chs/urc quality improvement collaborative project change … · 2019-02-19 · studenic and neeraj...

Center for Human Services

CHS/URC Quality Improvement Collaborative Project

Change Package

February 2019

Quality Improvement

Collaborative to Improve Access

to and Use of Quality Assured

Viral Load Test Results at

District and Site Level

Throughout Malawi

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Acknowledgements This project was supported by The Bill & Melinda Gates Foundation (BMGF) Investment ID

OPP1158420. The Change Package was prepared by Dyson Mwandama, Chikondi Mendulo, Amy

Studenic and Neeraj Kak.

Malawi Ministry of Health, Department of HIV/AIDS

We acknowledge the Malawi Department of HIV/AIDS for their enormous contributions and support for

the entirety of this process. We would also like to thank the District Health Management Teams in the

participating districts for their willingness and efforts to participate in the implementation in the quality

improvement initiatives and approaches.

CHS-URC Headquarters

We would like to thank the CHS-URC headquarters team led by Neeraj Kak. Thanks to the technical team

including Amy Studenic and for their tireless support and guidance.

Quality Improvement Teams

We sincerely thank all the quality improvement team members and team leaders who successfully

engaged in the quality improvement work.

DISCLAIMER

The contents of this report are the sole responsibility of Center for Human Services (CHS)/University

Research Co., LLC (URC) and do not necessarily reflect the views of the Bill & Melinda Gates

Foundation.

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Table of Contents Acronyms ..................................................................................................................................................... 4

Project Background .................................................................................................................................... 5

Document Overview .................................................................................................................................... 5

CHS-URC Continuous Quality Improvement Approach ....................................................................... 5

Key Indicators Targeted for Improvement .............................................................................................. 6

Proportion of clients eligible for VL testing with sample collected ......................................................... 7

Proportion of VL results returned to facility within one month of collection. .......................................... 7

Proportion of clients with unsuppressed VL completing IAC .................................................................. 8

Summary of Successful Change Ideas ....................................................................................................... 9

Health promotion engagement with ART clients ...................................................................................... 9

Viral load and EID test results management and data quality and documentation ................................... 9

Work/client flow mapping modification ................................................................................................... 9

Facility staff modification ....................................................................................................................... 10

Health worker capacity building ............................................................................................................. 10

Enhanced coordination with molecular laboratories ............................................................................... 10

Enhanced coordination with sample/result transportation provider on sample transport ....................... 10

Enhanced district partner’s engagement ................................................................................................. 10

Detailed Change Package ......................................................................................................................... 11

Appendix 1: Summary of Health Facilities Included in Project ........................................................... 16

Appendix 2: Quality Improvement Team Composition ........................................................................ 17

Appendix 3: Summary of Change Ideas Tested ..................................................................................... 18

Change: To maintain high initiation rate of clients on ART after testing positive ................................. 18

Change: To increase the proportion of clients that meet their VL appointment dates ............................ 19

Change: To increase the proportion of clients with VL samples collected at 6 Months ......................... 20

Change: To improve viral load sample collection at all routine milestones ........................................... 21

Change: To increase proportion of clients with documented results in registers and client card ........... 22

Change: To increase percentage of VL results entered into electronic database .................................... 23

Change: To increase proportion of clients with HVL that are notified of their results ........................... 24

Change: To increase the percentage of clients with HVL results enrolled on intense DSD model ........ 26

Change: To increase the proportion of clients with HVL that complete IAC sessions ........................... 27

Appendix 4: Results of Tested Change Ideas ......................................................................................... 28

Appendix 5: Methodology for Harvesting Change Ideas ...................................................................... 34

Appendix 6: VL and EID Harvesting Change Ideas Tool ..................................................................... 35

Appendix 7: Example Daily Health Talk Roster .................................................................................... 37

Appendix 8: Example of Optimized Client Flow ................................................................................... 38

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Acronyms

BMGF Bill & Melinda Gates Foundation

CHS Center for Human Services

CHW Community Health Workers

CQI Continuous Quality Improvement

DHO District Health Office

DSD Differentiated Service Delivery

EID Early Infant Diagnosis

HC Health Center

HDA HIV Diagnostic Assistants

HSA Health Surveillance Assistants

HTS HIV Testing Services

HVL High Viral Load

IAC Intensive Adherence Counseling

M2M Mother 2 Mother

OPD Out Patient Department

PDSA Plan Do Study Act

PLHIV People Living With HIV

QI Quality Improvement

QIP Quality Improvement Projects

QIT Quality Improvement Teams

R4H Riders for Health

URC University Research Co., LLC

VL Viral Load

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Figure 1: Model for Improvement

Project Background

The Quality Improvement Collaborative to Improve Access

to and Use of Quality Assured Viral Load Test Results at

District and Site Level in Malawi began in 2017 with

funding from the Bill and Melinda Gates Foundation and

implemented by the Center for Human Services (CHS), an

affiliate of University Research Co., LLC (URC). The

project aims to define, share and ensure effective

implementation of good practices in providing access to and

ensuring use of HIV viral load testing to improve care of

people living with HIV (PLHIV) at five facilities in each of

four focus districts: Balaka, Dedza, Karonga and Mchinji (20

facilities total). See Appendix 1 for a summary of the

facilities supported by project activities. The project has five

key objectives:

1. Improving access to quality laboratory services

2. Promoting district level collaboration in quality

management systems

3. Improving use of laboratory data – specifically viral

load results – for managing HIV patients

4. Proving technical support to improve patient centered care

5. Improving laboratory infrastructure

Document Overview

The overall purpose of this document is to outline the successful interventions tested to date through the

Quality Improvement Collaborative project aimed at improving access to and use of quality assured

laboratory data for the management of patients living with HIV/AIDS in Malawi. First the document

provides an overview of the continuous quality improvement approach used and key indicators tracked to

measure performance across the viral load (VL) and early infant diagnosis (EID) testing cascades. The

remainder of the document describes successful change ideas, or quality improvement interventions,

identified and tested during the project that could be scaled up and spread to improve access to and use of

quality assured viral load and EID testing for patient management within and outside of Malawi.

CHS-URC Continuous Quality Improvement Approach

Continuous quality improvement (CQI) is often defined as the

group of activities, structures and values that an organization

develops, allowing it to systematically measure, report and improve

the quality of its main healthcare processes. CHS-URC’s CQI

approach focuses on reviewing and improving processes to ensure

that health care delivery is effective, efficient, equitable and

responsive to clients. Using quality improvement (QI) methods,

providers can identify quality gaps between desired practices (what

the evidence indicates are best care practices to positively affect

patient outcomes) and the actual practice at a health care facility.

