Utilization of QI approaches to improve TB/HIV treatment outcomes in Swaziland 2018 IHI Africa Forum on Quality and Safety in Healthcare Presented by Dr. Samson Haumba Country Director, University Research Co., LLC- Swaziland
Presentation Outline Context Objectives Methods Results End-line evaluation Lesson learned
Context Swaziland has a population of about 1 million; with the highest TB/HIV per capita burden in the world (1287 new TB cases/100,000; HIV prevalence 26% in adults) in 2006. Yet TB treatment success was low 42%, and unfavorable out comes were 58% There was no TB/HIV service integration The need to improve quality TB/HIV services and treatment outcomes in Swaziland was imperative and the question was how By 2014, TB treatment success was 86% and TB/HIV services fully integrated
Objectives and Methods Improvement objectives: increasing TB treatment enrolment & success, Increasing TB/HIV integration (HIV testing for TB patients, Cotrimoxazole prophylaxis), increasing ART uptake for TB patients QI methods used for problem analysis, problem prioritisation and improvement interventions in the context of TB/HIV and HSS implemented;
Timeline, Interventions and Scale-up National TB Coordinating Committee created Regional TB/HIV Committees formed TB declared an emergency Revised WHO guidelines for TB/HIV adapted Evaluation of TB/HIV Collaborative activities 2006-07 2009-10 2010-11 2012-13 2014 Quality improvement approaches launched 2006 First training of national TB Program and Clinic Nurses Established facility based QI teams incrementally: 3 teams in 2006, 12 teams teams in 2007, 22 in 2008, 66 in 2011, with scale-up to 87 by 2014
Methods 1: Change packages 1) Redesigning of the existing care delivery processes in order to enable the implementation of the intervention (guidelines and standards of care, task shifting-htc, ART-initiation, cough screening, supply chain); 2) Training HCW on QA/QI, QI tools for performance measurement, problem analysis, QI projects; 3) Onsite coaching of facility QI teams to ensure compliance to guidelines, standardised documentation & reporting to next level implemented;
Methods 2: Site QI teams working together to systematically identify and overcome barriers to implementation PROBLEM Protocols guidelines SYSTEM ANALYSIS GREAT IDEAS Plan IMPLEMENT Act Test out ideas in a small way before changing everything Do SUCCEED/ SUSTAIN Study
Methods 3: Onsite coaching
Methods 4: Change packages 4) Testing and implementing specific changes and adopting changes that work; 5) Quarterly collaborative learning and sharing sessions (QRMs) for sharing improvement data (using run charts, histograms, and story boards); 7) Twinning approach to capacity within the NTP for QI 8) Supporting MOH to take leadership for planning, monitoring and executing system-level changes
Methods 5: Standard Evaluation System What are the evidence-based practices emerging from the QI teams? Learning Session Collaborative-level Synthesis of Best Practices Collaborative-level Database QI team site Which changes are really improvements? Site-level synthesis Site-level summary QI team representative Site-level journal Site-level database Collaborative coach or manager
Results 1: Treatment success and uptake of TB/HIV services for 66 TB facility QI teams
% TB/HIV Patients % TB/HIV Patients Results 2: Superior performance at sites receiving intensive QI support in comparison to all sites combined nationally 100% 90% Development of tools: Patient Flow charts, TB/HIV 97% 100% 90% 87% 80% 80% 80% 80% 70% 70% 60% Deployment of Nurse led ART initiation 60% 50% 50% 40% 40% 30% 20% QI training and Harmonization of TB/HIV tools and data quality audits 30% 20% 10% 10% 0% Q2 1 2 Q3 1 2 Q4 1 2 Q1 1 3 Q2 1 3 Q3 1 3 Q4 1 3 Q1 1 4 Q2 1 4 Q3 1 4 Q4 1 4 ART Uptake RFM Hospital 56%58%69%65%78%82%89%87%88%92%83%97% ART uptake National 58%58%67%69%73%71%69%73%76%76%77%80% Q1 15 12 0% ART Uptake Pigg's Peak Hosp Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 54%57%74%89%74%91%88%95%97%92%91%89%87% ART uptake National 57%58%58%67%69%73%71%69%73%76%76%77%80%
Results -3 Qualitative HCWs embraced QI principles and have shown ownership of solutions and thus ensuring sustainability of improvements. Expansion of QI in scale and scope Adoption of QI approaches beyond TB/HIV to include HIV services, Laboratory services; The MOH QA programme established, national QA strategic plan developed, printed and due for dissemination QI department started tracking 15 key QI indicators on TB, HIV care and treatment, PMTCT, HTC; Implementing partners started collaborating in the scale up QI intervention across MOH programmes
Results 4-HCWs embraced QI principles and ownership of solutions
Results 5: End-line-Evaluation methods Setting: 11 care and treatment facilities selected to represent all 4 regions and public facility types (clinic, health center, hospital) Provided both TB and HIV services and operational 1 year Population: HIV-positive TB patients identified from TB registers;>15 years and seen between July 1 Sept 30, 2014 Clinical history retrospectively assessed until TB treatment outcome (cure, treatment completion, treatment failure, default, death, transfer out) 466 HIV+ TB patients 240 male (52%), 225 female (48%) Median age 36 (IQR 31 43) for men, 32 (IQR 27 40) for women Facility type: 35% clinic, 24% health center, 41% hospital
Results 6: End-line-Evaluation of the TB treatment outcomes for HIV-positive TB patients in Swaziland 189 (41%) already on ART; 274 (59%) started ART after TB treatment initiation; 5 (1.8%) did not receive ART within 6 months 99% of HIV-positive TB patients on ART by 6 months 90% initiated ART within 8 weeks; median time 15 days Possible effect of QI, taskshifting and TB/HIV integration efforts 86% TB cure or treatment completion TB Treatment Outcome N % Cured 154 56.2 83 30.3 Completed Failure 7 2.6 Default 8 2.9 Died 16 5.8 Transfer 5 1.8 Out Missing 1 0.4 TOTAL 274
Lessons learned Government commitment and leadership is critical for sustainability of QI Before large scale implementation, testing changes on a small scale results in more rapid scale up and success, with new sites quickly building on the work from the initial sites QI methods can make significant contributions in HSS and has the potential to enhance the use of limited resources available from government and partners to achieve a shared goal.
ACKNOWLEDGEMENTS