QUALITY IMPROVEMENT CHANGE PACKAGE

STRENGTHENING UGANDA S SYSTEMS FOR TREATING AIDS NATIONALLY QUALITY IMPROVEMENT CHANGE PACKAGE Synthesis of the most robust and effective interventions to institutionalize continuous Quality Improvement Approaches in SUSTAIN supported hospitals in Uganda AUGUST 2017 The SUSTAIN project is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement number 617-A-10-00007-00. The project team includes prime recipient University Research Co., LLC (URC) and sub-recipients; The AIDS Support Organization (TASO), Integrated Community Based Initiatives (ICOBI), Uganda Catholic Medical Bureau (UCMB), Uganda Protestant Medical Bureau (UPMB), Uganda Muslim Medical Bureau (UMMB), Child Chance International (CCI Uganda), AIDS Information Centre (AIC) and ACLAIM Africa.

Quality Improvement Change Packages Series The purpose of the quality improvement packages is to provide a synthesis of the most robust and effective QI interventions for effective HIV programming. The quality improvement packages series thematic areas include: prevention of mother to child transmission, laboratory, monitoring and evaluation, adolescent friendly health services, voluntary medical male circumcision, nutrition, HIV care and treatment, supply chain, Tuberculosis, and quality improvement. USAID/SUSTAIN acknowledges the work of the project staff, technical officers at MoH, and counterparts at supported facilities who have been instrumental to the project s many successes through implementation of the quality improvement interventions. The publication and production of these packages, as well as the work of the SUSTAIN project, was made possible by the generous support of the American people through USAID. The SUSTAIN project is led by University Research Co., LLC and works in partnership with: The AIDS Support Organization (TASO), Integrated Community Based Initiatives (ICOBI), Uganda Catholic Medical Bureau (UCMB), Uganda Protestant Medical Bureau (UPMB), Uganda Muslim Medical Bureau (UMMB), Child Chance International (CCI Uganda), AIDS Information Centre (AIC) and ACLAIM Africa, under Cooperative Agreement No. 617-A-10-00007-00. The views and opinions expressed here do not necessarily state or reflect those of USAID or the United States government. Quality Improvement Change Package i

Contents Quality Improvement Change Packages Series... i Acronyms... iv Introduction...1 Harvest Meeting...3 Change package for institutionalizing the culture of quality improvement at high-volume hospitals in Uganda...7 Intended Use...7 Improvement Aim 1: To establish quality improvement teams in all departments in SUSTAIN supported hospitals in Uganda...7 Improvement Aim 2: To improve of QI interventions at all SUSTAIN supported hospitals in Uganda...10 Improvement Aim 3: To establish a culture of sharing learning emanating from QI interventions at all SUSTAIN supported hospitals in Uganda... 14 Key Challenges...18 Moving Forward...19 Appendix: List of contributors during the harvest meeting...20 Quality Improvement Change Package iii

List of Acronyms ART Antiretroviral therapy CME Continuing Medical Education CPD Continuing Professional Development CQI Continuous Quality Improvement HC Health Center MOH Ministry of Health PDSA Plan-Do-Study-Act PMTCT Prevention of mother-to-child transmission QAD Quality Assurance Department QI Quality Improvement RRH Regional Referral Hospital SUSTAIN USAID Strengthening Uganda s Systems for Treating AIDS Nationally TB Tuberculosis USAID United States Agency for International Development VMMC Voluntary Medical Male Circumcision iv Quality Improvement Change Package