QI approaches mobilize various levels of health care providers and

managers, give them a framework to solve problems, and build on

their insights and efforts. The model for improvement (Figure 1),

frames improvement efforts for providers working in teams by

focusing on client needs and using data to implement and test

The purpose of this change package is to provide a synthesis of the most robust and effective quality improvement (QI) interventions for improved access to and use of viral load testing for patient management in Malawi. This change package represents a synthesis of the strongest and most effective change ideas tested through continuous QI approaches at 20 health facilities in Malawi since 2017. The change package is a result of activities which included:

1) establishing QI teams at hospitals and health centers;

2) mentoring QI teams to document their improvement processes; and

3) supporting QI teams to share learning and experiences with peers and other stakeholders.

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Figure 2: Activities and Bottlenecks Across Testing Phases

changes to the care system. The model starts with teams discussing and answering three questions: 1)

What are we trying to accomplish?; 2) What changes can we make that will result in an improvement?;

and 3) How will we know if that change is an improvement?

Using the answers to the above questions as their guide, teams test and implement changes in the care

delivery system to improve results. The power of quality improvement is its focus on making iterative

changes in the processes that make up health systems and on consistently measuring the results of these

changes on quality of care and health outcomes. Making changes in how specific tasks are performed or

how care is organized and tracking the effects (positive and negative) of these changes allows health care

workers to determine what changes lead to improvements in compliance with standards and outcomes.

This CQI approach is implemented by clinical QI teams at district hospital and health center levels who:

• Conduct regular chart audits to track key indicators

• Develop and implement facility level quality improvement plans

• Develop and test changes, solutions and approaches to reduce identified gaps

• Meet regularly to review progress and track improvements in patient management towards viral

suppression and other key outcomes

While the project baseline assessment revealed the existence of quality improvement teams (QITs) in all

assessed districts, few were functional and most lacked terms of reference or understanding of their roles

and responsibilities. Since June 2017, the project has been working steadily to revamp QITs at the facility

and district levels in the four target districts. This included setting up and developing terms of reference

for QI teams, training of QI champions on CQI in HIV VL and EID at each of the 20 participating

facilities, providing routine mentorship, and facilitating regular QI planning and review meetings. A

summary of quality improvement team composition by facility is found in Appendix 2. Project efforts

through October 2017 focused on QIT strengthening and coordination, and QIT interventions and efforts

began in November 2017 with 11 QI projects (QIPs) across the four districts. As of December 2018, the

project has initiated 74 QI projects, with 52 completed QI projects to date. Examples of improvement

aims and change ideas tested, including run charts detailing quality improvement interventions and

results, are included in Appendices 3 and 4.

Key Indicators Targeted for Improvement

Throughout QI implementation, the project monitored key indicators related to VL and EID testing at pre-

analytical, analytical and post-analytical testing phases. Critical activities within each testing phase are

detailed in Figure 2, as well

as bottlenecks identified and

addressed during project

implementation using quality

improvement methods and

close collaboration with

stakeholders and partners.

Key indicators that the

project monitors specific to

these three phases include:

Pre-analytical phase

• % of clients eligible

for six months

testing with VL

collected

• % of clients eligible

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for 24 months testing with VL collected

• Number of VL and EID samples transported per month by sample transportation system

Analytical phase

• % of VL results returned to facility within one month of collection

• % of EID results returned to facility within 14 days

Post-analytical phase

• % of clients with suppressed VL on multi-month prescribing

• % of clients with unsuppressed VL receiving greater than 1 month of refills

• % of clients with unsuppressed VL completing intensive adherence counseling (IAC)

• % of clients with unsuppressed follow-up VL switched to second line regimen

• % of EID results returned to care givers within 14 days and linked to care

Further details on some of these key indicators are included below, including selected improvement

trends over the life of the project, bottlenecks identified, and areas targeted for QI interventions.

Proportion of clients eligible for VL testing with sample collected

Malawi national guidelines include routine viral load monitoring at six- and 24-months following ART

initiation. The project monitors the number of clients eligible for VL testing at both six- and 24-months

ART milestones on a monthly basis, compared to the number of VL samples collected from those eligible

for testing. Bottlenecks identified that affect performance of these indicators include weak knowledge of

and demand for testing at ART milestones and limited ability to track clients who are due for routine VL

testing. Areas targeted for QI intervention included health promotion on the importance of VL testing,

screening of patient master cards to identify clients eligible for VL testing, and use of expert clients to

follow-up with clients who miss appointments. In the districts covered by the project, the introduction of

these QI interventions resulted in an increased proportion of clients receiving VL testing six months after

ART initiation from 57% in June 2018 to 94% in November 2018, as seen in Figure 3.

Figure 3: Proportion of eligible clients with VL sample collected at six months - June to November 2018

Proportion of VL results returned to facility within one month of collection.

The national target for VL results turnaround time is one month from sample collection to results received

at the facility. Malawi struggles with meeting this recommended one-month period, with inconsistent

performance in the four districts supported by this project between January and November 2018 (see

Figure 4 below). Numerous bottlenecks have been identified including increased numbers of samples for

testing and inadequate staffing levels at molecular laboratory facilities. The project closely collaborates

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with the CDC-funded Strengthening High Quality Laboratory Services Scale-Up for HIV Diagnosis,

Care, Treatment, and Monitoring in Malawi under PEPFAR project, implemented by URC, to implement

strategies to improve sample testing and resolve bottlenecks across the analytical phase in all target

districts. Potential interventions include increasing staffing, instituting multiple laboratory shifts, and

introducing innovations to eliminate cumbersome logging and data entry tasks.

Figure 4: Trend of VL Results Returned within One Month, January-November 2018

Proportion of clients with unsuppressed VL completing IAC

Under the post-analytical testing phase, the project monitors performance across the viral load cascade of

care, including enrollment and completion of IAC for clients with high viral load (HVL) (VL >1000

copies per ml), administration of a follow-up VL test, and appropriate switches to a second line ART

regimen if warranted. Numerous bottlenecks can be present during this phase, including failing to record

results in patient cards and registers, poor coordination among providers resulting in limited follow-up to

clients with high VL results, and poor adherence to IAC guidelines among providers and clients. Areas

the project targeted for QI interventions included identifying staff responsible for updating results in

appropriate registers and cards, using color codes to identify clients on IAC, and increased on-site

coaching and mentorship on current ART treatment guidelines to ensure optimized patient management.

Project performance from June to December 2018 is found in Figure 5.

Figure 5: Trend of IAC performance June to December 2018

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• Re-engineer the client flow for all clients due for VL testing to first have the blood draw

and finish with drug collection.

Summary of Successful Change Ideas

Following implementation of quality

improvement activities throughout

the project-supported sites, project

staff reviewed data and results trends

of the indicators detailed above to

track improvements over time and link those to successful changes tested. Additionally, the most

successful change ideas were captured through harvesting learning sessions; the harvest learning session

methodology is described in Appendix 5. Below we present successful change ideas that led to

improvements in the uptake and utilization of VL testing and results utilization across all the sites. Further

details on how the change ideas were implemented is included in the following section.

