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Table of Contents

Introduction Page 1

Overall Goal Page 1

20,000+Partnership Page 2

Best Care Always! Page 3

Aurum Page 4

ARV Chronic Care Clubs Page 6

CAPRISA Page 6

R&D Page 7

Publications Page 7

Contact Information Page 8

Institute for Healthcare Improvement

South Africa Country Report

May 2012 - September 2012

Introduction

The South African (SA) country program was started by the Institute for

Healthcare Improvement (IHI) in 2005. Over the past seven years, the

IHI-SA team has worked closely with a growing group of local partners

and the Department of Health (DoH) to help save South African lives

and improve the experience of patients interacting with the health

system.

Overall Goal

The IHI-SA country program is intended to accelerate sustainable

improvement in health and health outcomes for individuals and

communities nationwide. IHI-SA partners closely with local, regional and

national health system leaders in the Department of Health and with a

dynamic group of South African academic and non-governmental

organizations (NGOs), thereby influencing the thinking and practice of health at scale. IHI-SA has two clear goals:

improving safety in hospitals throughout the country and improving the care of patients living with HIV. With

both, the specific aims are simple: save the most possible lives in the shortest possible time and learn as much we

can along the way.

Recent Highlights:

• IA Course Wave 27 – IHI-SA is planning to host its second Improvement Advisor (IA) Professional Development

Program in Johannesburg, South Africa, from February 2013 to September 2013. The South African offering

follows on the heels of a successful IA training in Durban/Cape Town last spring. Led by Brandon Bennett, with

support from faculty Ron Moen and Lloyd Provost, our faculty will teach the essentials of Quality

Improvement (QI) over 10 months. This course is intended to provide QI capacity to our partners all over the

world.

• Leading and Facilitating Quality Improvement Teams – A newly designed, intensive ten-week program is being

launched in early 2013. This program is specially designed for people actively involved in health care

improvement projects. Participants will use the Model for Improvement as a framework on an improvement

project and learn how to coach teams and work with leaders on improvement projects. Email to:

dheaney@ihi.org for more details on either course.

Spotlight on: Dr. Michele Youngleson

Dr. Youngleson has been with IHI for since the beginning of the South Africa programme

in 2005. Currently, she is working with IHI on reducing hospital acquired infections with

Best Care…Always!, strengthening the PMTCT program with the Aurum Institute, and

spreading a model for efficiently managing large numbers of patients on antiretroviral

therapy (ARV clubs), actively combining her healthcare interests in medicine,

epidemiology, and psychology. She is an avid public health researcher, completing

Medical School at the University of Cape Town and her postgraduate honors degree in

epidemiology at the University of Stellenbosch. Her primary research interest is focusing

on methods and impact with health systems improvement in public healthcare settings.

Her passion is focusing on supporting staff at the frontline of care to ensure that they are able to liberate positive

energy and compassion throughout their communities. Previously, Dr. Youngleson has worked for the public

healthcare system in primary care clinics within Cape Town, was an epidemiologist for the Medical Research

Council, and held her own private practice focusing on the psychology of illness. She enjoys spending time with

family and friends, cooking & eating, surfing, and walking in the vineyards and mountains around Cape Town. Dr.

Youngleson and her husband started surfing 5 years ago; they enjoy sharing the waves with seals, dolphins, and

the occasional great white shark (at which point they make a dash out of the water!).

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20,000+ Partnership

Overview of the Partnership:

20,000+ is a partnership between the Kwa-Zulu Natal (KZN) Department of Health, the University of KZN and IHI

which aims to eliminate perinatal transmission of HIV in the Province and has already shown a decrease of MTCT

rates to below 3%. The project has expanded from 3 initial Districts to all 11 Districts in KZN Province and has

launched efforts to improve infant nutrition. The project supports the National Department of Health’s efforts to

eliminate mother to child transmission by 2016. They have also started the Nompilo project aimed at examining

the impact of interventions to improve child survival through community health workers enabled to use QI.

Recent Highlights:

• 20,000+ assists KZN province to sustain improvement as evident in the line graphs provided below. Data is

being used for action through the “PMTCT dashboard” and KZN Provincial DOH is leading the way with the

support of 20,000+ by spreading key change ideas and scaling up improvements across the country.

• Regular monthly conference calls with the 11 PMTCT district coordinators and information officers promotes a

culture of using information for improvement. This is led by DOH and 20,000+ analyses of the dashboard data.

• Training of community care givers (CCGs) in integrated case management and quality improvement has

commenced in Ugu district, KZN. It builds on the existing community framework training provided by DOH.

These CCGs provide household interventions for maternal, neonatal and child health care.