Introduction Since 2010, the United States Agency for International Development (USAID) has been working with Uganda s Ministry of Health (MoH) to improve HIV and AIDS service delivery at select health facilities through the Strengthening Uganda s Systems for Treating AIDS Nationally (SUSTAIN) project. Over the last seven years, the SUSTAIN project has aimed to: n Support the MoH to scale up Prevention of Motherto-Child Transmission of HIV (PMTCT) and Voluntary Medical Male Circumcision (VMMC) as HIV infection prevention interventions within selected public regional referral hospitals (RRHs) and general hospitals Table 1: List of SUSTAIN supported health facilities Name of Facility Level of Facility Abim General hospital Arua Regional referral hospital Fort Portal Regional referral hospital Gulu Regional referral hospital Hoima Regional referral hospital Jinja Regional referral hospital Kaabong General hospital Kabale Regional referral hospital n Ensure provision of HIV care and treatment, laboratory and tuberculosis (TB)/HIV services within selected public RRHs, general hospitals and health center (HC) IVs n Enhance the quality of PMTCT, VMMC, HIV care and treatment, laboratory and TB/HIV services within selected RRHs, general hospitals and HC IVs, and n Increase stewardship by the MoH to provide sustainable quality HIV prevention, care and treatment, laboratory and TB/HIV services at project-supported healthcare facilities. Kawolo Kotido Lira Masaka Matany Mbale Moroto Mubende Soroti General hospital Health Centre IV Regional referral hospital Regional referral hospital General hospital Regional referral hospital Regional referral hospital Regional referral hospital Regional referral hospital The USAID/SUSTAIN project has supported 17 health facilities to institutionalize practices of continuously improving the quality of health services they offer through embracing the culture of continuous quality improvement (CQI). At the national level, SUSTAIN has supported the Ministry of Health to launch and implement the National Quality Improvement Framework and Strategic Plan, and the functionality of quality improvement (QI) structures at both national and sub-national levels. Within hospitals, SUSTAIN supported the establishment and functionality of QI structures at different levels (facility, major departments and units) of 17 hospitals across the country. The project has provided technical, coordination and operational support to these 17 health facilities to institutionalize the culture of continuous quality improvement, in accordance with the Ministry of Health policies and guidelines (National Quality Improvement Framework and Strategic Plan, Supervision and Mentorship guidelines). Through ongoing onsite mentorship and coaching sessions, facilities have been supported to establish QI committees and teams to innovate and test ideas, document their improvement processes and share their successes with colleagues grappling with similar challenges. SUSTAIN s approach to QI was guided by collaborative learning and the Model for Improvement (shown on the right) that was developed by Associates in Process Improvement and uses the Plan-Do-Study-Act (PDSA) cycles to accelerate improvement in projects. This Model for Improvement has two parts of equal importance: Quality Improvement Change Package 1

1. Answers to three fundamental questions: a. What are we trying to accomplish? b. How will we know whether a is an improvement? c. What s can we make that will result in improvement? What are we trying to accomplish? How will we know whether a is an improvement? What s can we make that will result in improvement? 2. The PDSA cycle that tests and implements s in actual work settings SUSTAIN technical advisors, led by their Quality Improvement Technical Advisor and the Ministry of Health technical staff from various departments, particularly HIV/ AIDS and quality assurance department (QAD), supported the formation of multi-disciplinary improvement teams at the department levels in each of the 17 supported health facilities. It was these teams that implemented the CQI approach. This improvement collaborative approach, where teams work to identify and address a myriad of challenges affecting the content and processes of care, is consistent with the Ministry of Health s Quality Improvement Framework and Strategic Plan. On a monthly basis, QI teams were supported to identify gaps in their area of care, prioritize specific areas to improve, and then develop, test and implement innovative ideas following iterative PDSA cycles. Peer learning fora were organized for different facility teams to come together and share their innovation and findings at central level (learning sessions) and during the national QI conference. This package represents a synthesis of the most robust and effective s in institutionalizing the culture of continuous quality improvement in 17 health facilities (12 RRHs, three general hospitals and two HC IVs) in Uganda. The ideas recommended here are based on SUSTAIN s experiences and observations over the last six years in: a) establishing QI committees and teams at hospital and departmental levels b) getting QI teams to document their improvement processes, and c) supporting QI teams to share learning and experiences with peers and other stakeholders. 2 Quality Improvement Change Package

Harvest Meeting After six years of project implementation, hospital administrators, departmental heads, records officers and QI focal persons from the 17 health facilities gathered for a harvest meeting in August 2016 to reflect on the improvements they had registered in institutionalizing QI in their health facilities. During the same meeting, participants were also asked to closely examine the causal pathways that led to those improvements. Guided by their experiences at both the hospital and departmental levels, participants agreed on a set of best practices that they felt could benefit other health facilities in the country and the region to set up a culture of continuous quality improvement. While divided in small groups, participants discussed the ideas they had tested, the steps they had followed in introducing and testing these s, and the results they had observed. Group discussions were followed by plenary sessions, in which the ideas were discussed further by a larger and wider group of participants. The plenary sessions were also used as a platform to evaluate and score the different ideas based on their relative importance, level of simplicity and scalability. All the parameters (relative importance, simplicity and scalability) were scored 1-5 by the participants. A score of 1 (one) for relative importance, for example, means that that idea was not important, yet a score of 5 for scalability means the is easily scalable. Figure 1 explains the scoring, and how each value should be interpreted. The average scores are presented in Tables 2 4. Tables 5 7 provide a comprehensive list and description of all the ideas tested, with notes on the specific steps taken to implement the, the observed results and the number of facilities (scale) that implemented the specific s. Figure 1: Guide to interpreting the rating of ideas 1 2 3 4 5 n Change was not n Only important n Change can n Change was n Change was important in a few aspects be important important very important n Change idea was n Change is often n Change can n Change is n Implementation too complex complex be complex sometimes is always smple n Change is n Scalable with n Scaling simple n Change is easily difficult to scale significant requires effort n Scalable with scalable challenges limited effort Quality Improvement Change Package 3

