Quality improvement efforts in Nigerian public health facilities A presentation of FHI Nigeria at the maiden conference of the Society for Quality Healthcare in Nigeria 7 July, 2009 Dr Christoph Hamelmann Country Director
FHI Nigeria program development 1988 1997 1998 2004 2005 2007 2008-2009 Sexual and reproductive health programs (SRH) HIV/AIDS and SRH Global Health Initiatives: HIV/AIDS TB SRH Malaria Health systems strengthening and integration of global health initiatives Single disease program Multiple disease programs Global Health Initiatives (GHI)s Health systems and integrated GHIs
What Quality Improvement is Concerted efforts to improve the quality of medical care the degree to which health services for individuals and population increases the likelihood of desired health outcomes and are consistent with current professional knowledge The Institute of Medicine
FHI Quality Assurance Quality Improvement guiding principles Identify quality gaps and performance issues Identify the improvement goal/objectives Measure performance against standards QA Address issues Test system changes QI Develop the improvement measurement system Implement standards Develop standards Develop ideas for changes
What aspect of quality improvement does FHI Nigeria target? QI Framework Structure Process Outcome FHI specific interventions at public health facilities Institute facility-led QI initiatives Entrench quality improvement culture Establish Electronic Medical Record (LAMIS) for longitudinal patients monitoring & management Establish system-wide leadership for development through Quality Improvement Project (QIP) team and Multicenter LAMIS Evaluation Group (MLEG) Improve systems for delivering quality healthcare services Enhancing the methods for quality assurance and quality controls in service delivery Performance measurements Improve quality of clinical outcomes and public health interventions using evidence-based practices
Generic service blueprint
Three good QI examples PMTCT TB/HIV ART Improvement of ARV prophylaxis uptake Improvement of case detection of TB/HIV co-infection Improvement of switching to 2nd line ARVs
PMTCT Fishbone diagram: root-causes for low ARV prophylaxis uptake Inadequate staffing Providers False address New tool - diaries Policy National Guidelines for commencement of ARV prophylaxis POS with same day result Posting, resignation High staff turn over Low hospital delivery rate Inadequate information to track patients Policy issues HW resistance to change Timing of ARV administration Transport costs Low ARV prophylaxis uptake Distance Late ordering of drugs Lack of CD4 machines in stand-alone sites Resources Cultural beliefs Expensive Low rate of return visits to facility Partner disclosure issues Domestic violence Stigma Patients
PMTCT Impact on HIV testing and ARV uptake 1200 Pre-QI Post-QI 1000 800 600 400 200 0 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Pregnant women tested HIV positive Pregnant HIV positive woman completed ARV prophylaxis - total Total number of public health facilities involved in PMTCT QI intervention = 62
TB/HIV Root-cause analysis for low case detection of TB/HIV co-infection Poor understanding of the National guidelines on TB/HIV collaboration Policy Unavailability of National guidelines and policy documents at sites Broken-down/non-functional microscopes Poor infrastructure (non-conducive waiting room) Inconsistency in the content of counseling provided at different CT units Personnel Lack of HCT providers in the CT unit of Chest Clinic Poor documentation in TB lab register (patients HIV status not documented) Inappropriate information to clients referred to TB lab from main HCT center Difficulty in locating TB lab Lack of training for lab scientist on use of TB tools Poor documentation of HCT services at blood bank Inadequate number of trained staff at blood bank Wrong referral from blood bank Low detection of TB/HIV co-infection Incessant stock-outs of anti-tb drugs, lab reagents and RTKs Resources Occasional clients opt out of TB and HCT services Patients
TB/HIV Clinical TB screening profile at HIV service delivery points QI Intervention begins Mid Cycle Review & Correction 100% 80% 60% 40% 20% 0% Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Proportion of HIV negative clinically screened for TB Proportion of HIV positive clinically screened for TB
TB/HIV Impact on TB diagnosis amongst HIV positive individuals 100% QI Intervention begins Mid Cycle Review & Correction 80% 2 pt moving average 60% 40% 20% 0% Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Proportion of new HIV positive individuals with TB clincal screening score 1+ with 3 AFB sputum smear examinatio This chart presents results of TB/HIV QI intervention in 1 pilot site in Nigeria The key system changes/intervention that led to significant quality improvement is being tested in 42 sites in Nigeria
ART Root-cause analysis for failure to switch to 2nd line ARVs Recurring CD4 machine breakdown Lab. factors Envisaged 2nd line drugs toxicity Failure to review clients investigation Providers Inadequate information and training of HW on how/when to switch High staff attrition Work overload for physician Restricting sample collection due to manpower shortage Stock-out of 2nd line drugs Late ordering of 2nd line drugs Poor patient monitoring Resources Low rate of return visits Transport costs Distance from the public health facilities Patients not submitting samples for follow-up investigation Request for investigation not made Failure to switch to 2nd line drugs Missed appointments LTFU Patients
ART Antiretroviral treatment QI Enhanced QA/QI using FHI s EMR, LAMIS Automatically generated performance indicators Multicentre LAMIS Evaluation Group acts as the QA/QI team
ART
LAMIS: Performance indicator data dictionary
Proportion of current ART patients who had a clinical staging done at last clinical visit prior to the reporting date in Massey Street Children hospital, Lagos (N= 663) 100% 90% 80% 70% Percentages 60% 50% 40% 30% 20% 10% 0% May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr
LAMIS: Scoring system
Comparative rankings for facility improvements on percentage of current ART patients who had a clinical staging done prior to the reporting date 100 90 80 3 2 1 1 70 Percentages 60 50 40 30 20 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Mas Facility sey1 Maitama Facility 2 Mainland Facility 3
Conclusions Facility-led QI efforts for public health services supported by TA organization are feasible and successful in lifting quality of services at public health facilities in Nigeria
Thanks for listening!