Health promotion engagement with ART clients

• The ART provider/staff advises clients during appointments that expert clients/community health

workers (CHWs) will contact clients via community follow- up or phone when the VL results are

in.

• Advise clients on ART not to send a third person to collect drugs on their behalf.

• Advise clients that have a blood draw for VL testing to avoid transferring to another facility until

their results are in.

Viral load and EID test results management and data quality and documentation

• As soon as results are received, flag unsuppressed results for immediate follow up by CHWs

and/or expert clients.

• Appoint, on rotation, one member of the QIT to attach the VL results to the clients’ master cards

each time results are received.

• QIT members review their facility data after the clinic day and see that all the registers and source

documents are complete.

• The ART clerk reviews the client contact information (phone number, physical address, village

etc.) at every visit.

Work/client flow mapping modification

• Consider the feasibility of dispensing one-month drug re-fill for all clients that have a blood draw

for VL testing.

• Retrieval and review of all client master cards, one day prior to clinic day.

• Assigning one staff at the waiting area to screen master cards and identify all clients that are due

for viral load testing.

Note: Change ideas in boxes below should be considered for prioritization based on importance and beneficial impact to patient management outcomes, particularly in locations with goals related increased VL scale-up.

• QI teams develop a roster for daily health talks on topics related to VL and EID testing

and ART management in general.

• Color code client master cards using stickers to indicate the client is due for VL testing,

has unsuppressed VL, and/or is on an intense model of care (IAC, etc.).

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• Frequent feedback on prolonged turnaround time (TAT) and determination of solutions to

reduce TAT.

• Linkage with molecular laboratories to understand the reasons and strategies to mitigate

delays of sample processing and release of results.

Facility staff modification

• ART clinic in-charge develops and utilizes a working roster for the facility-based staff with

proper shifts making sure the ART clinic is adequately staffed.

• Task shifting certain responsibilities to other cadres for efficiency in service delivery; for

example, expert clients taking client’s weight and vital signs and providing health talks in the

waiting area.

• Expert clients conduct community follow-up to track clients with HVL to come to the clinic and

enroll them into intense models of care as soon as results are received.

Health worker capacity building

• Provide on-site coaching on QI methods and national current treatment guidelines to optimize

services.

• Peer learning for all ART clinic staff on the current treatment guidelines for ART clients.

Enhanced coordination with molecular laboratories

• Frequent feedback on reasons for invalid samples and missing results and collaborate closely with

clinical partners to address issues related to sample collection.

• Frequent feedback and coordination to identify solutions to address prolonged TAT.

Enhanced coordination with sample/result transport provider on sample transport

• Close collaboration with sample/result transportation to determine the optimal number of visits

and visit schedule to each facility to facilitate sample pick-up and results delivery.

• Regular coordination on missing results and sharing the list with the sample and results

transportation provider to follow up with molecular labs during their next sample collection visits.

Enhanced district partner’s engagement

• Facilitate monthly data sharing with all partners providing care in the district.

• Facilitate quarterly shared learning with the QITs and all partners to share technical briefs,

success stories, best practices and lessons learned

• Facilitate District quality improvement monthly meetings and on-site visits to support the QITs in

the provision of quality care to clients.

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Detailed Change Package

The following table summarizes the recommendations from the QI teams who were involved in testing

change ideas for quality assured VL testing and EID in the four districts supported by the project (Balaka,

Dedza, Mchinji and Karonga). The change ideas recommended are the changes that yielded the best

results for the improvement aims. The section provides details on how QI teams implemented the change

ideas and other elements to consider when implementing a similar change idea. See Appendix 5 for the

methodology of selecting change ideas for inclusion in the change package and Appendix 6 for the tool

used to harvest change ideas.

Change Concept: Health Promotion Engagement with ART Clients

Change Idea Details on how change idea was implemented Further implementation

elements to consider

Provide daily

health talks on

related topics

• The head of each facility developed a daily roster

including date, staff name, health talk topic and

signature. An example roster is found in

Appendix 7

• Assigned staff (including clinicians, nurses and

expert clients) presented health talks on various

topics, including VL importance and milestones,

adherence, and EID testing, as well as other health

related topics including tuberculosis, family

planning, nutrition, and hygiene and sanitation

• QIT members provided supportive supervision to

staff ensuring health talks were completed and

conducted with appropriate information

Health talks were based

on the national treatment

guidelines developed by

the Department of

HIV/AIDS. It is essential

to standardize information

delivered to clients and

ensure that the

information is evidence-

based

Engage expert

clients and

community health

workers in

unsuppressed VL

result

communication

• ART providers and other staff advised ART

clients during sample collection that expert clients

or CHW would be in contact if unsuppressed VL

results were received, either by home visit or

phone

• When results were received at the facility, expert

clients/CHWs communicated with any patients

with unsuppressed VL results (through home visit

or phone)

Clinical partners were

engaged to provide

credits to CHW to call

clients with high VL

results

Advising clients

on appropriate

ART management

activities

• ART providers and other staff provided ongoing

counseling and advice to clients including:

o Advising clients on ART not to send another

person to collect drugs on their behalf

o Advising clients who have had a recent VL

blood draw or are currently in IAC to wait, if

at all possible, before transferring to a new

health facility (due to relocation, etc.)

All teens (<15 years) are

encouraged to be

accompanied by parents

or guardian when

attending ART services

Change Concept: Viral Load and EID Test Results–Management, Data Quality and

Documentation



Flag unsuppressed

VL results for • When results arrived at facilities, the HIV

diagnostic assistants (HDA’s) recorded the results

Districts and facilities

should collaborate to

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immediate follow-

up

in the VL register

• The results are then given to CHW’s/expert

clients for filing into patient cards

• All patient cards with unsuppressed VL are

flagged with a sticker and distributed across

CHW’s for client follow-up

standardize color-coding

Color code client

master cards to

indicate VL

milestones and

actions

• The project purchased stickers in different colors

to indicate various VL milestones and actions on

client master cards. For example:

o Color 1: Due for VL collection

o Color 2: Unsuppressed VL

o Color 3: On IAC

o Color 4: Completed IAC and low VL result

• The ART provider (clinician or nurse) posted a

color code label interpretation in staff areas (ART

providers room, registry room, HIV testing

services (HTS) room, etc.)

• Stickers were placed on client master cards on an

ongoing basis, usually by ART data clerks and

HDA’s

The project supplied the

stickers in different

colors, but consideration

should be given to

ongoing funding

Example of color code

label interpretation:

Assign staff to

attach VL results

to client master

cards

• The ART Clinic In-Charge appointed on rotation

a data clerk to attach VL results to client master

cards as soon as results came in from molecular

laboratories

Conduct regular

review of facility

data for

completeness and

quality

• After each clinic day, QI team members reviewed

facility data to ensure all registers were complete

• Registers were also compared to source

documents (client master cards) to review data

quality

• All missing information was updated in the

register to reflect client master cards

• On a monthly basis, the project district

coordinators conducted audits to review master

cards for completeness and accuracy

Review and

update, as needed,

client contact

information at

each visit

• At each visit, ART clerks were responsible for

reviewing contact information with clients,

including phone number, physical address and

associated landmarks, village, etc.