Table 2: Rating of s introduced to support hospitals establish QI teams SN Change idea Number of facilities testing this Relative importance Rating Criteria Simplicity (not difficult or complex) Scalable Total score Average overall score 1. Orientation of staff members in QI during staff meetings 2. Introducing QI concepts, tools and structures to hospitals top management 3. Provision of refreshments to all staff during QI meetings 4. Assignment of specific roles to individual members on QI teams 5. Writing appointment letters for QI team members, which motivates them 6. Discussion of QI projects allocated time during staff meetings 7. Coaching and mentorships by MOH and IPs covering how facilities can establish QI teams 8. Internal supervisory/mentorship teams formed and trained 11 4.8 4.5 4.3 13.7 4.6 11 4.9 4.8 4.4 14.2 4.7 11 4.8 4.2 3.8 12.8 4.3 11 4.8 4.0 3.6 12.5 4.2 11 4.9 4.2 3.8 13.0 4.3 11 4.8 3.5 3.5 11.9 4.0 12 4.9 4.1 3.7 12.7 4.2 12 4.9 4.2 4.2 13.2 4.4 9. Supervision checklist developed 11 4.9 4.3 3.6 12.8 4.3 Table 3: Rating of ideas introduced to improve of QI work SN Change idea 1. Sensitization of staff on importance of at various levels 2. SUSTAIN oriented staff on QI journals, what they are and how to use them Number of facilities testing this Relative importance Rating Criteria Simplicity (not difficult or complex) Scalable Total score Average overall score 12 4.9 4.2 3.6 12.8 4.3 11 4.8 4.6 4.3 13.8 4.6 3. Writing minutes of QI meetings with action points 12 4.9 4.2 3.9 13.0 4.3 4. Filing of QI minutes, action plans, activities by QI focal persons 5. SUSTAIN introduced the use of QI journals in HIV/ antiretroviral therapy (ART) clinics, later spread to other departments 6. Submitting requests for booklets and other stationary to SUSTAIN and other supporting implementing partners 12 4.8 4.2 3.7 12.8 4.3 11 4.8 4.6 4.5 13.8 4.6 8 4.4 3.8 3.4 12.2 3.9 4 Quality Improvement Change Package

Table 3: Rating of ideas introduced to improve of QI work, SN Change idea 7. Performance review and bench marking of performance on 8. Selection of a focal person for taking minutes during meetings 9. Training nurse interns to assist with using QI journals, and consistently updating them 10. Utilizing the support of peers and volunteers in arranging and filing journals 11. Reminder placed on walls emphasizing the importance of accuracy and completeness of data captured in journals Number of facilities testing this Relative importance Rating Criteria Simplicity (not difficult or complex) Scalable Total score Average overall score 12 4.7 3.7 3.4 11.8 3.9 10 4.5 4.2 3.9 12.6 4.2 7 4.4 3.1 2.8 10.3 3.4 10 4.9 3.8 3.7 12.4 4.1 11 4.7 4.2 4.0 12.8 4.3 Table 4: Rating of ideas introduced ensure learning sessions are conducted and other sharing opportunities are availed SN Change idea 1. Approvals for study leave conditioned on attendance of at least 10 facility learning sessions in a year, as evidenced in the attendance book 2. Provision of facilitating allowances to presenters/ leaders of learning sessions 3. Provision of drinks and snacks (refreshments) to participants in learning sessions 4. Scheduling and communicating continuing professional development 5. Making provisions for alternative staffs to attend continuous medical education CMEs on behalf of their colleagues 6. Delegating student interns to remain on wards and/ or continue seeing patients while staff members attend CME 7. Sharing QI projects captured in the journal with all departmental in-charges 8. Onsite coaching by peers and QI focal persons, facilitating spread of learning between facilities/ departments Number of facilities testing this Relative importance Rating Criteria Simplicity (not difficult or complex) Scalable Total score Average overall score 4 4.2 3.3 2.7 10.2 3.4 5 4.7 3.5 3.2 11.4 3.8 11 4.8 4.4 3.8 13.0 4.3 12 4.8 4.2 3.7 12.8 4.3 6 4.2 3.8 3.4 11.3 3.8 11 4.2 3.7 3.3 11.2 3.7 9 4.8 3.7 3.7 12.2 4.1 11 4.8 4.2 3.8 12.8 4.3 Quality Improvement Change Package 5

