TB QI Project, South Africa

Transcription

1 TB QI Project, South Africa Msunduzi Sub district Mrs Noxolisa Mntungwa umgungundlovu District TB Manager 21 February 2018 IHI AFRICA FORUM TB QI Initiative, Africa

2 Facility QI Team Members 2 Name Mrs. N. Mtungwa Ms. S. Kunene Mr. N.S Hlela Ms. N. C. Masondo Mrs. A.N Dlamini Mr. M.R Ngwenya Mrs. S. Ngcobo Ms. N. Tshingilane Ms. G.Kgwasa Position District TB Co-ordinator District TB Supervisor District TB Supervisor District Trainer Sub- district Trainer OM MDR TB Hospital Sub -district PHC Supervisor Khethimpilo Mentor HST Mentor

3 Team Members Picture 3

4

5 UMGUNGUNDLOVU DISTRICT- Msunduzi TB Incidence rate( district) 685/ MSUNDUZI SUB DISTRICT Estimated number of TB new cases per year = Estimated number of TB new cases per quarter = HEALTH FACILITIES HOSPITALS = 6 CHC = 2 PHC = 24 Sub district Population:

6 Background Context & Problem Statement 6 District of UMgungundlovu estimated population UMsunduzi, the largest municipal Sub-district with population of (61%) of the total population This sub district is densely populated at people /sq km- which remains a challenge to combating Communicable diseases like TB Uninsured population ( 84%) Health Facilities under UMsunduzi = 24 fixed; 6 mobiles; 2 CHC; 1 District hospital,1 Regional hospital,1 Tertiary hospital and 2Psychiatric hospitals.4 Private hospitals and 2 Correctional centers. Disease profile- 3 Leading causes of death HIV District TROA TB New cases per QRT NCD estimated ( Diabetes and HPT)

7 How to eat an elephant

8

9 9 Problem statement TB screening performance in the sub district was at 81% vs. 90% before the project started. Majority of clients were missed due to poor mapping of the processes within our facilities

10 Aim Statement (SMART) 10 We from UMsunduzi sub-district therefore aim to improve TB Screening from 81% to 90% by 30 September Start date of Project: 1 April 2017

11 Problem Analysis & Tools Used 11 When we brainstormed, it was clear that our problems for low TB screening in clients 5 years and older were multi-pronged Therefore to analyze the problems, Fishbone tool was more suitable for doing the Root cause analysis to discover the causes that had contributed to low screening in our Sub district

12 Root Cause Analysis - Fishbone Data management Poor usage and interpretation of data before submission to next level Poor data collection and collation Leadership ship No allocation of staff to relieve during lunch and after hours No central TB screening point Processes Poor monitoring of performance of TB data by supervisors at facility and sub- district level Poor quality of TB screening No conduction of TB screening during lunch hours, afterhours and holidays More than one entry and exit point TB screening rate below 90% Poor documentation Poor identification of presumptive TB clients on TB register Staff

13 Change Idea(s) Tested 13 2 Key contributing factors No central TB screening points in facilities Poor monitoring of data by supervisors at facility and district level Change Ideas Support centralization of TB screening in all Msunduzi sub district facilities Daily monitoring of data by supervisors at facility and district level

14 Quarterly cascade data Msunduzi Msunduzi Sub district Total Headcount ( 5yrs and older) Screened for TB( 5yrs and older) TB Presumptive Number tested Number tested positive No started on treatment QRT 1 ( Ap-June % 4% 73% 3% 113% QRT2 ( July-Sep 2017) % 8% 33% 5% 115% QRT3 (Oct-Dec2017) % 3% 86% 6% 94%

15 Quarterly cascade data Msunduzi Organisation unit Data Apr to Jun 2017 Jul to Sep 2017 Oct to Dec 2017 kz Azalea Clinic kz Edendale Gateway Clinic kz Edendale Hospital kz Songonzima Clinic TB symptomatic client 5 years and older TB symptomatic client 5 years and older TB symptomatic client 5 years and older TB symptomatic client 5 years and older

16 Organisation unit Data Apr to Jun Jul to Sep 2017 Oct to Dec 2017 kz Doris Goodwin TB Hospital Screen for TB symptoms 5 years and older kz Doris Goodwin TB Hospital kz Doris Goodwin TB Hospital kz Doris Goodwin TB Hospital kz Doris Goodwin TB Hospital PHC headcount 5 years and older PHC headcount 5-9 years PHC headcount years PHC headcount 20 years and older kz Edendale Hospital Screen for TB symptoms 5 years and older kz Edendale Hospital kz Edendale Hospital kz Edendale Hospital kz Edendale Hospital PHC headcount 5 years and older PHC headcount 5-9 years PHC headcount years PHC headcount 20 years and older kz Northdale Hospital Screen for TB symptoms 5 years and older kz Northdale Hospital kz Northdale Hospital kz Northdale Hospital kz Northdale Hospital PHC headcount 5 years and older PHC headcount 5-9 years PHC headcount years PHC headcount 20 years and older