• Incorrect or outdated information was updated

immediately and re-confirmed at the next visit

Change Concept: Work and Client Flow Mapping Modification



Re-engineer client

flow from client

check-in to drug

collection

• QI team members worked with providers and

facility staff to optimize client flow charts from

check-in to check-out, to include clear processes

for VL testing blood draws, collection of results

and visits with providers when unsuppressed VL

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was detected

• New client flow maps and narratives were posted

at the facilities to facilitate providers and staff to

guide patients through visits

• See Appendix 8 for an example optimized client

flow chart and narrative

Dispense one-

month drug refills

to clients awaiting

VL results

• All clients who had their blood drawn for VL

testing were provided a one-month prescription of

medication to ensure they returned to the facility

to receive the results of their VL test and discuss

clinical care next steps with the provider

Close coordination with

Ministry of Health and

HIV/AIDS departments is

required on policy

feasibility and

implementation, as often

delays in receiving VL

results can place an undue

burden on patients who

must return to facilities

for drug collection,

despite the unavailability

of their VL test results

Conduct retrieval

of client master

cards one day

prior to clinic day

• On the day prior to clinic day, expert clients and

data clerks are assigned to collect all client master

cards for those clients with appointments

• The cards are sorted according to the needs of the

clients, including those due for VL collection or

those due for IAC sessions

• The cards are shared with the data clerks who take

client vital signs and hand over master cards to

clients as they meet providers

• Prior review and sorting of the cards allows the

data clerks to highlight key services the clients

should receive during their visit and avoid missing

key VL milestones

Assigning staff

member to screen

master cards for

those due for VL

testing

• Expert clients and data clerks are assigned to the

waiting area to screen all master cards and

identify all clients that are due for VL testing

• As soon as the clients’ vital signs have been

recorded they are sent for VL sample collection

before proceeding with the remainder of their visit

Change Concept: Facility Staff Modification



Ensure facility

ART clinic is

always adequately

staffed

• The ART Clinic In-Charge developed and tracked

a roster for the facility-based staff with proper

shifts to make sure the ART clinic was staffed

adequately each day, taking into account leave

schedules, trainings, etc.

Use of locum (temporary)

staff, in the event all

providers at the clinic are

engaged in other activities

Implement task

shifting to increase • QI team members, with guidance from the district

health office (DHO) and facility management,

It was essential to engage

DHO in these efforts and

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efficiency in

service delivery

discussed task shifting opportunities, with DHO

providing approval of any task shifting decisions

• Specific responsibilities were shifted to other

cadres including:

o Expert clients were assigned to measure and

record client weights and vital signs

o Expert clients were assigned to provide health

talks in clinic waiting room

o Data clerks were assigned to place color-

coded stickers on health passports

• The district ART Coordinator was responsible for

informing cadres of new responsibilities

obtain approval for any

task shifting decisions

Engage expert

clients in

unsuppressed VL

result follow-up

• When VL results were received, expert clients

were tasked with conducting community follow-

up to track patients with unsuppressed VL results,

encouraging them to come to the clinic and enroll

into intense models of care

Change Concept: Health Worker Capacity Building



Provide routine

on-site coaching

on QI methods

and current

treatment

guidelines

• The project district coordinators and ART nurses

provided monthly on-site mentorship covering QI

methods and current treatment guidelines to

optimize services

• QI methods covered included:

o Fishbone analysis; driver diagrams; plan-do-

study-act (PDSA) cycles; presentation of data

through run charts to determine if change idea

led to improvement

All treatment guidelines

coaching was aligned

with current national

Malawi Guidelines for

Clinical Management of

HIV in Children and

Adults

Conduct peer

learning for all

ART clinic staff

on treatment

guidelines

• Clinical meetings are held every morning on ART

clinic days, where all staff discuss current

treatment guidelines, difficult cases and patient

management strategies, and any policy or clinical

management updates

• Copies of current national treatment guidelines are

available throughout the facility in the ART room

and HTS room for reference by providers during

testing, counseling and treatment sessions

Change Concept: Close Coordination with Molecular Laboratories



Meet regularly to

discuss

bottlenecks that

delay sample

processing and

release of results

and identify

• On a routine basis, project staff met with

molecular laboratory staff and managers to

understand the reasons for sample processing and

results release delays and identify strategies for

addressing bottlenecks

• Examples of mitigation strategies included:

o Addition of extra data clerks at molecular

Any relevant sample

transportation entities and

clinical implementing

partners should also be

involved in the

discussion.

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mitigation

strategies to

decrease

turnaround time

laboratories

o Utilization of extra shifts to analyze additional

samples per day, up to 24 hours a day as

needed

Provide frequent

feedback on issues

related to sample

collection

• The project met regularly with molecular staff and

clinical implementing partners to discuss feedback

on reasons for invalid samples and missing

results. All partners were engaged to fix issues

and decrease sample rejection rates

Change Concept: Enhanced Coordination with Sample/Result Transport Entity



Determine optimal

visit schedule for

sample pick-up

and results return

• Through the CDC-funded Malawi Laboratory

Project, the project engaged facility staff, clinical

implementing partners and Riders for Health

(R4H), the chosen sample transport provider

• R4H was advised to visit each project site twice

per week to retrieve samples and deliver results

between the facilities and molecular laboratories

Provide regular

feedback on

turnaround times

• Project staff provided frequent feedback on

prolonged turnaround times and results delays and

discussed any transportation issues with R4H

management

Staff from molecular

laboratories and any

clinical implementing

partners should also be

involved in the

discussion.

