Increasing the Proportion of ART Patients Receiving CD4 Testing 6 Months After Initiation on Treatment: A Storyboard from Rugarama Health Center in Rwanda Project Specifics Name of Facility: Rugarama Health Center Team Leader: Alphonse Muhizi (Head of ART clinic) Team Members: Data Clerk, Laboratory Technician, Pharmacy technician, Social Worker, & Peer Educator Background The Rwandan Biomedical Center s Institute of HIV/AIDS and Disease Prevention and Control (RBS/IHDPC), in conjunction with HealthQual, began the implementation of a site-level continuous quality improvement (CQI) program in May 2011 in order to improve the quality of HIV clinical services in Rwanda. To support this effort, RBC/ IHDPC convened a CQI steering committee to spearhead project implementation.
Nine health facilities were selected for inclusion in the first phase of the project. Six clinical indicators were selected to monitor site performance and inform CQI activities at the site level. Rugarama Health Center, located in Kigali, was one of the nine sites selected for the first phase of the program. Data collected by RBC/IHDPC indicated that only 58% of ART patients were receiving CD4 tests six months after initiation on ART at Rugarama, so site staff selected this indicator to improve through CQI activities. RBC/IHDPC and HealthQual conducted a basic CQI training, provided CQI mentorship through coaching visits and trained staff in performance measurement and data collection for Rugarama and the other 8 health facilities. This storyboard will illustrate the process undertaken by Rugarama Health Center staff to improve performance on the CD4 testing indicator. Improvement Project Goal To increase the proportion of patients who receive CD4 testing 6 months after initiation on ART as per the national standard at Rugarama Health Center from 58% to 85% between May 2011 and December 2011. Root Cause Analysis Rugarama staff used a fishbone analysis to identify all the possible gaps in their CD4 testing system.
Fishbone Diagram: Identifying Site-Level Gaps in the CD4 Testing Process for ART Patients at Rugarama Health Center Patients Geography Inaccessibil ity Stock out Insufficient request Lack of reagents Equipment Climate Culture Preventive maintenance of lab equipment not done Lack of information Illiterac y y Staff Patients do not understand importance of CCD4 test timing Lot of patient blood samples at the hospital Lack of proper utilization of the machine CD4 machine not properly working Specimen taken once a week only Lack of provider reminder system Staffs forget to remind patients Specimen taken before 10 AM Multiple appointment dates in a month CD4 control at month 6 for patients on ART Limited time allocated for taking blood sample Patients are not traced early Lack of early tracing mechanism Procedures Patients are expected to come for clinical follow up, pharmacy pick up & CD4 at different days in a month
CD4 Testing Process Gaps Selected for Intervention Rugarama staff prioritized the CD4 testing process gaps they could potentially be addressed with appropriate interventions: - The lack of a standardized and harmonized appointment system was a possible cause of missed appointments in multiple areas not just CD4 control. - Patients who missed appointments were not identified until nearly one month after the appointment was missed - There was no system for reminding clinicians to inform patients about their next CD4 appointment - Many patients were unaware of the importance of CD4 testing in their clinical follow-up The Plan, Do, Study, Act (PDSA) Cycle: Summary of Activities Implemented by Rugarama Health Center to Increase the Proportion of ART Patients Receiving CD4 Testing 6 Months after ART Initiation QI question: Will the harmonization of appointment dates, the institution of an early tracing strategy, a posted clinician reminder and patient sensitization sessions increase the proportion of patients coming in for CD4 control measurement 6-months after initiation on ART? Prediction: the proportion of patients who receive CD4 testing 6 months after initiation on ART as per the national standard at Rugarama Health Center from 58% to 85% between May 2011 and December 2011. Plan: Revise & harmonize the ART appointment system to decrease the number of visits scheduled for patients per month and, hopefully, decrease the number of missed appointments. The social worker, in collaboration with the pharmacy, is responsible for harmonizing the pharmacy pick-up, clinical follow-up and CD4 control appointment dates for ART patients one month prior to the CD4 testing date. Conduct focus group discussions with patients to assess their level of satisfaction with the new appointment system. The team leader conducts the focus group discussion. Calculate the actual date of appointment for the 6- month CD4 control from the date of initiation of ART for patients initiated on ART during the project period & beyond. The ART nurse will do this when the patient is initiated on ART.