Table 4: Rating of ideas introduced ensure learning sessions are conducted and other sharing opportunities are availed, SN Change idea 9. Morning assembly at departments once a week, used to share information 10. CME conducted on scheduled days for the different departments, ensuring that they don t conflict and staff are available to attend them 11. Holding performance review meetings, quarterly and annually, for departments to share progress made with their QI projects 12. Selection of CME topics done by CPD focal person in consultation with different units/departments 13. Health education for patients and CPDs for staff conducted concurrently to minimize patient waiting times 14. Holding annual hospital day/week for staff to receive community views about the services they are receiving 15. Holding quarterly general staff meetings, and scheduling slots for sharing learning 16. Monthly senior manager s meetings, that provide platforms for knowledge sharing 17. Holding weekly staff (Monday morning) meetings to review facility performance Number of facilities testing this Relative importance Rating Criteria Simplicity (not difficult or complex) Scalable Total score Average overall score 7 4.1 3.1 2.8 9.9 3.3 9 4.7 4.2 3.9 12.8 4.3 10 4.9 3.8 3.4 12.1 4.0 12 4.8 4.1 3.8 12.7 4.2 1 4.6 2.6 2.4 9.6 3.2 3 4.6 3.3 2.9 10.8 3.6 10 4.8 4.2 3.8 12.8 4.3 10 4.5 3.5 3.4 11.5 3.8 9 4.3 3.4 3.4 11.1 3.7 6 Quality Improvement Change Package

Change package for institutionalizing the culture of quality improvement at high-volume hospitals in Uganda Intended Use Hospital administrators, department heads and QI focal persons are the primary intended users of package. Others like the Quality Assurance Department at MOH, partner organizations supporting QI initiatives and members of the district health team will find ideas described in the following pages helpful. It should be noted that QI teams should not simply copy and paste these ideas, rather, they should adapt them to suit the specific circumstances and contextual challenges they are facing. The next section provides a detailed description of what s led to improvement, and how such improvement was arrived at. The section is structured into three subsections, corresponding with the three improvement aims that the SUSTAIN project set out to achieve in relation to institutionalizing QI. Each sub-section outlines the QI concept applied, the problem being addressed, the ideas tested, steps followed in introducing each idea and the evidence that the specific led to improvement. Improvement Aim 1: To establish quality improvement teams in all departments in SUSTAIN supported hospitals in Uganda Table 5: Specific s introduced to support the establishment of QI teams in all departments of SUSTAIN supported hospitals Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Build technical competencies of staff QI teams hadn t been formed due to lack of knowledge on QI concepts Orientation of staff members in QI during staff meetings Through CMEs hospital management introduced ART staff to the key QI concepts: including QI principles, steps, tools and model for improvement Increasingly more hospitals and departments formed QI teams 11 health Orientation was guided by training manuals and job aids provided by SUSTAIN and MOH From ART clinic, other departments were also trained in QI SUSTAIN provided financial support for the meetings Quality Improvement Change Package 7

Table 5: Specific s introduced to support the establishment of QI teams in all departments of SUSTAIN supported hospitals, Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Build technical competencies of staff Hospital top management had not been involved in QI, and was not supportive Introducing QI concepts, tools and structures to hospitals top management QI advisors from SUSTAIN held briefing meetings with top leadership of supported hospitals, introducing the QI concepts They also introduced the hospital QI focal person, who had been selected from amongst hospital staff In subsequent CME sessions, top leadership would participate Top management was thereafter tasked with supervising and monitoring the progress of QI projects in the different departments QI teams that had been formed at hospitals started meeting regularly, and getting identifying ideas that could lead to improvement 11 health Only those health workers who had attended QI trainings and workshops had knowledge on QI, and its application in health care Coaching and mentorships by MOH and IPs covering how facilities can establish QI teams Ongoing onsite coaching sessions were used to impart QI knowledge to all staff since such sessions targeted all members of the department/facility Different topics would be covered during the different coaching sessions, in response to the specific needs expressed by the health workers Key QI principles would be repeated during the subsequent sessions, both as a refresher for old staff but also as an introduction for new staff Knowledge on QI spread throughout all members of departments and facilities, and not just a few 12 health Provide incentives for staff to behavior Non-functional departmental QI committees Provision of refreshments to all staff during QI meetings SUSTAIN liaised with the hospital management to provide drinks and light snacks during departmental QI meetings These items would be picked on credit from the local canteen, with approval from the QI focal person Hospital staff became motivated, and would actively participate in QI meetings 11 health Similar refreshments would also be provided during CMEs/CPD sessions The resulting bill would be settled by the SUSTAIN finance team within a month Low motivation and interest to participate in QI activities Writing appointment letters for QI team members, which motivates them Hospital administrators wrote official letters to QI team members officially recognizing them as members of the hospital/department QI teams This sense of recognition encouraged QI team members to work harder on their projects, holding monthly meetings, documenting their processes and monitoring performance results With recognition from the top leadership, staff commitment to QI projects and team work improved 11 health 8 Quality Improvement Change Package