Coordinate

regularly on

delayed and

missing results

• Project staff, in coordination with the CDC-

funded Malawi Laboratory Project, shared a list of

missing results with R4H, who followed-up with

molecular labs during their next sample drop-off

visit

Change Concept: Consistent Collaboration with District Partners



Facilitate routine

data sharing

• Relevant project staff organized monthly data

sharing with all partners providing care in each

facility, including QIT members and facility staff,

led by the QIT chair of the facility

Facilitate quarterly

shared learning

• The project organized quarterly shared learning

sessions, where QI team members and all partners

could share technical briefs, success stories, best

practices and lessons learned during the QI

process

Facilitate

collaborative

district quality

improvement

• Project staff organized monthly district quality

improvement team meetings and monthly on-site

mentoring visits to support the QI teams in the

provision of quality care to clients

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Appendix 1: Summary of Health Facilities Included in Project

Table 1: District Hospitals Summary

District Hospitals

District HIV Prevalence Catchment

Population

Number of

Staff

Number of HIV

patients

Dedza 1.5% 830,512 69 12,403

Balaka 4.1% 159,446 44 6,615

Mchinji 0.8% 602,305 6 4,602

Karonga 7.3% 62,348 19 4,532

Table 2: Health Center Summary

Health Centers

District Health

Center Name

HIV

Prevalence

Catchment

Population

Number of

Staff

Number of

HIV patients

Balaka Mbera 3.2% 48,960 21 1,569

Kalembo 4.3% 43,743 32 1,867

Phalula 5.4% 26,069 22 1,420

Phimbi 3.0% 26,423 17 800

Dedza Mayani 2.8% 26,820 11 758

Mtendere 2.6% 69,080 22 1,812

Chikuse 1.1% 32,335 5 365

Mtakataka 2.8% 22,393 6 619

Mchinji Nkhwazi 2.6% 52,667 7 1,345

Kochilira 2.5% 489,44 6 1,210

Kapiri 3.9% 63,983 7 2,519

Mkanda 4.1% 47,991 6 1,970

Karonga Chilumba 17.0% 18,900 18 3,217

Nyungwe 5.8% 40,122 14 2,317

Kaporo 6.7% 61,115 16 4,121

Ngana 4.1% 4,230 4 175

17

Appendix 2: Quality Improvement Team Composition

Table 3: Quality Improvement Team Composition at Each Level of the Health System

District Hospitals

District Number of QIT

Members

Team Composition

Dedza 12 ART District Coordinator, Laboratory Manager, ART Clinic

in-charge, ART Nurses, ART clerks, ART clinicians, ART

nurses, Patient attendants, Data clerks, HIV Diagnostic

Assistants (HDAs), Expert Clients, HTS Counselor

Balaka 9

Mchinji 11

Karonga 15

Health Centers

District Name of Facility Number of QIT Members Team Composition

Balaka Mbera 10 Facility in-charge, ART

clinicians, ART nurses, Data

clerks, Health Surveillance

Assistants (HSAs), HDAs,

HTS Counselors, Expert

Clients, Patient Attendants

Kalembo 11

Phalula 18

Phimbi 12

Dedza Mayani 8

Mtendere 8

Chikuse 8

Mtakataka 8

Mchinji Nkhwazi 10

Kochilira 8

Kapiri 12

Mkanda 11

Karonga Chilumba 9

Nyungwe 10

Kaporo 10

Ngana 9

18

Appendix 3: Summary of Change Ideas Tested

Change: To maintain high initiation rate of clients on ART after testing positive

Objective/specific

problem addressed

Change concept Change ideas tested,

how exactly was the

change idea tested (who,

how, when, resources

required etc.)

Evidence that the

change led to

improvement

Scale of

implementation

(Sites that tested

change idea)

Increase the proportion of

clients who start treatment

early after HIV positive

result (following a test-

treat policy)

Follow up of clients with

HIV positive result

Assigning a community

health worker to actively

follow up positive clients

who do not start ART

after testing and

sensitizing them on the

importance of early

initiation to treatment

Proportion of clients who

started early treatment

after HIV positive results

remained above 90%

Phalula

19

Change: To increase the proportion of clients that meet their VL appointment dates

Objective/specific problem

addressed

Change concept Change ideas tested, how exactly

was the change idea tested (who,

how, when, resources required etc.)

Evidence that

the change led to

improvement

Scale of

implementation

(Sites that tested

change idea)

Complete documentation in

the registers

Daily review of

registers to

capture all the

data

The QIT reviewed registers at the end

of each clinic day

Percentage of

clients that meet

their appointment

dates has

significantly

increased from

87.9% to 95.8%

Applied to all sites

To identify clients who are

due for VL test appointment

Prior sorting of

master cards

Assigning one member of the QI team

to sort Master cards of booked clients

before the clinic day


Increase awareness of clients

on benefits of timely testing

Health promotion

on advantages of

meeting VL

appointments

Sensitizing clients on the importance

of not missing VL appointment dates

by ART staff


20

Change: To increase the proportion of clients with VL samples collected at 6 Months

Objective/specific

problem addressed

Change concept Change ideas tested,

how exactly was the

change idea tested (who,

how, when, resources

required etc.)

Evidence that the

change led to

improvement

Scale of

implementation

(Sites that tested

change idea)

Increase clients’

awareness on health

benefits of timely VL

testing

Health talks to VL clients Depending on the topic,

clinicians/nurses/expert

clients giving health talks

to clients on VL testing

Percentage of clients

tested increased from

48% to 88%

Karonga DHO

Reduce number of clients

who miss VL testing

during clinic visit

Clients triaging Triaging of clients due for

VL testing by ART staff*

Karonga DHO

Increase number of

clients with VL samples

taken

Active follow up of VL

clients

Following up intensively

of clients due for VL

collection by expert

clients

Karonga DHO

Reduce proportion of

clients who miss VL

testing at 6 months

Use of mobile phones Lead Expert Client/ HDA

Supervisor phone calling

clients who are due for

VL testing

Karonga DHO

* Note: Triaging involves checking of clients’ health passports while the clients are in the waiting room and those identified as due for VL collection are

immediately sent to VL collection room

21

Change: To improve viral load sample collection at all routine milestones

Objective/specific

problem addressed

Change concept Change ideas tested, how exactly was

the change idea tested (who, how,

when, resources required etc.)

Evidence that

the change led

to

improvement

Scale of

implementation

(Sites that tested

change idea)

To increase clients’

awareness on benefits of

VL testing

Health talks on

advantages of VL testing

CHW conducting health talks Proportion of

eligible clients

that had VL

taken increased

from 60.7% to

104% (Note:

the above

100% results

includes

additional

clients who

missed their

appointments

and came on a

clinic day

which they had

no appointment

alongside

clients who had

appointments

(expected

clients) on

particular day)

Mchnji DHO,

Kochilira

Phimbi, Phalula,

Balaka DHO, Mbera

To improve efficiency in

sample collection and

documentation operations

Identification of specific

personnel to carry out

sample collection and

documentation

Assigning of specific personnel to

oversee sample collection and

documentation

Mchinji DHO

Increase proportion of

clients meeting VL

milestones

Review of master cards

and passbook to screen

for VL milestone

ART staff assessing master cards and

health passbook to screen for VL

milestone

Kapiri, Kochilira,

Chikuse, Phimbi,

Phalula, Balaka

DHO, Mbera

Increase number of VL

samples collected

Assigning VL sample

collection to available

personnel

ART clinic In-Charge allocating VL

sample collection monthly target to

available VL sample collection personnel

Kapiri

Increase number of VL

samples collected

Increase quantity of staff

in VL sample collection

room

ART clinic In-Charge ensuring

availability of officers and addition of

another officer in the VL sample

collection room.

