALE REGIONAL REFERRAL HOSPITAL. Academic Supervisor: Dr. Elizeus Rutebemberwa

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1 RONALD M.KASYABA, HIV/AIDS Fellow IDAH K. NDYABANAWE, HIV/AIDS Fellow of KABALE REGIONAL REFERRAL HOSPITAL An Interventional project to improve quality of care for HIV clients seeking Antiretroviral Therapy in Kabale Hospital Academic Supervisor: Dr. Elizeus Rutebemberwa 14 th August,2009

2 KRRH, a 280 bed capacity secondary level hospital was established in 1930, serves 4 districts in S.W Uganda, with a catchment area of 1,231,300 people (2007 estimates). The Regional HIV prevalence of 5.9%, the hospital cumulatively has 6,295 HIV clients under Chronic HIV care, and 40% of which are on Anti-Retroviral Therapy (ART). This project intended to assess the quality of care in the ART clinic of Kabale Hospital, identify gaps and implement measures to improve care.

3 A hospital based Quality Improvement Team was constituted by the HIV/AIDS Fellows, in August 2008 and, Various problem areas affecting quality of care in the ART clinic were identified through Brainstorming & Flow charting With the aid of a theme selection matrix, long waiting times for clients at the clinic was chosen as the theme area for improvement by the team

4 A baseline Time & Motion study conducted prior to project intervention revealed an average ART clinic waiting time of 6 hours, 2hrs longer than expected for the clinic s standard waiting times. Waiting time for a service in an out-patient clinic is a proxy measure of quality of care, and long waiting times result in client dissatisfaction, and consequent missed appointments & disrupted adherence The long waiting times at the clinic were a contributing to the poor quality of care

5 The General Project Objective The overall objective of the project was to reduce the long waiting time to receive ART services at the clinic in Kabale Regional Referral Hospital from six hours to four hours so as to improve quality of health care services at the clinic.

6 Specific Objectives The project was intended that by the end of the project, 1) The team would lobby for the recruitment of a Phlebotomist (Laboratory staff) to improve on the existing manpower at the Laboratory station. 2) The team would lobby for the recruitment of another clinician to improve on the existing manpower at the clinician s station. 3) Provision of on-site tea to reduce long break times, at the ART clinic.

7 The actionable root causes (Lobby of additional staffing at the clinic stations significantly contributing to the care delays) were identified through the Fish-Bone analytical tool Three Lobby meetings were held with the clinic management, The team also undertook to introduce and enhance on-site break teas

8 By end of January 2009, The two vital staff (a medical doctor, & a phlebotomist) at the two clinic stations responsible for 75% of the delays were recruited Break teas were being provided on-site, and additional equipment for tea were in place Following the recruitments, a post-lobby (intervention) time and motion study was conducted to determine response to clinic waiting times.

9 Time (min) The average waiting time at the ART clinic reduced from 348 minutes to 220 minutes, a 36.8% reduction in overall clinic waiting time. There was a 42.4 % reduction in waiting time at the clinician & Laboratory stations (shown in graph beside) Graph showing effect of Intervention Waiting time at Lab & Clinician BEFORE 148 Waiting time at Lab & Clinician AFTER

10 Clinic Staffing norms affect client/patient waiting time for care service Management s involvement and understanding of a quality of care problem area, Identification of bottlenecks to quality of care in a clinical setting is better when its internal The project enhanced Team spirit within the hospital

11 Effecting changes in a system was a bottleneck embracing change The constraint of time resource Delayed access to Financial assistance for the implementation of project activities

12 The findings of the project have been disseminated to hospital management highlighting the importance of maintenance of staffing norms to assure quality of healthcare The project team intends to conduct a repeat timeand-motion study 6 months from the end of the project to review progress in clinic waiting times The Fellows have encouraged colleagues in the ART clinic to consider undertaking a Fellowship in CQI to better appreciate quality care provision

13 The Fellows would like acknowledge and Thank the following persons, and organisations for their immense educational, moral and financial support towards the successful completion of this Programme; Centres for Disease Control & Prevention, Uganda/ U.S.A Makerere University School of Public Health, Fellowship Office, and the entire teaching staff Dr. Elizeus Rutebemberwa, and Dr. Michael O.Osinde (our supervisors) Members of the Kabale Hospital Quality Improvement Team Management & Staff of Kabale Regional Hospital ART clinic and, Our respective families.

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