Table 5: Specific s introduced to support the establishment of QI teams in all departments of SUSTAIN supported hospitals, Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Realign individual roles Understaffing had resulted in one-man QI committees, expected to perform all the team roles Assignment of specific roles to individual members on QI teams QI team members assigned specific roles to each of their colleagues, based on interest and capabilities The different roles included a team leader, secretary for taking minutes, mobilizer for convening meetings and a time keeper to ensure promptness of meetings More staff became actively involved in QI meetings, and in the implementation of QI projects 11 health SUSTAIN continuously provided onsite coaching support to the teams, to enable them perform their roles well Deliberately spread learning QI was initially limited to ART clinic QI spread to other departments, and included as an agenda item during staff meetings Initially, QI projects were only being implemented in ART clinic Other departments were supported to establish QI teams, and ART staff acted as peer-topeer mentors to their colleagues in those departments During monthly all-staff meetings, QI would be included as an agenda item and different departments would share progress on their work QI teams were established in all departments and the resulting inter-departmental competition encouraged innovation 11 health Promote ownership at the local level Inadequate (time-limited) and infrequent supervision of QI teams by MOH and IPs Internal supervisory and mentorship teams formed and trained on how to support their peers Hospital QI focal persons identified staff to be on the internal supervisory team These were mainly from ART clinic, since they had the longest experience implementing QI projects. Team was trained by MOH and SUSTAIN coaches on how to supervise, coach and mentor teams During supervision, the team was joined by the hospital administrator/director QI teams started holding meetings more consistently, and documenting their QI projects since they were aware that they were to be supervised every month 12 health Members of this internal supervisory team held monthly meetings with all departments in the hospital and reviewed their QI projects Standardize procedures to eliminate mistakes Unfocused coaching sessions, covering different aspects Supervision checklist developed to guide internal coaching sessions Internal supervision team developed a supportive supervision checklist to guide their monthly QI supervisory sessions with the different departments Checklist was developed in consultation with MOH QI guidelines, and working closely with SUSTAIN coaches It guided the supervisors to check on existence of the QI teams, their composition, frequency of their meetings, minutes of those meetings, and the QI projects teams are working on This guide helped supervision teams establish consistency in the support and coaching they provided to different departmental teams 11 health Quality Improvement Change Package 9

Improvement Aim 2: To improve of QI interventions at all SUSTAIN supported hospitals in Uganda Table 6: Specific s introduced to improve of QI interventions at the SUSTAIN supported hospitals Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Build capacity and competencies of staff Health workers did not see value in documenting their work Sensitization of staff on importance of at various levels Hospital directors communicated to all staff that there were gaps in the of processes of care in their hospitals, and that this a priority they wanted addressed then summoned and held discussions with senior hospital staff, identifying the magnitude of the problem and the departments most affected Departmental heads then sensitized their respective staffs of the importance of, the observed gaps, and how the administration had planned to address them The culture of correctly, consistently and accurately documenting processes of care at OPD, wards, lab and at ART clinics picked up at the supported facilities 12 health In periodical staff meetings, the same message was consistently aired Most health workers did not know how to correctly use the journal, and some had simply forgotten Orientation of all staff on QI journals, what they are and how to use them The need and schedule for trainings would be communicated to the hospital directors, who would (through the QI focal persons) identify the most appropriate persons to benefit from such trainings During these trainings, participants were introduced to the journal and guided on how to fill-in the different sections Structured of QI processes was observed in the supported hospitals 11 health During facility/departmental CMEs, QI focal persons would review and address gaps in their teams understanding of the journals 10 Quality Improvement Change Package

Table 6: Specific s introduced to improve of QI interventions at the SUSTAIN supported hospitals, Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Realign roles and tasks among QI team members QI teams would have no record of responsible persons for their action points Identified a focal person for writing QI meeting minutes and highlighting action points QI focal person identified a secretary from the QI team, whose task was to document proceedings of monthly meetings The team also procured a counter-book from the hospital administration and used it as their minute book During meetings, the team brainstormed on which ideas can address specific challenges and how the ones previously suggested, are performing. These discussions would then be captured in the minute book. Minutes of QI meetings consistently captured action points, responsible persons and performance of tested s 12 health Specific action points would be displayed on the hospital notice boards, with responsible persons and timelines visible to everyone In the subsequent meetings, and during supervision and coaching sessions, these minutes would be referenced QI discussions used to be captured in random note books which could not be traced by the time of the next meeting Filing of QI minutes and action plans to ease reference and retrieval Hospital administrators provided file folders for the QI team, with additional support from SUSTAIN File folders would clearly be labelled and used to keep journals, coaching notes and in some cases meeting minutes QI focal person would take overall responsibility in filing and retrieving QI minutes and other reference Records of QI discussions were neatly filed and retrievable in all facilities that tried 12 health QI focal persons would chair meetings and be responsible for taking minutes, which was ineffective Selection of focal persons for taking minutes during QI meetings Note takers were identified among members of QI teams, and tasked with taking minutes of discussions held during QI meetings The format of these minutes was also agreed upon, and it had to include a list of attendees for that meeting Prior to subsequent meetings, note takers would provide minutes of previous meetings and ensure they are properly filed and accessible The quality of minutes taken during QI meetings greatly improved, making it easy to track improvements and follow-up on action points 10 health Quality Improvement Change Package 11