Kochilira

Improve follow up of

clients due for VL

Use of HAS’s and partner

field officers in tracking

clients

HSA’s and Mother 2 Mother (M2M)

officers assisting in tracking clients due

for VL

Ntakataka

Flagging eligible clients

for VL testing for easy

follow up

Generation list of eligible

for VL testing at 6

months 24 months

HDA’s generating list of eligible clients

from ART registers per cohort (6 months

and 24 months)

Mayani

To increase proportion of

clients meeting VL

appointments

Active follow up by

expert clients

Using expert clients to assist in tracking

those who miss appointment

Mayani

Easy identification of

clients due for viral

Use of colored stickers HDAs/ ART Nurse putting colored

stickers on the master card

Phimbi, Phalula,

Balaka DHO, Mbera

22

Change: To increase proportion of clients with documented results in registers and client card

Objective/specific

problem addressed

Change concept Change ideas tested, how

exactly was the change

idea tested (who, how,

when, resources required

etc.)

Evidence that the

change led to

improvement

Scale of implementation

(Sites that tested change

idea)

Reduce delays in

documentation of results

when they arrive at the

facility

Empower HDAs in

results documentation

Empowering HDAs in

documenting results soon

after arrival at the facility

Proportion of

results

documented

increased from

22.8% to 95.3%

Chilumba

Involvement of all key

facility staff in VL clinics

Mentorship of clinicians

and nurses on use of

HVL register

Mentoring of clinicians and

nurse on how to use the

HVL register

Karonga DHO

To increase proportion of

results documented and

quality of other VL

testing services

Regular weekly

departmental meetings

ART Clinic In-charge

intensifying regular

meetings at department level

(weekly) to discuss issues of

documentation and other

quality issues

Karonga DHO

Improve accessibility of

HVL results to expert

clients

Generation of HVL

results for use by expert

clients

HDA’s generating list of

clients with high viral load

results and give it to expert

clients to assist in tracking

of the clients

Dedza DHO


results for utilization

Use of focal persons to

oversee documentation

Choosing focal persons to

oversee documentation by

ART Clinic In-charge

Dedza DHO

23

Change: To increase percentage of VL results entered into electronic database


addressed

Change

concept

Change ideas tested, how exactly was

the change idea tested (who, how,

when, resources required etc.)

Evidence that the

change led to

improvement

Scale of

implementation

(Sites that

tested change

idea)

Increase the proportion of

results entered in the

electronic database

Mentorship

of data entry

clerks

ART Coordinator mentoring data entry

clerks in electronic data entry

86.5% of the results were

entered into electronic

database from 5%

Karonga DHO

Full time engagement of data

entry clerks in data entry

Supportive

supervision

of data entry

clerks

Conducting supportive supervisions to

clinics by District- QI Team

Karonga DHO

24

Change: To increase proportion of clients with HVL that are notified of their results


addressed Change concept

Change ideas tested, how

exactly was the change idea

tested (who, how, when,

resources required etc.)

Evidence that

the change

led to

improvement

Scale of

implementation

(Sites that tested

change idea)

To increase number of clients

that receive results as soon as

possible

One-month drug re-fill

ART provider prescribing one-

month drug re-fill for all clients

that had VL sample collected

Proportion of

clients with

HVL notified

of their results

increased from

46.6% to

71.6%


Reduce cross transfers from one

clinic to another clinic Retain the client at a clinic

Providers (ART Nurse and

clinicians) not allowing clients

that had viral load sample

collected to get transferred to

another clinic

Mbera, Phimbi

To locate clients for result

notification

Obtain clients physical

location land marks

Assigning one QI member to

collect physical land marks that

give exact location of clients for

easy follow up


To improve daily

documentation of results in

master cards for easy follow up

of clients

Daily documentation of VL

results in master cards

ART clerk documenting VL

results in master cards on daily

basis


To streamline EID/VL activities

at the clinic

Identification of one person

to be responsible for

EID/VL clinic

Assigning an EID /VL focal

person at the clinic Balaka ART

To improve timely result

notification to clients

Flag VL results in registers

for action

Using stickers to flag results in

registers by ART staff Applied to all sites

To improve timely result

notification to clients

Screening of master cards

one day prior to clinic day

to identify clients with

outstanding results

Screening of master cards

before clinic day by ART staff Applied to all sites

Increase awareness of clients on

benefits of regular VL testing

and knowing the results

Health talks CHW conducting health talks

consistently Applied to all sites

25

Improved timely notification of

results by designated result

notification officer

Usage of duty roster by

designated result


Ensuring availability of duty

roster to designated result



Increase number of clients

notified of their results during

subsequent drug collection

Collection of drugs by

clients themselves

Providers preventing guardians

from collecting ARVs for more

than once.


Improved timely notification of

results

Active clients follow up by

expert clients

Tracing of clients using Expert

clients/health surveillance

assistants (HSAs)/CHWs


26

Change: To increase the percentage of clients with HVL results enrolled on intense differentiated service delivery model

Objective/specific

problem addressed

Change concept Change ideas tested, how

exactly was the change idea

tested (who, how, when,

resources required etc.)

Evidence that the

change led to

improvement

Scale of implementation

(Sites that tested change

idea)

Increase clients’

awareness on VL testing

Counselling at point of

VL collection

Providers intensively

counselling clients at the

collection point emphasizing

the need to provide collect

addresses for easy tracking.

Proportion of clients

with HVL enrolled in

IAC increased from

49.5% to 78.4%

Dedza DHO

Improve communication

between clinic staff and

expert clients

Improved and frequent

communication with

expert clients

The ART providers holding

regular and feedback meetings

with expert clients

Dedza DHO, Mayani

Ensure immediate access

to HVL results by expert

clients for follow up of

clients

Ensure expert clients’

availability on Fridays

Expert clients coming every

Friday to clinic when the

results are in to provide

counselling.

Dedza DHO

Increase number of

clients notified of HVL

results

Provide list of clients to

expert clients

Generate list of clients with

high viral load results and give

it to expert clients to assist in

tracking clients

Chikuse


clients with VL collected

One-month appointment ART staff giving one-month

appointment to HVL clients

Mtendere


results

Documentation of VL

results in registers

Properly documenting results

in the viral Load register by

ART Clerk

Mtendere


clients notified of their

results and enrolled into

IAC

Intensified follow up

clients through expert

clients

Enhancing follow up of clients

through expert clients.

Mtendere, Mayani


HVL clients properly

managed

Orientation of staff in

management of HVL

clients

Orienting ART staff on

management of HVL clients

Mtendere

27

Change: To increase the proportion of clients with HVL that complete IAC sessions Objective/specific

problem addressed

Change concept Change ideas tested, how exactly

was the change idea tested (who,

how, when, resources required

etc.)

