Institute for Healthcare Improvement South Africa Country Report May September 2012

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1 Institute for Healthcare Improvement South Africa Country Report May September 2012 Introduction The South African (SA) country program was started by the Institute for Healthcare Improvement (IHI) in Over the past seven years, the IHI-SA team has worked closely with a growing group of local partners and the Department of Health (DoH) to help save South African lives and improve the experience of patients interacting with the health system. Overall Goal The IHI-SA country program is intended to accelerate sustainable improvement in health and health outcomes for individuals and communities nationwide. IHI-SA partners closely with local, regional and national health system leaders in the Department of Health and with a dynamic group of South African academic and non-governmental Table of Contents Introduction Page 1 Overall Goal Page 1 20,000+Partnership Page 2 Best Care Always! Page 3 Aurum Page 4 ARV Chronic Care Clubs Page 6 CAPRISA Page 6 R&D Page 7 Publications Page 7 Contact Information Page 8 organizations (NGOs), thereby influencing the thinking and practice of health at scale. IHI-SA has two clear goals: improving safety in hospitals throughout the country and improving the care of patients living with HIV. With both, the specific aims are simple: save the most possible lives in the shortest possible time and learn as much we can along the way. IA Course Wave 27 IHI-SA is planning to host its second Improvement Advisor (IA) Professional Development Program in Johannesburg, South Africa, from February 2013 to September The South African offering follows on the heels of a successful IA training in Durban/Cape Town last spring. Led by Brandon Bennett, with support from faculty Ron Moen and Lloyd Provost, our faculty will teach the essentials of Quality Improvement (QI) over 10 months. This course is intended to provide QI capacity to our partners all over the world. Leading and Facilitating Quality Improvement Teams A newly designed, intensive ten-week program is being launched in early This program is specially designed for people actively involved in health care improvement projects. Participants will use the Model for Improvement as a framework on an improvement project and learn how to coach teams and work with leaders on improvement projects. to: dheaney@ihi.org for more details on either course. Spotlight on: Dr. Michele Youngleson Dr. Youngleson has been with IHI for since the beginning of the South Africa programme in Currently, she is working with IHI on reducing hospital acquired infections with Best Care Always!, strengthening the PMTCT program with the Aurum Institute, and spreading a model for efficiently managing large numbers of patients on antiretroviral therapy (ARV clubs), actively combining her healthcare interests in medicine, epidemiology, and psychology. She is an avid public health researcher, completing Medical School at the University of Cape Town and her postgraduate honors degree in epidemiology at the University of Stellenbosch. Her primary research interest is focusing on methods and impact with health systems improvement in public healthcare settings. Her passion is focusing on supporting staff at the frontline of care to ensure that they are able to liberate positive energy and compassion throughout their communities. Previously, Dr. Youngleson has worked for the public healthcare system in primary care clinics within Cape Town, was an epidemiologist for the Medical Research Council, and held her own private practice focusing on the psychology of illness. She enjoys spending time with family and friends, cooking & eating, surfing, and walking in the vineyards and mountains around Cape Town. Dr. Youngleson and her husband started surfing 5 years ago; they enjoy sharing the waves with seals, dolphins, and the occasional great white shark (at which point they make a dash out of the water!). 1 P a g e

2 20,000+ Partnership Overview of the Partnership: 20,000+ is a partnership between the Kwa-Zulu Natal (KZN) Department of Health, the University of KZN and IHI which aims to eliminate perinatal transmission of HIV in the Province and has already shown a decrease of MTCT rates to below 3%. The project has expanded from 3 initial Districts to all 11 Districts in KZN Province and has launched efforts to improve infant nutrition. The project supports the National Department of Health s efforts to eliminate mother to child transmission by They have also started the Nompilo project aimed at examining the impact of interventions to improve child survival through community health workers enabled to use QI. 20,000+ assists KZN province to sustain improvement as evident in the line graphs provided below. Data is being used for action through the PMTCT dashboard and KZN Provincial DOH is leading the way with the support of 20,000+ by spreading key change ideas and scaling up improvements across the country. Regular monthly conference calls with the 11 PMTCT district coordinators and information officers promotes a culture of using information for improvement. This is led by DOH and 20,000+ analyses of the dashboard data. Training of community care givers (CCGs) in integrated case management and quality improvement has commenced in Ugu district, KZN. It builds on the existing community framework training provided by DOH. These CCGs provide household interventions for maternal, neonatal and child health care. 120% 100% 80% 60% 40% 20% 0% Sustaining improvment over time All three districts HIV Testing Rate Ugu, ethekweni and Umgungundlovu data improvemnt project Dataelement change Percentage= Baby HIV antibody test at 18 months over DTaP-IPV/Hib 4th dose 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Monitoring DHIS data learning by sharing Amajuba District18 Months rapid testing uptake (DTaP-IPV/Hib 4th dose) Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 M&E program Aug-11 Sep-11 Oct-11 Nov-11 Conferencecalls Dec-11 Jan-12 Feb-12 Mar Jan-10 Feb-10 Mar-10 Apr-10 May-10 KZN - Clients eligible and Initiated on HAART 2 year experience QI projectpmtct co ordirnator dashboard Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Antenatal client initiated on HAART Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Antenatal client eligible for HAART Feb-12 Mar-12 Percentage= Baby PCR test pos. around 6 weeks over Baby PCR test around 6 weeks 14% 12% 10% 8% 6% 4% 2% 0% Jan-10 Feb-10 The power of data over time KZN Province Babies PCR Positivity around 6 weeks Mar-10 QI project PMTCT co- Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Raw Numbers Promoting exclusive breastfeeding KZN Province Babies Exclusively Breastfed at 14 weeks Introduction of new data element Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 2 P a g e