17 Case finding and linkage to care Msunduzi Sub-district TB Cascade Q1;2 and %; 33%; 86% Tested TB positive yield =3%; 5%; 6% 99% Treatment started :113%; 115%; 94% Presumptive TB Tested for TB TB positive TB treatment started

18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 % 140 Msunduzi: TB symptoms child under 5 years screened in facility rate HOSPITAL REPORTING / DUPLICATION OF REPORTING FOLLOWING CENTRALISED SCREENING LS1 LS2 0

19 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 % Msunduzi: TB symptoms 5 years and older screened in facility rate CCMDD CLIENTS /VISITORS REPORTING / HOAPITAL DATA EXCLUDING IN THE DENOMINATOPR LS1 LS2 0

20 kz Midlands Mobile 1 kz Caluza Mobile 1 kz Caluza Mobile 4 kz Masons Clinic kz Caluza Mobile 3 kz Edendale Gateway Clinic kz Willowfountain Clinic kz Ntembeni Clinic kz Central City Clinic kz Woodlands Clinic kz Ngubeni Clinic kz Mafakathini Clinic kz Mpumuza Clinic kz Impilwenhle Clinic kz Eastwood Clinic kz Northdale Clinic kz Khan Road Clinic kz Caluza Mobile 2 kz Ncwadi Clinic kz Taylors Halt Clinic kz Caluza Clinic kz Imbalenhle CHC kz Grange Clinic kz Pata Clinic kz Sobantu Clinic kz East/Boom CHC kz Esigodini Clinic kz Sinathing Clinic kz Songonzima Clinic kz Midlands Mobile 2 kz Northdale Gateway Clinic kz Scottsville Clinic kz Azalea Clinic Msunduzi: December 2017 : TB symptom 5 years and older screened in facility rate 20

21 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 % 21 Msunduzi: TB positive client 5 years and older rate AFFECTED BY PRESUMPTIVE CASES OUTLIERS REPORTED 5 4 LS LS2

22 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 % 22 Msunduzi: TB sputum 5 years and older test rate LS1 LS NHLS STRIKE 0

23 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 % Msunduzi: TB child under 5 start on treatment rate 80 NEW INDICATOR: INITIATIONS CURRENTLY IN HOSPITALS LS1 LS2/ Nerve centre meetings implementation 20 0

24 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar Msunduzi: Raw- TB clients positive vs started on treatment REPORTING CHALLNGES : DENOMINATOR DEFINITION A CHALLENGE ( NIDS/PROGRAM REPORTING) LS1 LS2 TB symptomatic client 5 years and older test positive TB client 5 years and older start on treatment

25 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 % Msunduzi: TB client 5 years and older start on treatment rate LS1 LS2

26 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 % Msunduzi: HIV positive new clients start on IPT rate THE CONFUSION OF NEW CLIENTS TO BE STARTED PRIORITISING UTT OVER IPT LS1 LS2 0

27 Successes 27 Improved team work within the District Quality Improvement Team members. 1 TB QIP orientation session for DMTs 5 sessions conducted centrally for 36 facility OMs and champions to provide support on generation of change ideas, PDSA, TB case finding data monitoring through run charts. 22/36=61% facilities visited on-site for support with developing TB Quality Improvement PDSA Total of two LS conducted ; which promote testing of change ideas; and cross learning and sharing across health facilities

28 28

29 Challenges 29 Data quality at facility level remains a challenge leading to outliers reported by facilities; thereby inaccurate data reported TB management in private facilities remains a challenge Competing priorities ( TB/HIV integration system; Ideal clinic etc.) limits the frequency of meetings and support visits ( however integration models need to be looked at)

30 Challenges 30 There are no unique identifiers and this results in duplication of clients when they are retested and also shopping around. Poor involvement of the outreach teams including CCG in the management of clients. Clients referred to the outreach teams when they have defaulted treatment; not in the initial treatment initiation stage Initially, Poor support by partners on the project

31 Remedial actions 31 District Support Partners workshop conducted on the 31 st Jan 2018 to support facilities onsite with District team Support Nerve centre meetings are conducted in facilities as well as at District office weekly that looks at TB cascade indicators including HIV key indicators Facility Data Quality Audits conducted supported by NDOH and partners to identify and support facilities on improving data quality challenges Involvement of data management to be part of the team

32 Project early lessons 32 Buy in and will at all levels of care Ownership of the project Onsite mentorship and support to poorly performing facilities Facilities do need support in the application of replicable Continuous Quality Improvement principles to resolve identified gaps

33 Acknowledgements 33 NDOH- LEADERSHIP AND SUPPORT KZN DOH- SUPPORT UMGUNGUNDLOVU DISTRICT MANAGEMENT IHI- NDOH PARTNER ON THE TB QI PROJECT KHETHIMPILO DSP HST DSP

34 34 WE BEAT TB