Table 6: Specific s introduced to improve of QI interventions at the SUSTAIN supported hospitals, Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Avail adequate stocks of the necessary tools Lack of tools, especially journals SUSTAIN distributed copies of QI journals first in HIV/ART clinics, and later spread to other departments SUSTAIN and other IPs supporting QI availed copies of printed journals to various QI teams in the hospitals The QI focal person was the designated custodian of QI tools This was after all staff had been trained on how to utilize the journals In some cases, SUSTAIN provided computers, stationary and printers for supporting of QI work through the resident M&E officers Consistency in use of journals was observed in all health facilities 11 health Tap into existing alliances and resources Hospital budgets were to small and to stretched to address stationary needs of QI teams Submitting requests for stationary to SUSTAIN and other supporting IPs For bulky stationary needs, like printing and photocopying of large volumes of documents, hospitals would request for assistance from IPs QI focal persons and hospital directors would contact IPs, with specific needs for computing, printing and/or photocopying services Stationary needs were addressed not only QI work but also for other aspects of health service delivery 8 health facilities tested this Understaffing in hospitals made it difficult for health workers to allocate adequate time to Training nurse interns to assist with QI Nurse interns were identified as potential contributors to QI processes They were trained on how to use the journal, and how to take minutes during QI meetings In addition, these interns also helped with filing and retrieval of journals Nurse interns eased the burden of off the other health workers, who spend time taking care of patients 7 health facilities tested this Limited attention was given to proper filing of journals Utilizing the support of expert clients and volunteers in arranging and filing journals Hospital QI focal persons identified expert clients and volunteer staff with interest in supporting QI work The volunteers and expert clients were then trained in proper filing of journals in clearly labeled box files as per technical area, improvement objective or period Appropriate filing enabled efficient retrieval and future reference Filing of journals at supported hospitals greatly improved 10 health 12 Quality Improvement Change Package

Improvement Aim 3: To establish a culture of shared learning emanating from QI interventions at all SUSTAIN supported hospitals in Uganda Table 7: Specific s introduced to facilitate the establishment of a culture of sharing lessons learned Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Provide incentives for staff to influence behavior Few staffs were attending CPDs, CMEs and other learning opportunities organized within the hospitals Approvals for study leave conditioned on attendance of at least 10 facility learning sessions in a year, as evidenced in the attendance book To emphasize the importance of continuous learning in the health care practice, hospital administrators conditioned approvals for study leave to consistent attendance of CPD sessions For every staff requesting for study leave, they should have attended at least 10 CPD sessions the previous year Evidence for attendance was picked from the attendance lists of the CPD sessions In the supported hospitals, attendance to CPD and CME sessions improved from 20% to 70%, and the skills picked up during these sessions where evident in the quality of care 4 health facilities tested this Key resource persons were not keen on organizing CPDs as the time invested in preparing and delivering did not seem valued Provision of facilitating allowances to presenters/ leaders of learning sessions Hospital administrators, department heads and CPD focal persons resolved that facilitators of learning sessions should be facilitated For facilitators who would come from other hospitals, they had their transport costs refunded CPD focal persons would liaise with the hospital administrators to have the facilitation allowance ready for each completed session Quality of facilitybased learning sessions improved as facilitators were better motivated 5 health facilities tested this Details of upcoming learning sessions were shared with the departmental heads and hospital directors in advance, allowing for adequate time to plan for the needed allowances Staffs generally had a poor attitude towards attending CPDs, CMEs and other learning opportunities organized within the hospitals Provision of drinks and snacks (refreshments) to participants in learning sessions Hospital administrators approved the provision of soft drinks and snacks as refreshments during professional development sessions Focal person for CPDs would pick items on credit from the hospital canteen or nearby kiosk, and due payment would be done subsequently All attendees were required to register their names, phone numbers and departments, to verify that they attended the learning sessions Attendance to CPDs improved from 20% to 70% 11 health 14 Quality Improvement Change Package

