jamaica quality improvement...

JAMAICA QUALITY

IMPROVEMENT COLLABORATIVE

Clive Anderson

Clinical Coordinator CHART RCU

Collaborative Chairman JaQIC

Slide -2

Quality Improvement in

Healthcare

3rd CHART-CCAS-CMLF Joint Meeting

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Quality Improvement:

Bridging the Implementation Gap

Implementation

Gap

Where we want

to be

Current status Pro

gre

ss

Time


Slide -4

Collaborative Quality

Improvement model

• Well tested approach that

involves frontline health care

providers in developing and

implementing changes that

improve the quality of healthcare


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Improvement Collaborative (1)

An Improvement Collaborative is:

• an organized network of a large number of sites

• that work together for a limited period of time

(usually 12 - 18months)

• to rapidly achieve significant (often dramatic)

improvements in a focused topic area through

shared learning and intentional spread methods.


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Improvement Collaborative (2)

• Build will & excitement for Quality

Improvement – for improved quality of care

• Demonstrate that frontline staff can make

impactful changes

• Build a cadre of HCWs with experience in

Quality Improvement to spread the word

• Increase ability of site teams to collect,

analyze and act on their own data


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Guiding Principles for a Collaborative

• All teach, all learn!

• Learning by doing

• Learning from each other

• Using data for learning (not

judgment)


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Laboratory monitoring of HIV

• Monitor disease progression

• Guide OI prophylaxis

• Indicator of need for ART

• Assess response to therapy

• Important indicator of retention in

care


Slide -9

National Adult Antiretroviral Treatment Guidelines

(Jamaica, 2011)

Baseline Follow-Up

Before ART

Initiation

After ART

Initiation or

Switch

Follow-Up

on Effective

ART

Treatment

Failure or

Clinical

Indications

CD4 x At 3 & 6

months.

Then every 6

months

x

VL 6 months 12 months x


Slide -10 3rd CHART-CCAS-CMLF Joint Meeting

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CHAI (2013)

37%

42%

26%

42%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

SERHA SRHA NERHA WRHA

Current data shows

~42% CD4 Uptake

island wide.


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State of CD4 Testing

• 26 – 42% of patients are receiving

CD4 tests as indicated by known

standards of care.

• In other words, 6-7 of 10 patients are

leaving without the recommended

diagnostics

JAQIC

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JAMAICA QUALITY IMPROVEMENT

COLLABORATIVE


JaQIC!

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JAQIC! AIMS( AT EACH SITE)

• Increase CD4 tests ordered and

completed for active patients from

baseline to at least 80% by March,

2014

• Increase viral load testing from

baseline to at least 80% by March,

2014

Slide -15

JAQIC! MEASURES

• % of active* patients with CD4 count in last 6 months

• % of active* patients on ART for at least 6 months with VL count in last 12 months

• Time in days for CD4 and VL test results to come from NPHL and Cornwall Regional Laboratory

• % of dockets that have last ordered CD4 and VL results on the day of patient visit.

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Collaborative Planning Group

• Co – Directors: Clive Anderson (Clinical Coordinator, UWI

CHART), Tina Hilton-Kong (Medical Director, ERTU CHART

Jamiaca) will serve as the co-Directors.

• Dr. Nicola Skyers – Director Treatment Care & Support, NHP

• Dr. Geoff Barrow - Medical Director, CHARES, UWI

• Content Faculty: Chris Behrens (Clinical Advisor, I-TECH)

• Improvement Advisors: Shay Bluemer Miroite, QI Advisor, I-

TECH

• Karen Zeribi, Independent QI Consultant

• Measurement Analyst: Malene Townsend, M& E Specialist

UWI-CHART

•


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Faculty members

• Members of the Collaborative Planning Group

• Director Immunology NPHL – Dr.

Michelle Hamilton,

• NHP M&E Officer - Zahra Miller,

• CHAI - Krystal Lawrence


Slide -19

William Edwards Deming

“Put everybody in the organization

to work to accomplish the

transformation. The

transformation is everybody's

work.”


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QI Methodology

• Each sites forms multidisciplinary team

• Site teams meet regularly – every 2 weeks

• All teams are joined into a collaborative learning network

• All teams are convened regularly ( every 3-4 months) at a learning session to review progress, learn from each other

• Teams use systems change strategy based on – PDSA cycles


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What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

Act Plan

Study Do

Langley, et al. p96

Goals

Measures

Ideas


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Key Points for PDSA Cycles

Do initial cycles on smallest scale possible

• Think small…a “cycle of one” usually best

• Small test does NOT equal small results!

• “Failed” cycles are good learning opportunities when small

Fail early and fail often to avoid failing spectacularly….


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Quality Improvement Teams

• Teams reviewed data and planed changes to be tested weekly.

• Carry out tests of change, and collected data

• Share data transparently in collaborative monthly reports. Submit a brief narrative report each month describing the work done, successes, and challenges.

• Participate in three Learning Sessions (3 people), monthly calls, and site visits.


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Learn with Rapid PDSA Cycles

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

A P

S D

Very Small Scale Test:

Follow-up Tests

Wide-Scale Tests of Change

Implement Change

Source: Langley et al. The Improvement Guide.