Evidence that the

change led to

improvement

Scale of

implementation

(Sites that tested

change idea)

Early initiation of IAC Active follow up

of HVL clients

Assigning CHWs to follow up

clients with HVL results

Proportion of clients

that complete three

months IAC sessions

increased from 56.1%

to 77.1%

Phalula, Balaka DHO

The client not to miss VL

sample collection

Improve client

flow

The QIT re-designed the client flow

mapping-the client passed through

the HTS for VL sample draw before

drug collection


Clients not to miss IAC

sessions

One-month drug

refill

ART provider prescribing one-

month drug re-fill to clients


Active follow up of

patients visits

Documentation of

clients visits in

patients’ cards

ART clerk staff documenting

properly clients visits in patients’

cards.


Ensure HVL clients are

initiated on IAC

Active follow up

of clients

HSA’s and expert clients following

up actively clients with HVL results


To improve identification

of clients on IAC in master

cards

Use of green

labels to identify

clients on IAC in

master cards

ART staff sticking green labels on

master cards of clients on IAC and

with HVL results


To identify in advance

clients on IAC before

clinic

Review of master

cards before clinic

Checking client master cards to

capture those on IAC and with HVL

results by ART staff


28

Appendix 4: Results of Tested Change Ideas

In this section, we present several examples of improvement aims and change ideas tested by participating

sites during the demonstration phase, including run charts detailing QIP interventions and results.

To increase proportion of results notified to clients at Dedza DHO - May-July 2018.

Dedza District Hospital ART Clinic QI team identified a gap through the review of their records of low

notification of VL results to clients. This affected the provision of quality client management. As shown

in Figure 6 below, from a baseline of 13% (17/127) in April, Dedza DHO set out to improve the

proportion of results notified to clients between May and July 2018 to 60%. A root cause analysis

identified that the low percentage of clients notified of their results was attributed to poor documentation

by the ART clerks and failure to review their facility data on a regular basis. However, when focal

persons were identified to oversee documentation, the proportion of clients steadily increased for three

successive months: 76%, 77% and 86% in May, June and July 2018 respectively.

Figure 6: Proportion results notified to clients at Dedza DHO - May-July 2018

29

To increase proportion of clients enrolled into differentiated service delivery model (IAC)

at Mayani health center (HC), Dedza – October 2017 – March 2018.

The current Malawi ART guidelines recommend that clients with HVL should be enrolled into intense

differentiated service delivery models (including IAC) for three months. Mayani HC, in Dedza district,

aimed to increase the proportion of clients enrolled into IAC from 30% (3/10) in September 2017 to 50%

between October 2017 and March 2018. Although the proportion of clients increased to 38% (3/8) in

October 2017 as Figure 7 below illustrates, the gain was undermined in November 2018 due to

inadequate knowledge of clinic staff to manage HVL clients resulting in only 25% (1/4) of the HVL

clients being enrolled in IAC during the month. Nevertheless, the proportion of clients tremendously

increased to 81% (56/69) in December 2017 due to use of expert clients to track clients missing

appointments, before dropping to 71% and 58% in January and February 2018 respectively. The drops

were still due to inadequate knowledge of clinic staff in HVL clients’ management, a gap that was fixed

in March 2018 when an orientation meeting with ART staff was conducted to help them identify and

follow up HVL clients. In addition, the orientation helped to sharpen ART staffs’ understanding of the

entire IAC cascade together with the recommended guidelines at each stage, resulting into 100% of the

HVL clients enrolled in IAC.

Figure 7: Proportion of clients enrolled in IAC at Mayani HC, Dedza – October 2017 – March 2018

30

To increase proportion of clients collected and tested for VL at six months from Karonga

DHO- June-Sept 2018

At Karonga DHO, the QIP team aimed to increase the proportion of clients with samples collected and

tested for VL at six months between June and September 2018. As shown in Figure 8, from a baseline of

48% (48/70) in May 2018, the proportion of clients collected VL did not improve in June. When various

change ideas, including expert client follow-up of clients in person and by phone and educating clients on

benefits of timely VL testing were implemented, the proportion of clients with VL samples collected and

tested at six months steadily increased in July (84%) and September (88%).

Figure 8: Proportion of clients collected and tested for VL at six months from Karonga DHO- June-Sept 2018

31

To reduce notification period of VL results from 6 weeks to 1 week (7 days) at Nanga HC,

Karonga, from June to September 2018

At Ngana health center in Karonga district, staff tested change ideas to reduce VL results notification

from six weeks to one week. As Figure 9 below shows, from a baseline of 20% (1/5) in May 2018, the

proportion of clients notified of results within 7 days increased to 100% in June before backtracking to

57% in July. The increase in June was largely attributed to active follow up of clients by HSA’s while the

decline in July was due to cross-border clients who were difficult to follow-up with and get notified of

their results. Phone calling of clients by lead expert clients proved very effective in increasing the

proportion of clients to 100% in September 2018.

Figure 9: Proportion of clients notified of their results within 7 days at Ngana HC, Karonga, from June –September 2018

32

To increase proportion of HVL clients enrolled in IAC at Balaka out patient department

(OPD) - July -October 2018.

At Balaka OPD in Balaka district, the QI team aimed to improve the proportion of clients who were

enrolled in IAC sessions, from 50% (8/16) in June, to 70%, between a period of July and October 2018.

Figure 10 below shows that during the first month of project implementation, the proportion of clients

enrolled increased from 50% to 83% (5/6) mainly due to the use of colored stickers in master cards to flag

HVL results and ensure that HVL patients were strictly given one-month drug refill. Although the

proportion of clients stagnated in August at 80%, intensive documentation of results in master cards

significantly increased the proportion of clients to 94.7% in September before dropping to 60% in

October due to some clients who gave false addresses making follow up challenging. To address this,

facility staff are emphasizing the importance of providing correct addresses and biodata during health

talks and ensuring patient are aware that the information will only be used for medical purposes.

Figure 10: Proportion of clients enrolled in IAC sessions at Balaka OPD, Balaka-July – October2018

33

In addition to the QIPs illustrated above, the project also implemented collaborative QIPs at four sites in

Balaka district namely Balaka DHO, Mbera HC, Phimbi HC and Phalula HC. These QIPs included the

following:

• Increasing VL routine testing of eligible clients from 61% in March to 90% between May and

August 2018 and the QIP completed with 100% of the eligible clients virally tested at the four

high burden sites in Balaka. The change ideas tested included:

- Screening of masters’ cards before the clinic day

- Use of colored stickers

- One-month drug refill

- Health education talks on the benefits of VL testing in patient management

- Re-engineered the client flow, in that the drug collection is done as the last process.