Revise the tracing system for patients who miss appointments. Phone calls and/or home visits for patients with missed appointments are made two days after the actual appointment date. The social worker will make the phone calls & the peer educator will make the home visits for those without phone numbers: Flow Chart : Improved Tracking of ART Patients with Missed Appointments Initial Process: >1 Month to Track Patient Patients who have not come for CD4 control are identified by the social worker Revised process: 2-3 Days to Track Patient Patients who have not come for CD4 control are identified by the social worker List of patients with missed appointment is communicated to the Multi-disciplinary team (MDT) by the social worker during the monthly meeting (the list is communicated almost a month after the patient misses her/his appointment The team will request the social worker & peer educator to contact patients using phone and/or home visits No Social worker communicates the list of patients with missed appointment to the QI team leader the next day Social worker waits for patients with missed appointments for two days Does the patient come within two days after the date of appointment? The team leader will request the social worker & peer educator to contact patients using phone and/or home visits Yes List is not communicated to the QI team leader Social worker starts contacting patients & updates the team during the monthly meeting Social worker & peer educator start contacting patients via phone and will request
Include sessions the importance of CD4 testing for monitoring the health of ART patients during group & individual patient education & counseling Post a note reminding the clinician & pharmacy technician to inform patients of their next appointment on the wall in front of the clinician & pharmacy technician work stations. The team leader will prepare, orient & post the reminder. The reminder: Please have a look at small card (appointment card) & second page of file of all your patients & remind them about the date of their next visits for CD4 control, clinical follow up & pharmacy pick up. Thank you very much for doing so.
Do: The appointment system is harmonized, patients are expected to come only once per month to undergo CD4 testing, collect their drugs & undergo a clinical examination. Two to three rounds of focus group discussions were conducted after starting implementation of the harmonized appointment system. Appointment dates for 6- month CD4 testing was calculated from the date of initiation of ART for newly ART initiated patients. This was cross-checked by the data manager & the team leader. Phone calls were made to patients who missed their appointments Reminder was posted in the pharmacy & clinician rooms. The QI team noticed an increase in proportion of patients who respected their appointments for CD4 control by 10-15% from previous months. The QI team also noticed an increase in proportion of patients who are returned to care using phone calls and/or home visits by 10-15% as compared to previous months. Patients who come to the health center for CD4 control measurements also collect their drugs from the pharmacy on the same day. In addition to CD4 testing patients coming for harmonized appointments, other patients also come to the health center only to pick up their drugs from the pharmacy on this day. This has led to an increase in the workload for the pharmacy staff on the day CD4 testing is performed. The QI team observed that home visits are time-consuming & more costly than phone calls. The QI team also observed that patients without phone numbers were able to provide phone numbers of their family members, friends and/or neighbors after the patient education & counseling sessions got improved. Study: Patients expressed their satisfaction with the new harmonized appointment system. They said that it decreased their transport expenses & absenteeism from work. They also suggested applying the changes to other patients. The proportion of patients with CD4 control at 6-months6 has increased from a baseline of 58 % to 88 % after 6 months & 97 % after 9 months. These results indicate that Rugarama health center surpassed their targeted performance on this indicator.
Proportion of ART Patients who Received a CD4 Test 6-Months after ART Initiation at Rugarama Health Center: Results from Baseline, 6- and 9- Months Act: The date for 6-month CD4 testing for new ART patients was correctly calculated for all ART patients after the start of the QI program. This was confirmed through patient file review by the data clerk & QI coaching team. By harmonizing the appointment date, the QI team observed a consistent decrease in the rate of missed appointments. Additionally, the QI team observed a consistent incremental increase in the proportion of patients who were brought back to care using phone calls and/or home visits. Harmonization of appointment date will also be applied to subsequent cohorts of ART patients. The QI team will either revise the appointment system to decrease the number of patients coming only for pharmacy pick-up on the date when the blood specimens for CD4 measurement are drawn or request an additional day for CD4 measurement from Muhima District Hospital..
Next cycle: The harmonization of appointment dates for CD4 control, pharmacy pick up & clinical follow up will continue. Blood for CD4 measurement is drawn at the health center. But, the test is done at Muhima District Hospital. The hospital has allocated one day per week for each of the 9 health centers found in its catchment area for this purpose. The chance of getting an additional day in a week for CD4 measurement from the hospital is unlikely because the hospital also has a large number of patients & the CD4 machine cannot process for more than 50 patients per day. Therefore, the appointment system will be revised to decrease the number of patients coming only for pharmacy pick-up on the date when blood specimen for CD4 measurement is drawn. The calculation for 6-month CD4 testing from the date of initiation of ART will continue. This will also be applied to subsequent cohorts. The QI team will trace patients who miss appointments using phone calls because they are cheaper and more efficient than home visits. Home visits will be used for patients who cannot be reached by phone. Next Steps: Monitor the implementation of activities as per the work plan & present the findings at monthly QI team meetings Measure the performance on the 6 QI program indicators, discuss the findings with the QI team members & post the results on the wall of the clinic Work very closely with the community, involve patients in the QI team & conduct regular focus group discussions to assess patient level satisfaction of service Share the QI findings with other staff members at the health center in order to initiate quality improvement activities in other services areas. Lessons Learned: Evidence-based change in health facility processes can result in clinical performance improvement Team work & involving patients in QI discussions can help to achieve better results Improvement can be achieved using available resources. Involving the patients & the community during the planning phase, prior to implementation, will help design better strategies to improve the quality of services