Slide -25 25

Institute for Healthcare Improvement, www.ihi.org

Improvement Collaborative Structure


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The Process

• Learning Session I (Oct 1-3, 2013) • Baseline site level data shared at LSI was a surprise

to all. Some teams were as high as 57%, some as low as 2%.

• Challenges in getting baseline VL data.

• Teams shared average turn around time for CD4 and VL results.

• Aim: Increase the percent of CD4/ VL tests completed according to national guidelines from baseline to 80% by March 2014.

• Ideas for improvement were generated using tools including FMEA and swim lane.

• PDSA concept introduced and plans for improvement made.

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Swimlane flow charts ARE fun!


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PDSA = Learning + Improving!

Act • What changes

are to be made?

• Next cycle?

Plan • Objective

• Questions and

predictions (why)

• Plan to carry out the cycle

(who, what, where, when)

• Plan for data collection

Study • Complete the

analysis of the data

• Compare data to

predictions

• Summarize

what was

learned

Do • Carry out the plan

• Document problems

and unexpected

observations

• Begin analysis

of the data


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Example of Repeated PDSA Cycles at

Cornwall Regional Hospital

Hunches

Theories Ideas

Changes That Result in

Improvement

A P

S D

A P

S D

Very Small Scale Test: Tried flagging dockets that need CD4

and VL tests with just 10 dockets

Follow-up Tests: Tried putting order sheet in dockets

(no change)

Folow-up Tests: Identified docs who weren’t

ordering tests and met with them

Follow –up Tests:

Re-tried inserting order

form for test into dockets of

patients who need tests

Source for Ramp Concept: Langley et al. 1996. The Improvement Guide: A Practical

Approach to Enhancing Organizational Performance.

Change Concept:

Identify in advance dockets of

patients that need an

updated Viral Load or CD4

test

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The Process cont’d

• Action periods

• Immediately following LS1 (Friday October 4) four

sites with support from ITECH and UWI-CHART

were visited to help with start up and sharing ideas

to larger team.

• Sites tested ideas and made changes as

necessary.

• UWI-CHART and CHART Ja conducted and

supported an average 3 site visits per site

including 1 exchange site visit. 3rd CHART-CCAS-CMLF Joint Meeting

Slide -33


• Learning Sessions II and III

• Ten sites came together to share progress and learn from each other ( steal shamelessly).

• All sites had seen an improvement after 2 months of implementation but the December period saw a dip in CD4 and VL uptake.

• VL baseline was shared at LSII.

• Improvement was seeing in turn around time for CD4, but lab challenges with VL processing caused continued lengthy waits for VL results.


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• Learning Sessions II and III

•Patients invited to share their

experience at LSII. .


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Examples of Changes Tested

• Phlebotomist comes on site to take

blood.

• Education/Instruction kits/cooler for

driver transporting samples.

• Drivers route examined and changed

to allow faster delivery of results 3rd CHART-CCAS-CMLF Joint Meeting

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• Assign patients 3 and 6 week test

return date for CD4 and VL

respectively before actually clinic

appointment.

• Call & Schedule follow up visit for

patients missing appointments.


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• Increase in the number of days for sample

collection

• Contact Investigator verifies with the lab the

following day if blood was drawn.

• Pre-pull and review dockets prior to

appointments.

• Place reminders in dockets for clinicians to

order CD4/Viral load tests where applicable.


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THE RESULTS: Combined sites: CD4

Uptake

35%

44%

56%

45%

54% 55% 58%

68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 Mar '14 May '14

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3 JaQIC! Sites Achievements

57%

72% 74%

67% 70%

32%

64% 66%

59% 60%

2%

36%

44%

53% 53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Baseline October November December January

Site X

Site Y

Site Z

JaQIC Learning Session 1: October 1, 2013

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THE RESULTS : Combined sites: VL

Uptake

40% 36% 37%

30%

49%

38%

54%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Oct '13 Nov '13 Dec '13 Jan '14 Feb '14 May '14


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8 month outcomes

• Significant improvement in important measure

achieved

• QI methodology validated in our setting

• Cadre of healthcare workers trained in QI

methods

• Sustainability assured as QI

accepted as job function of TCSOs


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Most Importantly

• HCWs convinced of importance of

generating/analyzing their own data and using

it to improve care

• Genuine sense of a multidisciplinary TEAM

generated

• Frontline staff accepted responsibility for

improving the quality of care delivered at their

site


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CONCLUSIONS

• The delivery of modern health services is

complex and dynamic

• It is feasible to study the process of health

care and find ways to improve it— to direct

change

• Our hypotheses about how to improve health

care should be tested before we accept

them— the scientific method

• • 3rd CHART-CCAS-CMLF Joint Meeting

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• Frontline health workers can do

most of this work (with support) —

they know the system - they are the

system experts

• A few simple analytical tools, like

flowcharts, can apply to most health

system issues


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QI Collaboratives - excellent tool

• More rapid progress - Each team learns from

work of the others: don’t re-invent the wheel

• Peer group provides motivation/competition for

QI work

• Facilitates spread of improvements--more

efficiently

• Pressure for better quality, quantitative

records

• Framework for rapid scale up 3rd CHART-CCAS-CMLF Joint Meeting

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3rd CHART-CCAS-CMLF Joint Meeting DANK JE

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