0%

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Sustaining improvment over time

All three districts HIV Testing RateUgu, eThekweni and Umgungundlovu

Data element change20 000+ data

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Antenatal client initiated on HAART Antenatal client eligible for HAART

QI project PMTCT co ordirnator

dashboard

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KZN Province Babies PCR Positivity around 6 weeks

QI project PMTCT co-

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Promoting exclusive breastfeeding

KZN Province Babies Exclusively Breastfed at 14 weeks

Introduction of new data element

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Amajuba District18 Months rapid testing uptake(DTaP-IPV/Hib 4th dose)

M&E program Conference calls

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Best Care Always!

Overview of the Partnership

The “Best Care…Always!” (BCA) campaign is an initiative aimed at supporting SA hospitals to implement evidence-

based interventions to reduce healthcare associated infections (HAI) and ensure the judicious use of antibiotics.

Patterned after the IHI’s “100K lives” campaign, the Canadian “Safer Healthcare Now” initiative, and WHO’s World

Alliance for Patient Safety, BCA was launched in August 2009 to support SA’s private hospitals, and spread in May

2010 to include public sector hospitals. BCA seeks to enhance patient safety and improve quality in hospital care

through partnership with major public and private healthcare providers, funders and professional societies. Thus

far, over 200 private and public hospitals are enrolled each implementing at least one infection prevention and

control bundle. BCA works in the public health sector in Gauteng and the Western Cape.

Recent Overall BCA Highlights:

• Learning Sessions were held for public hospitals in Gauteng and Western Cape in June and Free State in July.

• A further Learning Session is planned for Gauteng in October and final Learning Session for the Western Cape

pilot project in November.

Recent Highlights (Western Cape):

• Months into the project, perseverance and hard work is beginning to show an excellent reduction in hospital

acquired infections in many of the 9 participating hospitals in the Western Cape as hospitals are able increase

compliance with the bundle elements.

• Western Cape projects are being put onto the IHI extranet database for ongoing data surveillance post 2012.

• The final Learning Session for the Western Cape pilot project in November that will address sustainability,

spread and dissemination of the learning.

Maternity Hospital – Reduction in Caesarian Section surgical site infections

Readmission rates for septic caesarian section Days between septic hysterectomy

Reduction in Vetilator Associated Pneumonia (VAP) in an ICU at a teaching paediatric hospital

VAP rates/100ventilator days Days between VAP

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Reduction in Catheter Associated Urinary Tract Infections (CAUTI) in three spinal units at a rehabilitation facility

Rate of CAUTI/catheter days Days between CAUTI

Improved overall compliance to bundle elements for preventing CAUTI in a secondary hospital

The Aurum Institute

Overview of the Partnership:

The Aurum Institute (Aurum) is a South African not-for-profit organization which has been working for more than a

decade to support the Department of Health to strengthen HIV and TB prevention, care and treatment services in

Gauteng, Limpopo, and North West Provinces. IHI’s partnership with Aurum aims to improve PMTCT, Pediatric and

Perinatal TB and HIV care in Ekurhuleni North (EKN) sub-district in Gauteng Province and Greater Tubatse and

Ephraim Mogale sub-districts in Limpopo Province. In addition, we seek to build QI capabilities both within the

Aurum team and with their DOH counterparts. Mother-to-child HIV transmission rates are already below 5% in

EKN and the aim is to further reduce the MTCT rate to 2% by September 2012, and to improve postpartum HIV/TB

follow-up and linkage to care for mother and infant.

Recent Highlights:

• Monthly data peer review meetings have been structured in all sub-districts to

support clinic supervisors and operational managers to use the data to

prioritise clinics for intervention.

• To encourage dissemination of the QI work, a writing workshop was held for

Aurum’s 10 mentors and 2 Improvement Advisors to write up improvements

made at specific clinics. These will be made into posters for display at the

second Learning Session and facilities.

• Up until now the QI project has focused on strengthening antenatal PMTCT

care and has recently included PMTCT in the Labour Ward. The second

Learning Session, to be held in the next quarter, will include a focus on

The antenatal (ANC) nurse and

data capturer at Moetsie West, a

rural clinic in Limpopo province,

explain the graphs they have

made to track antenatal PMTCT.

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postnatal care of mother and baby.

• Aurum has been awarded additional grant funding to extend the QI project from 3 sub-districts with 76

facilities to 5 districts comprising 23 sub-districts and 460 facilities. This spread phase will require a major

increase in QI capacity and redesign of the project to leverage capacity for the spread phase.

• Experiences, changes and tools from the current pilot project will be written up as resource material for the

spread phase

Key Results & Next Steps:

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ARV Chronic Care Clubs

Overview of the Project:

IHI’s previous Western Cape efforts to increase access to ART won a 2010 platinum Impumelelo Award for

excellence in service delivery. The award money was used to start a QI collaborative to achieve District-wide scale-

up of an “ARV Chronic Care Club” model—an approach developed by MSF to manage large cohorts of patients on

life-long ARVs. The project is a joint effort of the municipal and provincial departments of health, MSF and IHI in

the Cape Town Metro District. Recent analysis has shown that half of Cape Town’s 47 ART facilities each had over

1000 patients on life-long ART (range 1025-5266). The need for an efficient and effective model for managing

these large patient loads, within current resource constraints, was pressing. The ARV Chronic Club model uses

limited resources in an efficient and effective way to enable stable patients to be managed in groups of 30 by a

counselor and supportive clinical team. Outcomes in the MSF-supported prototype facility were excellent with

97.6% of patients still in care after 2 years. The spread effort began in Dec 2010 with 14 ARV clinics with an aim to

start 360 clubs for 10,000 stable patients representing 30% of all patients on ARVs in participating clinics by August

2012.