Table 7: Specific s introduced to facilitate the establishment of a culture of sharing lessons learned, Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Give people access to information Dates for CPDs would be communicated late, when many people had already planned for other activities Scheduling and communicating CPD dates early enough, to avoid any conflicting agendas CPD focal persons worked with hospital directors to produce quarterly schedules of planned CPD sessions Schedules for CPD sessions were shared and displayed on notice boards of different departments within the hospital Staff members can plan their monthly activities with complete knowledge of when CPDs are scheduled, and the topics that will be covered Attendance to CPD sessions increased, and episodes of conflicting dates reduced 11 health Focus on the what instead of the who Low attendance of CPD, CME and other learning sessions as targeted participants were often not available Making provisions for alternative staffs to attend learning sessions on behalf of their colleagues Most learning sessions would target a cadre of staff, like doctors, clinical officers or comprehensive nurses In instances where such persons were engaged in other activities, they would totally miss out CPD focal persons relaxed the requirement and allowed representation by staff from the same department, regardless of cadre Proportion of staff attending learning sessions improved amongst hospitals that tested this 6 health facilities tested this Tap into existing alliances and resources Many staff would find difficulty in choosing to attend learning sessions as patients would be left waiting and unattended to Delegating student interns to remain on wards and/or continue seeing patients while staff members attend learning sessions During scheduled learning sessions that were held within hospitals, departmental heads would arrange for interns to remain behind and take care of patients Adequate number of interns would be made available to provide a whole range of health care services as and when there was need However, the senior staff would still be on standby and ready to move if called upon by the interns In hospitals where was tested, efficiency in the provision of care was maintained despite staff taking time off to attend learning sessions 11 health Make deliberate efforts to spread learning Within the same hospitals some departments would have multiple successful PDSA cycles while others would be struggling to even get started Sharing QI projects captured in the journal with all departmental in-charges Hospital administrators facilitated the spread of learning between departments by requiring the early adopted of QI concepts to share their PDSAs with the late bloomers Departmental in-charges of ART clinic and maternity were asked to share their journals with the in-charges of stores and laboratory In-charges to learn from each other the process of introducing s, capturing s in the journals and examples of successful s Uptake of QI concepts improved as in-charges QIpoor departments learned from the work done by their QI savvy peers 9 health facilities tested this Quality Improvement Change Package 15

Table 7: Specific s introduced to facilitate the establishment of a culture of sharing lessons learned, Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Make deliberate efforts to spread learning Within the same hospitals some departments would have multiple successful PDSA cycles while others would be struggling to even get started Onsite coaching by peers and QI focal persons, facilitating spread of learning between facilities/ departments Peer-to-peer coaching would enable colleagues to learn from each other without the pressures of learning from a mentor or external coach Hospital administrators and QI focal persons would identify skilled staff in one department and pair them with less skilled staff from another department (or even from another facility) for purposes of passing on tacit QI knowledge Sharing of successes between peers motivated the weaker QI teams to try out new ideas 11 health Opportunities for sharing QI work limited to monthly departmental QI meetings Morning assembly at departments once a week, used to share information Departmental in-charges worked with QI focal persons to include discussions on QI projects in the weekly morning assemblies Team members were given time-slots to share which ideas they were testing and the results they were observing Other members of staff provided feedback on how the specific QI projects could be improved, or spread to other microsystems of care The sharing of ideas created awareness among all staff of the different ideas their colleagues were testing to improve services 7 health facilities tested this Provide platforms for shared learning Departmental CME would be held on the same day across departments, but this would hinder crossdepartmental participation CME conducted on scheduled days for the different departments, ensuring that they don t conflict and staff are available to attend them Staff could only attend CME of different departments if they were held on different dates from their own Departmental in-charges liaised with CPD focal persons of the different departments to re-align their CPD schedules so that they do not conflict which was especially helpful when discussing QI projects that cut-across different departments Closer collaboration was observed between ART clinics, the lab and TB units of the hospitals that tried 9 health facilities tested this Lack of schedule for departments to hold performance review sessions Holding performance review meetings, quarterly and annually, for departments to share progress made with their QI projects Departmental in-charges, QI focal persons and CPD focal persons worked with hospital administrators to schedule departmental review meetings on a quarterly and annual frequency In preparation for these meetings, teams would synthesize best practices from their QI projects in the previous quarter/year The meetings acted as learning sessions and provided a platform for QI teams to showcase their improvement projects and the results they had registered The competitive spirit of these meetings motivated QI team members to implement several innovative ideas 10 health Departments received improvement ideas from their colleagues, and obtained inspiration on how to overcome challenges 16 Quality Improvement Change Package