3 Best Care Always! Overview of the Partnership The Best Care Always! (BCA) campaign is an initiative aimed at supporting SA hospitals to implement evidencebased interventions to reduce healthcare associated infections (HAI) and ensure the judicious use of antibiotics. Patterned after the IHI s 100K lives campaign, the Canadian Safer Healthcare Now initiative, and WHO s World Alliance for Patient Safety, BCA was launched in August 2009 to support SA s private hospitals, and spread in May 2010 to include public sector hospitals. BCA seeks to enhance patient safety and improve quality in hospital care through partnership with major public and private healthcare providers, funders and professional societies. Thus far, over 200 private and public hospitals are enrolled each implementing at least one infection prevention and control bundle. BCA works in the public health sector in Gauteng and the Western Cape. Recent Overall BCA Highlights: Learning Sessions were held for public hospitals in Gauteng and Western Cape in June and Free State in July. A further Learning Session is planned for Gauteng in October and final Learning Session for the Western Cape pilot project in November. Recent Highlights (Western Cape): Months into the project, perseverance and hard work is beginning to show an excellent reduction in hospital acquired infections in many of the 9 participating hospitals in the Western Cape as hospitals are able increase compliance with the bundle elements. Western Cape projects are being put onto the IHI extranet database for ongoing data surveillance post The final Learning Session for the Western Cape pilot project in November that will address sustainability, spread and dissemination of the learning. Maternity Hospital Reduction in Caesarian Section surgical site infections Readmission rates for septic caesarian section Days between septic hysterectomy Reduction in Vetilator Associated Pneumonia (VAP) in an ICU at a teaching paediatric hospital VAP rates/100ventilator days Days between VAP 3 P a g e

4 Reduction in Catheter Associated Urinary Tract Infections (CAUTI) in three spinal units at a rehabilitation facility Rate of CAUTI/catheter days Days between CAUTI Improved overall compliance to bundle elements for preventing CAUTI in a secondary hospital The Aurum Institute Overview of the Partnership: The Aurum Institute (Aurum) is a South African not-for-profit organization which has been working for more than a decade to support the Department of Health to strengthen HIV and TB prevention, care and treatment services in Gauteng, Limpopo, and North West Provinces. IHI s partnership with Aurum aims to improve PMTCT, Pediatric and Perinatal TB and HIV care in Ekurhuleni North (EKN) sub-district in Gauteng Province and Greater Tubatse and Ephraim Mogale sub-districts in Limpopo Province. In addition, we seek to build QI capabilities both within the Aurum team and with their DOH counterparts. Mother-to-child HIV transmission rates are already below 5% in EKN and the aim is to further reduce the MTCT rate to 2% by September 2012, and to improve postpartum HIV/TB follow-up and linkage to care for mother and infant. Monthly data peer review meetings have been structured in all sub-districts to support clinic supervisors and operational managers to use the data to prioritise clinics for intervention. To encourage dissemination of the QI work, a writing workshop was held for Aurum s 10 mentors and 2 Improvement Advisors to write up improvements made at specific clinics. These will be made into posters for display at the second Learning Session and facilities. Up until now the QI project has focused on strengthening antenatal PMTCT care and has recently included PMTCT in the Labour Ward. The second Learning Session, to be held in the next quarter, will include a focus on The antenatal (ANC) nurse and data capturer at Moetsie West, a rural clinic in Limpopo province, explain the graphs they have made to track antenatal PMTCT. 4 P a g e

5 postnatal care of mother and baby. Aurum has been awarded additional grant funding to extend the QI project from 3 sub-districts with 76 facilities to 5 districts comprising 23 sub-districts and 460 facilities. This spread phase will require a major increase in QI capacity and redesign of the project to leverage capacity for the spread phase. Experiences, changes and tools from the current pilot project will be written up as resource material for the spread phase Key Results & Next Steps: 5 P a g e