Recent Highlights:

• In September 2012, the ARV Chronic Clubs project won a second Platinum Award from the prestigious

Impumelelo Social Innovations Centre that rewards excellence in service delivery. The Award will be used to

create a website to make the necessary tools, such as guidelines and registrars, available to an international

audience to promote the use of Adherence/ARV Chronic Clubs to other countries with a high HIV burden.

• Since the start of the project in December 2010, the project has now spread beyond the original 14 clinics to

over 450 ARV Clubs in 35 clinics in the Cape Town Metro District managing over 12,000 patients. Below are the

graphs for that progress with the original target lines.

Key Results:

CAPRISA

Overview of the Partnership:

The Centre for AIDS Research in South Africa is a leading global HIV research organization. Together with CAPRISA,

IHI faculty teach a CDC-sponsored “Implementation Science” course at the University of KZN to develop new

cadres of researchers with skills in doing practical operations-oriented research for improvement. This work has

kindled interest in using QI methods to more rapidly bring clinical research findings into common practice in public

health settings. Based on the success of tenofovir, a microbicide gel that women can use to prevent HIV infection

during intercourse, IHI is working with CAPRISA at two pilot facilities to strengthen the quality of reproductive

health services so that when and if this new drug becomes available, it can be utilized in the public health service

more effectively.

Recent Highlights:

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• Sixty CAPRISA employees have been trained on quality improvement. Seven QI projects were identified in the

various departments including the family planning (FP) initiative which is supported by IHI.

• The are no data to report due to steps in the approval process, however, the quality of care indicators and

indicator definitions have been agreed upon e.g. uptake of family planning services, HIV counseling and testing

in family planning, adverse effects monitoring, and Pap smear in family planning clinic. DOH and facility data

will be used to report these measures and a data collection system has been articulated to capture these data.

Research & Development

IHI’s 90-day innovation process is our engine for

research and development. The process was designed

to provide a reliable and efficient way to research

innovative ideas, assess their potential for advancing

quality improvement, and bring them to action. IHI

created a small Innovation Team with dedicated

resources to support this process, and the team begins

at least five new projects every 90 days. Projects are

selected by IHI’s leadership team along with the R&D

team based on IHI’s strategic plan and customer needs

and suggestions.

Current Wave of Projects:

The Joint Learning Network for Universal Healthcare Coverage (www.jointlearningnetwork.org)

The Joint Learning Network (JLN) is a network of insurance agencies in ten low and

middle-income countries working together to expand access to financial coverage

for universal healthcare. The JLN has four technical tracks: expanding coverage,

provider payment mechanisms, information technology and the quality track. IHI

and the NHS Institute for Clinical Excellence (NICE) jointly lead the “Quality Track” of the JLN. This 90-day cycle, we

are working to develop guidance for payers on how they can contribute to driving quality improvements in health

systems. This work relates to larger work that IHI is pursuing about how employers, health plans and provider

systems can all work together to improve quality in health system. In addition to general guidance on how payers

can influence quality, the 90-day cycle will explore three specific mechanisms that payers can use to drive

improvement based on the needs and interests of the JLN members: developing the key measures for tracking the

quality of health services from an insurers perspective, identifying the vital behaviors of an accreditation system

that promotes continuous improvement in care, and the development and testing of national quality strategies to

improve care amongst their beneficiaries. For more information on this R&D topic, please contact: Zoe Sifrim,

zsifrim@ihi.org

Publications

http://content.healthaffairs.org/content/31/7/1489.full.html

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Institute for Healthcare Improvement

South Africa Program Team

Nneka Mobisson-Etuk, MD, MPH, MBA, has joined IHI as Executive Director

of African Operations. Nneka is responsible for the operations and

implementation of IHI's existing work in Africa, as well as for developing IHI's

portfolio in Africa as part of the organization's work in low- and middle-

income countries. She is based out of Johannesburg, South Africa.

Dr. Pierre Barker – Senior Vice President

Maureen Tshabalala – Improvement

Advisor

Farzaneh Behroozi—Improvement Advisor

Dr. Kedar Mate – Country Director

Dr. Michele Youngleson – Improvement

Advisor

DeAnna Heaney – Project Coordinator

Institute for Healthcare Improvement

University of Kwa Zulu Natal

1st

Floor George Campbell Building

Durban, 4001

For more information, please contact: kmate@ihi.org