Prof E Seekoe Head: School of Health Sciences & ASELPH Programme Manager

Prof E Seekoe Head: School of Health Sciences & ASELPH Programme Manager

Strengthening health system though quality improvement is the National Health Ministers response to the need for transforming policy to ensure equity and provision of quality services. A priority in the health sector s 10 point plan for 2009-2014. Minister emphasised important areas of improvement that must continue beyond 2015: Achievement of MDG 4,5 and 6 Re-engineering of PHC in preparation for NHI is a focus for QI Introduction of National Health Insurance (NHI)

Quality Improvement is defined as achieving the best results within available resources. It includes activities that are designed to improve acceptability, efficiency and effectiveness of service delivery. It is achieved through combined efforts of the team. A powerful tool which encourages problem solving and creative thinking that results in changes being implemented using resources to improve outputs and critical health care out comes.

Critical component of implementing the NHI is ensuring that quality care as defined by National Core Standards and is delivered in all Public Health Facilities. A guide has been developed to encourage culture of QI in Health Care establishments across SA. The current health care system can be defined as How things are done now

Consortium conducted a comprehensive audit of 3 880 Public Health facilities focusing on (range of health services, facility profile, condition, availability and functioning of medical equipment, including an age analysis of equipment to determine replacement plan). Results on priority areas: Patient safety 34% Positive and caring attitudes 30% Waiting areas scored the highest compliance to vitality measures at 68% Functionality of clinical services at 38%

PHC facilities scored lower than hospitals in all priority areas Shortage of Dental, Therapeutic (Audiology, Speech Therapy, Psychology, EMS) and Laboratory services at PHC level. Physical infrastructure challenges: Facilities without electricity especially in rural areas Mud Clinics Water Supply depending on Rainfall Shortage of Medical & Supplies High Percentage of internet failure

Results were used to develop improvement plans for each audited facility. Resources mobilized and budget moved to provinces. A balance of (Quality, Efficiency, Profitability in achieving goals) was ensured. It is evident that SA s should embrace the culture of QI. NDoH continued with implementation of QI projects: Ideal Clinic, IMCD and Mom Connect

Clinic providing the ideal Primary Health Care (PHC) through action learning approach. Started by NDOH in July 2013 as a systematic way of improving deficiencies in PHC clinics in the Public sector identified through the NDoH baseline audit of 2011-2012. Piloted in 10 NHI Districts. Focussing on correcting weaknesses. Elements are: Client centeredness Working with community it serves Applying all the relevant resources at its disposal to provide quality PHC services Using its referral Network for benefits of Clients Ideal Clinic status is seen through a score of 80% and higher in an OHSC inspection It has 10 components aligned with OHSC domains

Assist facility operational managers in ensuring compliance and implementing the six priority areas of the National Core Standards for health establishments. Introduced in 3 provinces (Northwest, Gauteng and Mpumalanga to improve quality of PHC services. Improving staff values and attitudes, waiting times, cleanliness: through the facility re-organisation component of the ICDM model Patient safety and security, infection prevention and control: through the clinical management of the ICDM model Availability of medicines and supplies: through the system strengthening component of the ICDM

Booking of Chronic patients to reduce overcrowding and decongesting traffic at facilities e.g. (580 HIV in a clinic, 60 wellness, 780 non communicable= 1420 chronic care) divide by 20 days= 71 patients of wellness, ART and non communicable daily Re-organises the integration of patient flow

MCWH: scheduled/planned visits Patients for acute care and minor ailments: daily for unscheduled/unplanned visits Stable care clients : scheduled/planned visits Chronic Care Patients ART Non communicable diseases EPI scheduled/planned visits Advantages of ICM Good scheduling of patients at facilities Community involvement on daily basis Staff capacity Stability in chronic drug supply management Quality of care Staff not burned out

Main Question Is quality improvement at the level of facilities a Culture?

