A continuous quality improvement(CQI) approach directed at improving HAART initiation for eligible

pregnant women in the province of Kwa-Zulu Natal, South Africa

2012 SOMSA CONGRESS,

ST GEORGES, TSHWANE

04 DECEMBER 2012

Mrs Otty Mhlongo

PMTCT Manager - KZN

Background

• KZN Province is at the epicenter of the HIV pandemic, (highest antenatal HIV prevalence- 39.5 %(DOH, 2010) in SA).

• Problem statement: 43.7 % of maternal deaths in SA, is due to non pregnancy - related infections, primarily HIV/ AIDS. (Saving Mother's Report 2005 -2007).

• HIV positive women eligible for HAART are not initiated timeously, leading to high MTCT rates, and maternal deaths.

• In March 2010, 52% of pregnant women eligible for HAART (CD4<350 and WHO stages 3 and 4) accessed treatment.

• Simple method to identify gaps in the healthcare system

• Systematic way to close those gaps and safely improving the process of care

• Principles (WILL, IDEAS, EXECUTION):• Apply local wisdom • Focus on the data (stop the blame game)• Work “smarter” NOT just “harder”• Partnership and teamwork is the only way forward

“Quality Improvement” in healthcare

RegulationStandards

Professional oversight

Accreditation

Performance review

QA

QA and QI

Evidence

Guidelines, protocols,

SOPs

Training Competencie

s

CQIAims: what are the “gaps”

Measures: tools to measure the critical processes and outcomes

Changes: frontline methods and activities to close the “gap”

IMPROVED OUTCOMES

AIM • To increase initiation of all (100%) of pregnant

women who were eligible for ART onto treatment.

• Target population: All PMTCT/MCWH coordinators in the 11 Districts of KZN including operational health workers in all the public health facilities.

Intervention

• A Continuous Quality Improvement methodology, aimed at health systems strengthening, improving the reliable delivery of processes.

• A 'dashboard 'of key indicators was tracked. The 20,000+ partnership (made up of the KZNDOH, IHI and UKZN) used tools to identify root causes of process failure, iterative tests of change (Plan-do-study-act cycles), and local data to guide improvement.

• “Wedge” meetings – meetings between hospitals and feeder clinics, focusing on indicator performance

WHAT IS A DASHBOARD?

DASHBOARDS

• Helps view the whole and guide the improvement team to whether changes are leading to improvements.

• Always in front of your eyes- helps team to focus

• A useful dashboard will have outcome, process and balancing measures

Results

• HAART initiation increased to>80% (Q1 12/13 -85,3%)

• Data -focused approach to improvement using

• Noticeable decline in Maternal mortality from 392 in 2010 to 353 in 2011, and quarterly trend of Q1 2011/12 - 117 to Q1 2012/13 - 87.

• Reduced MTCT Q1 2012/2013 = 2.6%• MTCT – Collaborated with NHLS/MRC

Results (Cont…)• Strong ties/collaboration with feeder clinics

and mother hospital(Wedge approach)• Team approach into solving problems• Common shared aim- working towards

achieving same goal • Perinatal review meetings – CQI standing item

Jan-1

0

Mar-1

0

May-

10

Jul-1

0

Sep-10

Nov-10

Jan-1

1

Mar-1

1

May-

11

Jul-1

1

Sep-11

Nov-11

Jan-1

2

Mar-1

2

May-

12

Jul-1

2

Sep-12

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

110%

KZN ProvinceANC client Initiated on HAART

Months plus years

Pe

rce

nta

ge

=A

NC

clie

nt

init

iate

d o

n H

AA

RT

ov

er

AN

C c

lien

t e

ligib

le f

or

HA

AR

T

QI Project started

KZN ProvinceANC client Initiated on HAART

(Raw numbers)

Jan-

10

Feb-1

0

Mar

-10

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-10

Nov-1

0

Dec-1

0

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-11

Nov-1

1

Dec-1

1

Jan-

12

Feb-1

2

Mar

-12

Apr-1

2

May

-12

Jun-

12

Jul-1

20

500

1,000

1,500

2,000

2,500

3,000

Antenatal client initiated on HAART Antenatal client eligible for HAART

Ra

w N

um

be

rs

KZN Baby PCR Positivity around six weeks

Jan-10

Mar-10

May-10

Jul-10

Sep-10

Nov-10

Jan-11

Mar-11

May-11

Jul-11

Sep-11

Nov-11

Jan-12

Mar-12

May-12

Jul-12

Sep-12

0%

2%

4%

6%

8%

10%

12%

14%

Time in months/years

Perc

enta

ge=

Baby

PCR

tes

t po

s. a

roun

d 6

wee

ksov

er B

aby

PCR

test

aro

und

6 w

eeks

Changes Initiated

Maternal mortality 2010/2011

2010 2011330

340

350

360

370

380

390

400

392

353

Maternal mortality

QRT 1 2011/2012 QRT 1 2012/20130

20

40

60

80

100

120

140

117

87

Implications of a QI approach on the health system

• Quality Improvement approach is a leveraged strategy to improve health system performance towards better health outcomes.

• A multi-faceted/ multi-disciplinary approach that effectively improves the working and coordination of the health system through engaging:

- Leaders- Districts Programs / Data management team- Frontline workforce to be part of the solution- Data usage to guide improvement- Improved communication between hospitals and feeder clinics • End-product: Better use of existing resources and closing feedback

loop.

Recommendations and future actions

• A data focused quality improvement approach, mentorship/support by Provincial, District and support of Partners at all levels including systematic approach to improvement can facilitate rapid achievement of national PMTCT/MCWH targets, thus meeting the Millennium Development Goals

Conclusion

• Quality improvement approaches have helped to close the service delivery gaps for PMTCT interventions in KZN.

• The same replicable approaches can be applied to other areas of MCH care and other programs to help strengthen health systems.

• Applying same principles in working towards E-MTCT by 2015- Action Framework and achieving MDG 4, 5 and 6.

Acknowledgements

KZN DOHMs Pinky Phungula –MCWH

Province UKZN- 20 000+ Partnership

Team- PEPFAR CDC fundedAll Partners