6 ARV Chronic Care Clubs Overview of the Project: IHI s previous Western Cape efforts to increase access to ART won a 2010 platinum Impumelelo Award for excellence in service delivery. The award money was used to start a QI collaborative to achieve District-wide scaleup of an ARV Chronic Care Club model an approach developed by MSF to manage large cohorts of patients on life-long ARVs. The project is a joint effort of the municipal and provincial departments of health, MSF and IHI in the Cape Town Metro District. Recent analysis has shown that half of Cape Town s 47 ART facilities each had over 1000 patients on life-long ART (range ). The need for an efficient and effective model for managing these large patient loads, within current resource constraints, was pressing. The ARV Chronic Club model uses limited resources in an efficient and effective way to enable stable patients to be managed in groups of 30 by a counselor and supportive clinical team. Outcomes in the MSF-supported prototype facility were excellent with 97.6% of patients still in care after 2 years. The spread effort began in Dec 2010 with 14 ARV clinics with an aim to start 360 clubs for 10,000 stable patients representing 30% of all patients on ARVs in participating clinics by August In September 2012, the ARV Chronic Clubs project won a second Platinum Award from the prestigious Impumelelo Social Innovations Centre that rewards excellence in service delivery. The Award will be used to create a website to make the necessary tools, such as guidelines and registrars, available to an international audience to promote the use of Adherence/ARV Chronic Clubs to other countries with a high HIV burden. Since the start of the project in December 2010, the project has now spread beyond the original 14 clinics to over 450 ARV Clubs in 35 clinics in the Cape Town Metro District managing over 12,000 patients. Below are the graphs for that progress with the original target lines. Key Results: CAPRISA Overview of the Partnership: The Centre for AIDS Research in South Africa is a leading global HIV research organization. Together with CAPRISA, IHI faculty teach a CDC-sponsored Implementation Science course at the University of KZN to develop new cadres of researchers with skills in doing practical operations-oriented research for improvement. This work has kindled interest in using QI methods to more rapidly bring clinical research findings into common practice in public health settings. Based on the success of tenofovir, a microbicide gel that women can use to prevent HIV infection during intercourse, IHI is working with CAPRISA at two pilot facilities to strengthen the quality of reproductive health services so that when and if this new drug becomes available, it can be utilized in the public health service more effectively. 6 P a g e

7 Sixty CAPRISA employees have been trained on quality improvement. Seven QI projects were identified in the various departments including the family planning (FP) initiative which is supported by IHI. The are no data to report due to steps in the approval process, however, the quality of care indicators and indicator definitions have been agreed upon e.g. uptake of family planning services, HIV counseling and testing in family planning, adverse effects monitoring, and Pap smear in family planning clinic. DOH and facility data will be used to report these measures and a data collection system has been articulated to capture these data. Research & Development IHI s 90-day innovation process is our engine for research and development. The process was designed to provide a reliable and efficient way to research innovative ideas, assess their potential for advancing quality improvement, and bring them to action. IHI created a small Innovation Team with dedicated resources to support this process, and the team begins at least five new projects every 90 days. Projects are selected by IHI s leadership team along with the R&D team based on IHI s strategic plan and customer needs and suggestions. Current Wave of Projects: The Joint Learning Network for Universal Healthcare Coverage ( The Joint Learning Network (JLN) is a network of insurance agencies in ten low and middle-income countries working together to expand access to financial coverage for universal healthcare. The JLN has four technical tracks: expanding coverage, provider payment mechanisms, information technology and the quality track. IHI and the NHS Institute for Clinical Excellence (NICE) jointly lead the Quality Track of the JLN. This 90-day cycle, we are working to develop guidance for payers on how they can contribute to driving quality improvements in health systems. This work relates to larger work that IHI is pursuing about how employers, health plans and provider systems can all work together to improve quality in health system. In addition to general guidance on how payers can influence quality, the 90-day cycle will explore three specific mechanisms that payers can use to drive improvement based on the needs and interests of the JLN members: developing the key measures for tracking the quality of health services from an insurers perspective, identifying the vital behaviors of an accreditation system that promotes continuous improvement in care, and the development and testing of national quality strategies to improve care amongst their beneficiaries. For more information on this R&D topic, please contact: Zoe Sifrim, zsifrim@ihi.org Publications 7 P a g e

8 Institute for Healthcare Improvement South Africa Program Team Nneka Mobisson-Etuk, MD, MPH, MBA, has joined IHI as Executive Director of African Operations. Nneka is responsible for the operations and implementation of IHI's existing work in Africa, as well as for developing IHI's portfolio in Africa as part of the organization's work in low- and middleincome countries. She is based out of Johannesburg, South Africa. Dr. Pierre Barker Senior Vice President Dr. Kedar Mate Country Director Maureen Tshabalala Improvement Advisor Dr. Michele Youngleson Improvement Advisor Farzaneh Behroozi Improvement Advisor DeAnna Heaney Project Coordinator Institute for Healthcare Improvement University of Kwa Zulu Natal 1 st Floor George Campbell Building Durban, 4001 For more information, please contact: kmate@ihi.org 8 P a g e