Improving ART adherence assessment at Baylor-Uganda main clinic - - PowerPoint PPT Presentation

Improving ART adherence assessment at Baylor-Uganda main clinic Mulago Hospital

Fellows-Dr. Kisitu Grace Dr Tumbu Paul Supervisors- Dr.Allan Ahimbisibwe

• Dr. Ellizeus Rutebemberwa

Dissemination workshop at Imperial Royale Hotel

On 20/8/2010

Introduction

• Baylor provides HIV care &

treatment services to children, adolescents and adults

• Active patients ~ 4,800
• About 55% are on ART
• CQI project was undertaken

to improve ART adherence assessment

Problem identification

a) ART adherence assessment b) Continuity of care c) TB screening d) Growth monitoring e) Access to ITNs f) CD4 monitoring g) ART eligibility h) Septrin prophylaxis i) support counseling j) Patient waiting time

• Brainstorming was done during a routine CME
• Ten Quality Improvement indicators were

subjected to a voting process :

Problem identification

• Theme selection

process prioritized ART adherence assessment for the improvement

Problem statement and Justification

• All patients on ART should

be assessed for adherence

• By Sept 2009, 47% of

clients on ART where not assessed for adherence

• This can lead to:

– Patient/provider complacency – poor ART adherence – treatment failure – poor quality of life

Baseline situation

Series1, April, 26 Series1, May, 37 Series1, June, 37 Series1, Sept, 47

percentage Months /2009

% patients on ART not assessed for adherence

Project objectives

General objective:

• To improve adherence assessment among patients

receiving ART Specific objectives:

• To reduce the proportion of patients on ART in Baylor main

clinic who do not receive complete adherence assessment from 47% to 15% by March 2010

• To identify the factors contributing to the non-assessment
• f adherence among patients receiving ART
• To develop and implement practical solutions to the

factors contributing to the non-assessment of adherence among patients receiving ART

Project implementation

• Started with the problem analysis which was done in 2

parts i. Stratification of the problem by use of a pareto chart

• ii. Cause-effect analysis by use of a fish-bone diagram

Pareto chart

cumulative %, inappropriate tools used, 40 cumulative %, appropriate tool, but incomplete assessment, 71 cumulative %, inappropriate/ no appointment given., 100

Causes of none or incomplete ART adherence assessment

% of cases not assessed for ART adherence cumulative %

Cause-effect analysis

Category Root causes Tools & appointments

• Multiple tools & multiple

appointments Patients

• Not aware of need for assessment
• Some on Syrup medicines

Patient flow

• multiple service points

Clinicians

• not using scheduling guides

Reception nurse

• inserting wrong visit tools into

patient charts

Countermeasure matrix

Root cause Practical solution

• Multiple tools & multiple

appointments Reduce visit tools & adopt those that provide for assessment

• Patients not aware of need for

assessment

• Some patients on syrups
• Increase awareness through H/E
• Switch to pills (FDC’s)

multiple service points

• harmonize service points

Complex scheduling guides for clinicians

• revise and make simpler

scheduling guides

• Develop appointment cards

Inserting of wrong visit tools into patient charts at reception

• sensitize nurse on insertion of the

correct tools

Two practical solutions were not implemented:

• Development of patient appointment cards
• Revision of scheduling guidelines for clients

Project follow-up was done monthly by analyzing data

• n adherence assessment performance

40 patient files were assessed monthly, in total 200 files were analyzed during the course of implementation

Project outcomes

Series1, Apr-09, 26 Series1, May-09, 37 Series1, Jun-09, 37 Series1, Sep-09, 47 Series1, Nov, 25 Series1, Dec-09, 17 Series1, Jan-10, 10 Series1, Feb-10, 12 Series1, Mar-10, 12

INTERVENTION TARGET

TIME P E R C E N T A G E

Proportion of patients on ART not assessed for adherence

BEFORE AFTER

Lessons learnt.

• Team work is key to successful QI project

implementation

• Simple practical solutions can help improve health care

quality without extra financial burden to the program

• Not all solutions in quality improvement are as effective

as may be expected but through continuous innovation the most effective countermeasure may be attained

Lessons learnt

• A single practical solution may have a big impact on

its own to influence project outcome

• Identification of the true root causes of a problem

is critical for QI project development

• The CQI project findings can be used to validate the
• rganizations M&E reports

Challenges

• Two of the proposed counter measures were not

implemented for reasons below: – Development of patient appointment cards – Revision of the patient scheduling guides

• The records system was upgraded to the electronic

medical records (EMR) system shortly after the project ended. – No chance to further observe their QI innovation for sustained improvement in adherence assessment

Challenges

• The process of ongoing data collection and analysis

was tedious – carried outside official working hours

Conclusion/Next steps

• We managed to reduce the proportion of

patients not assessed for ART adherence from 47% to 12%, surpassing our target of 15%

• Apply the same QI principles to address the

remaining problems

• Support the QI programs in other Baylor

supported clinics

Acknowledgement

• The Management and staff of Baylor Uganda
• The Supervisors
• MUSPH-CDC fellowship program
• The CQI team
• CQI fellows