Table 7: Specific s introduced to facilitate the establishment of a culture of sharing lessons learned, Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Provide platforms for shared learning Limited opportunities for sharing knowledge among staff Holding quarterly general staff meetings, and scheduling slots for sharing learning During general staff meetings, emphasis was put on sharing and learning from each other Staff from the different departments shared their systematic approaches to problem solving, including the PDSA cycles they implemented For staff who attended external workshops/ trainings during the quarter, they presented key messages they took away from the trainings All health facilities were holding quarterly sharing sessions by 2016. 10 health Presenters during these meetings were rotated, between departmental heads, QI focal persons, nurses or any other staff Limited opportunities for staff to receive feedback from communities Holding annual hospital day/ week for staff to receive community views about the services they are receiving Hospital administrator put up notices in and around the hospital premises communicating the dates and purpose of the hospital week Health workers mentioned the same to their patients, encouraging them to mobilize their colleagues and come for the hospital week Departmental in-charges prepared talking points for the hospital week, and prepared for receiving community members while continuing to see sick patients Health workers obtained valuable feedback on how communities felt about the quality of service and how it can be improved 3 health facilities tested this During the hospital week, health workers shared the wide range of services the hospitals provide, and distinguished between those provided at a fee and those provided free of charge Members of the public provided feedback on how they felt about the services, the aspects that very good and those that need improvement Identify and use a focal person CME topics always about HIV care/ ART Selection of CME topics done by CPD focal person in consultation with different units/ departments Identify a focal person to be responsible for organizing and coordinating CPD and other learning sessions Such a person should develop the learning session schedule and liaise with the different departmental/technical heads to determine appropriate CPD topics Hospitals that tested experienced better organized and enriching CPD sessions 12 health S/he should also coordinate the invitations to targeted staff, organize the venue and ensure all required tools and equipment are in place Quality Improvement Change Package 17

Table 7: Specific s introduced to facilitate the establishment of a culture of sharing lessons learned, Change concept Specific problem being addressed Change ideas tested Steps in introducing the ideas Evidence that the s led to improvement Scale of implementation Do tasks in parallel Long waiting time for patients during staff CPD sessions Health education for patients and CPDs for staff conducted concurrently to minimize patient waiting times On scheduled CPD days for ART clinics, expert clients and nurse interns would be instructed to conduct health education of patients while health workers participated in CPD sessions CPD and health education sessions were structured to last about the same amount of time In the hospital that tried, patients did not feel abandoned while staff were attending CPD sessions 1 health facility tested this In case of emergency cases, health workers could still be called up to provide care Provide opportunities for sharing learning Limited opportunity to share QI work Sharing improvement stories at various national fora Through onsite coaching sessions, SUSTAIN identified health facilities whose innovative ideas resulted in establishment and functioning of QI teams Such teams were supported to write-up their experiences into technical papers that could be either presented at conferences or published in journal articles Health workers were supported to present QI related papers at the National QI conference and at the Pediatric HIV conferences 15 health Key Challenges As expected, some health facilities and improvement teams faced significant challenges while testing the different ideas aimed at institutionalizing QI approaches, which included: n Many health workers viewed QI work as additional assignments that should have been met with extra allowances. Such staff were always hesitant to fully participate in QI activities, and to wholesomely implement the suggested ideas. n Health workers often felt that implementation of QI activities came at the expense of seeing patients. They felt that the effort and time devoted to QI work (like QI meetings and onsite learning sessions) would be put to better use if they were seeing patients. n The idea of providing refreshments during QI meetings and related fora often caused conflicts, and was viewed as not sustainable as it was pinned to SUSTAIN support. n Little integration is seen between performance review and QI activities. 18 Quality Improvement Change Package

Moving Forward To get the best benefit from the ideas in this document, health facilities should establish and cultivate an environment that embraces to nurture improvements. The following ideas can help QI teams in getting started: n Improve Existing national and data monitoring tools need to be accurately and consistently used. It is through these tools that teams will be able to determine whether their performance is stagnating or improving, both before and after introducing these s. n Establish team work For any improvement work to yield positive results, health workers should collaborate and view themselves as members of a team responsible for the different steps in the processes of providing health services. n Analyze the entire process of care, and prioritize After analyzing their processes of care, and identifying existing gaps, health workers should prioritize which challenges need to be and can be tackled first and which ones can wait. Addressing one challenge at a time (while introducing a few s at a time) will enable health workers to systematically monitor the effectiveness of each in addressing a challenge, and the effect of a process gap on the overall service delivery. n Constantly communicate with your patients Improvements are designed to primarily benefit patients. Health workers should constantly seek feedback of their patients on the quality of service they are provided, and whether the s being implemented are benefitting them as well. n Combining performance review activities with QI activities will go a long way in improving evidence based QI work at facilities. In addition to health facility QI teams, other stakeholders have differing roles (as indicated in the table below) in the spread of these ideas as listed in the table below. Ministry of Health District Health Officials Development Partners Ensure the required tools, standard operating procedures and other resources are available throughout all levels of the health system Support coordination, capacity building, support supervision, resource mobilization as they relate to scale-up of QI interventions Supportive supervision, coaching and mentorship of health facilities attempting QI projects Provide technical support and avail resources to bridge funding gaps within the MOH Quality Improvement Change Package 19