• Increasing VL routine testing of eligible clients from 61% in March to 90% between May and

August 2018 and the QIP completed with 100% of the eligible clients virally tested at the four

high burden sites in Balaka. The change ideas tested included:

- Re-engineered client flow in such a way that drug collection is done last

- Use of stickers to identify eligible clients due for VL testing

- Orientation of staff on VL schedule/milestones as per guidelines

- Allocation of three providers on each clinic day

- Use of screen in HIV testing and counseling room to accommodate two providers

- Daily clinic data reviews after the clinic day

• Increasing VL testing of eligible clients at Phalula HC from 61% in March to 90% between

March and August 2018 and the QIP completed with 100% of the clients of eligible clients virally

tested at Phalula HC. The change ideas tested included:

- One-month drug supply

- Comprehensive healthy talks on the importance of VL testing

- Intensive screening of master cards to identify all the clients due for VL testing

- Assigning of HVL clients to CHWs for follow up

• To increase IAC enrollment from 78% in March to 95% between March and August 2018, and

the project completed with 100% of the clients enrolled in IAC in August 2018. The change ideas

tested included:

- Use of colored stickers for patients on IAC- the colors depict the client is on first, second

or third sessions respectively

- Assigning of a person responsible for communication VL results to the clients

- Provision of one-month drug supply while awaiting VL results

- Documentation of VL results on patient’s cards

- Withhold transfers for those awaiting VL results until the results are in and

communicated to the clients

34

Appendix 5: Methodology for Harvesting Change Ideas

Four harvesting learning sessions were held between October and November 2018. The twenty Quality

Improvement teams were provided with the tool for harvesting change ideas (Appendix 6) during the on-

site coaching to all the 20 sites included in the project. Project staff and HDA officers oriented all QIT

members on use of the tool. The teams were advised to score every change idea that they tested at their

site. The teams then presented to all the other members that gathered at the learning sessions on how the

change idea(s) were tested (who tested it, how it was tested, when was it tested, and resources if they were

used). Then each change idea was scored as per Figure 11 below.

Figure 11: Guide to Rating Change Ideas

35

Appendix 6: VL and EID Harvesting Change Ideas Tool

CHS BMGF Project

Viral load and EID Harvesting Change Ideas Tool

Date: Group Members (Sites):

Improvement aim:

Part A: Grading the change ideas

Tested

Change

Source

(which sites

implemented

this change?)

Evidence from

pilot sites (use

qualitative or

quantitative

data; for each

site that

implemented this

change, what was

their baseline vs

final outcome?)

Evidence from

sites (based on

previous column,

how strong is the

evidence that this

change led to an

improvement? 1 –

weak evidence | 5

– very strong

evidence

Relative

Importance

(1 – change

not that

important to

the success of

the project or

attainment of

results | 5 –

crucial to

success of the

QI project)

Simplicity

(1 – not

very simple

to

implement

change | 5 –

very easy to

implement

change in a

short

period)

Scalability (1 –

not very

scalable e.g.

hard to

implement,

depends on

special

circumstances

etc | 5 – easy to

scale up by

anyone willing

to test the

change)

Total Score

(add up all the

scores. The

change(s) with

the highest

score is the

most

implementable

change that is

likely to lead

to a positive

result in a

short period)

36

Part B: Documenting best practices – to be filled by each facility

Date: Site Name:

Group Members:

Specific problem or

indicator being

addressed

Change(s) tested; How

exactly was change

tested/implemented

(where, who, how,

when, resources etc)?

Change successful?

Yes/No? Evidence of

successful change?

Achievements/Promising

practices

Challenges and

Observations

Next Steps

37

Appendix 7: Example Daily Health Talk Roster

Date Name Department/Area Health

Topic

Total Health Talk

Participants Staff

Signature Female Male

Figure 12: Example Daily Health Talk Roster from Buyu Clinic in Karonga District

38

Appendix 8: Example of Optimized Client Flow

OLD ART CLIENT FLOW CHART NARRATIVE

WAITING AREA

Using the duty roster, health worker provides health education to clients on the topic of that day. Health education include some of the

following: importance of drug compliance/adherence, monitoring of clients on ART in their respective milestones, tuberculosis (TB) and HIV,

nutrition and also addressing any other concerns or questions raised by the clients.

After health education, clients are checked for weight, blood pressure and nutritional assessment. Then, the health provider at the reception

starts screening clients’ health passport books for VL information based on milestones, missed appointment dates and clients with HVL results

who are on or needs to be on IAC.

39

ART ROOM

All clients were referred to ART consultation room for drug refill then referred to HTS room for VL sample collection and IAC sessions.

HTS ROOM

Clients referred from ART room would receive VL sample collection and IAC sessions. Clients would sometimes depart the facility after

receiving their medications, therefore missing necessary VL sample collections and IAC sessions.

NEW ART CLIENT FLOW CHART NARRATIVE

WAITING AREA

Using the duty roster, health worker provides health education to clients on the topic of that day. Health education include some of the

following: importance of drug compliance/adherence, monitoring of clients on ART in their respective milestones, TB and HIV, nutrition and

also addressing any other concerns or questions raised by the clients.

After health education talks the clients are checked for weight, blood pressure and nutritional assessment. Then, the health provider at the

reception desk (usually expert clients, data clerks or patient attendants) start screening client health passport books for VL information based

on milestones, missed appointment dates and clients with HVL results who are on or needs to be on IAC.

ART ROOM

Client 1: This is a client who has latest VL results which are suppressed and hasn't missed appointments; on this day the patient has just come

for drug refill, so the client goes to ART consultation room. There they are screened on drug adherence and drug side effects and screened for

TB and any other anomalies. If the client has any medical condition or any drug side effect, he is referred to the Clinician for further clinical

support and management. If the client does not have any problems, such as drug side effects or illness, the provider refills drugs. The client

goes to expert clients who capture the whole visit to trace future missing appointment dates. After that the client can exit the facility.

Client 2: If a client’s follow-up VL result is unsuppressed, the client is referred to ART provider room for possible switching ART drug to

second line or further management.

HTS ROOM

Client 3: This client, upon screening in the health passport at the reception, has reached a VL milestone (6 months, 24 months, etc.) and is

referred to VL collection room for VL sample collection. After VL sample collection the client goes to ART provider room where thorough

routine screening and drug refill is performed. From there, they go to the expert client for recording the visit and exit the facility.

Client 4: Upon screening health passport book at reception, the client’s VL result is unsuppressed. If the client is not yet on IAC, he is referred

to the HTS Room for IAC initiation. If the client has unsuppressed VL results and completed only one or two IAC sessions he is also referred

to the HTS Room for IAC sessions. The client who has gone to HTS room attends the session where there is drug adherence education, IAC

protocol then documentation in high VL register and health passport for the session attended, pasting of color-coded stickers in health passport

and master card. Client then goes to ART drug provider room for refill and one-month appointment, then expert client and exits the facility.

chs/urc quality improvement collaborative project change … · 2019-02-19 · studenic and neeraj...

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