Analysis of DHIS Documents Discussions with District Manager and Team (District Deputy Directors: General Administration Information, Management Specialist Team, Information Management, Communicable Diseases, TB, Occupational Health and Safety, Planning and Reporting, Quality Assurance, HIV/AIDS & TB, Sub- District Team and Clinic Supervisors)

DHIS data indicators will be presented according to: Performance for 2012/2013 Annual target 2013/2014 Performance for 2013/2014

DHIS indicator Couple year protection rate annualised Performa nce 2012/2013 Annual Target 2013/2014 Performa nce 2013/20 14 27,5 36.0 29.9 ANC 1 st visit before 20 weeks rate 37.7 60.0 46.2 Antenatal Client initiated on ART rate Maternal mortality in facility ratio (annualised) 61.9 90.0 89.4 18.6 130.0 86.3 Mother postnatal visits within 6 days rate 65.8 79.0 68.7

DHIS indicator Performa nce 2012/2013 Annual Target 2013/2014 Performa nce 2013/2014 Infant 1 st PCR test around 6 weeks uptake rate Infant exclusively breastfed at HepB 3 rd dose rate Immunisation coverage under 1 year (annualised) Children under 5 years diarrhoea case fatality rate Children under 5 years severe malnutrition case fatality rate 212.2 100.0 125.6 0.0 32.0 40.0 65 90.0 69.6 8.1 4.0 5.3 18.0 11.0 8.7

Low maternal health performance-lack of access Distance from hospitals Public Transport unaffordable (R1000 per trip to hospitals) Lack of EMS Services Cultural beliefs leading to late presentations to health facilities PCR Not controlled at one facility Cross boundaries Denominator-Hospital Numerator-Clinic Immunisation Coverage affected by Drugs dependent on OR Tambo depo which is due to be closed Sub-districts working with PE do not have challenges

Discussions with team: For a team to function effectively the following were ensured: Leadership provided by the DM. Policies that guided support of the leadership, clinical & administration side as directed by the 6 building blocks of WHO. Solutions required creativity. Staff communication and buy in were ensured. Procedures to facilitate team work were set. Support of the team with resources such as staff, funding and buildings. Clear expectations were set.

2012 Focus on QI 6 Priorities areas & None negotiables Linking Priorities to Health Outcomes Conducted a 2 day Nurses Summit Taking Nurses back to basics Award Ceremony for the best performing health facility to create the culture of improving quality Process: Committee was elected including a QI Manager adjudicated and verified data of facilities Emphasised ethics (due to high cases of litigation and poor health outcomes)

Based on health indicator performance Current Strategy No summit for 2013 Quality Reviews were conducted Boardroom presentations at cluster and ward level Robot & Dash board Analysis done Focussed on output No4 NSDA (National Service Delivery Agreement)

Identification of non- performing clusters or wards Benchmarking and teams learning from each other Team approach to strengthen one another (facilities) Sharing of results (positive or negative) Sharing resources (drugs and transport) Look at supporting facilities Improve their patient satisfaction

Contribution of PHC Outreach Teams, Ward Based Team, Households and Family Improved quality of data: Guides the team in making decisions and planning for better health services provision Allocation of funding and resources to facilities

Focus will be on performance indicators on top of the 6 priorities of the National core standards as well as improved quality of data. Improvement will be noted in 2015/2016 where centres that performed will be awarded.

Health Services delivery support through: MOU and SLA (in process) Being part of the Summit Training (Health Science institute) on Leadership and Management, Clinical Care, Health Research, Administration, Pharmacy Assistants and community health care workers (formal and informal programmes) Research (Surveys on Households, Health Facilities Quality and Governance, Hospital Cost, Ward Based Primary Health Care Teams and Community Health Worker Training and Payment Model)

QI culture exists at Amatole District in the Eastern Cape. Mostly based on team approach. Challenges due to the rural nature of the district are continuously being monitored and resolved. Statistics shows significant improvement as compared to 2012/2013.

ECDOH District Management Team District Manager District Deputy Managers General Administration TB Information Management Occupational Health and Safety Specialist Team Planning and Reporting Communicable Diseases Quality Assurance Information Management HIV/AIDS & TB Sub-District Team Clinic Supervisors