Systems Analysis & Im Improvement proje jects in in resource - - PowerPoint PPT Presentation

Usin ing the CFIR IR to Evaluate Systems Analysis & Im Improvement proje jects in in resource lim limited settings: Experiences from the SAIA IA tria ial

Sarah Gimbel, RN, PhD, MPH Assistant Professor Departments of Family & Child Nursing, Global Health University of Washington sgimbel@uw.edu

CFIR use in LMIC increasing

• Vietnam
• Implementing tobacco use treatment guidelines in community health

centers in Vietnam

• Implementation Science 2015
• Donna, S., VanDevanter, N., Nguyen, N., Cleland, C.
• Mozambique, Rwanda, Zambia
• Creating resilient health systems through data quality improvement across

3 African countries using the CFIR: Results from the African Health Initiative

• HSR 2016, Submitted to BMC-Health Services Research
• Gimbel, S., Mwanza, M., Michel, C., Nisingizwe, M.P., Hirschhorn, L.
• Cote d’Ivoire, Kenya, Mozambique
• Evaluation of a systems analysis and improvement approach to optimize

PMTCT of HIV using the CFIR

• JAIDS 2016
• Gimbel, S., Rustagi, A, Robinson, J., Kouyate, S., Coutinho, J., Nduati, R., Pfeiffer,

J., Gloyd, S., Sherr, K.

• Many studies in the pipeline
• GAVI, DDCF, NIH supported studies

CFIR application

Evaluation Typology Label Formative Research Pre-implementation assessment Diagnostic systems-level info prior to developing study Formative Evaluation/ Developmental Evaluation Pre-implementation assessment & adaptation Assess best practices /determinants, barriers to implementation, buy-in Formative Evaluation/ Implementation-focused evaluation Concurrent implementation assessment and adaptation Improve likelihood of leading to change (barriers, facilitators) Formative Evaluation/ Progress-focused evaluation Concurrent implementation progress Optimize intervention/ reinforce progress (feedback) Formative Evaluation/ Interpretive evaluation Post-implementation retrospective evaluation Explain success or failure Summative Evaluation Post-implementation Determine degree of success

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Source: Stetler CB, Legro MW, Wallace CM, et al. The Role of Formative Evaluation in Implementation Research and the QUERI Experience. Journal of General Internal Medicine. 2006;21(Suppl 2):S1-S8. http://www.cfirguide.org/overview.html

pMTCT HIV IV Care Cascade

Antenatal care

• ANC attendance
• HIV counseling & testing
• CD4 testing
• Provision of ARV prophylaxis/ HAART to mother

Birth

• Safe delivery
• Provision of prophylaxis to infant
• Education on safe infant feeding and care

Postpartum care

• Safe infant feeding
• Infant follow up care and HIV testing
• Family planning
• Linkages to long-term HIV care and treatment

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World Health Organization, Towards Universal Access; Scaling up Priority HIV/AIDS Interventions in the Health Sector. Progress Report 2011. Joint United Nations Programme on HIV/AIDS, Together We Will End AIDS, 2012

Providing health workers & managers with a systems view = Novel, iterative approaches to improve pMTCT

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Systems Analysis and Im Improvement Approach (SAIA) Trial (R01HD075057)

• Aim 2: Evaluate the

impact of a 5-step systems analysis tool on pMTCT services

• Cluster randomized trial
• Cote d’Ivoire, Kenya and

Mozambique

Sherr, K., Gimbel, S, Rustagi, A, et al. Systems analysis and improvement to optimize pMTCT (SAIA): a cluster randomized

• trial. Implementation Science. 2014
• I. pMTCT Cascade

Analysis Tool

• II. Process Mapping
• III. Continuous

Quality Improvement

I.

• I. pMTCT Cascade Analysis Tool (P

(PCAT)

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II.

• II. Process Mapping
• A method for health care teams to jointly

describe their facility’s patient care pathway

• Builds common understanding
• Improved communication/ problem solving

II III. . Continuous Quality Im Improvement

• Step 3: Identify, define,

and implement facility- specific workflow adaptations to eliminate modifiable bottlenecks

• Step 4: Monitor changes

in routine performance data and initiate additional iterations

• Step 5: Repeat analysis

and improvement cycle

CFIR SAIA Study Aims

Using the CFIR as a lens we

• 1. Defined core and

adaptable components

• f the SAIA intervention
• Endline meeting with

country teams

• 2. Explained the

heterogeneity in SAIA’s success between facilities

• 6 FGD @ 6 HF (1 high, 1 low

performing per country)

• Interviews with study staff

and health system managers

• “Outer setting” domain

collected prospectively via secular events monitoring

Damschroder, L., Lowery, J.C. Evaluation of a large-scale weight management program using the CFIR. Implementation Sci. 2013

Scoring Sheet

Low performers High performers

• II. INNER SETTING

Mozambique Kenya Cote d'Ivoire Mozambiq ue Kenya Cote d'Ivoire 2.a

Structural Characteristics

+2 M

• 2

M M M m 2.b

Networks and Communication

+1 +1

• 1

+1 +2 +1 ** 2.c

Culture

+2 +1 M +2 +2 +1 2.d

Implementation Climate

2.d.1

Tension for Change

• 2

+1 +1 +2 * 2.d.2

Compatability

+1 M M +2 +1 M m 2.d.3

Relative Priority

• 1
• 1

+1 +2 M X * 2.d.4

Organizational Incentives and Rewards

M M M M M M m 2.d.5

Goals and Feedback

+1 M X +2 M +1 * 2.d.6

Learning Climate

+2 M M +2 +1 +1 m 2.e

Readiness for Implementation

2.e.1

Leadership Engagement

+1 +2 +1 +1 +2 +2 2.e.2

Available Resources

• 2
• 2
• 2

+1

• 1
• 1

** 2.e.3

Access to Knowledge and Information

+2 +1 X +2 +1 X

Results

• Core Components
• Flow mapping
• Sustainable
• Team building
• Uncovered discrepancies in service delivery
• CQI
• Defined methodology
• Ensured critical space for discussion
• Coordination across sectors
• Adaptable periphery
• PCAT
• Computer literacy
• Computer access
• Less relevant in low disease burden settings
• Cote d’Ivoire

Results

• Strongly distinguishing constructs
• Networks and communication
• Roles & tasks clearly communicated
• In poor performing sites not enough staff to be feasible
• Available resources
• Perennial issue
• Interventions that address logistical issues prioritized in high performers
• External change agents
• Strong study staff (experienced, well known, respected)
• Support work on the ground before meetings
• Executing
• Participation/buy in
• Get the right nurses to support during roll out
• Majority of nurses engaged
• Reflecting and evaluation
• Built into the “systems view”=strengthening of the intervention
• Flow maps
• Cascade analysis

Considerations of f applying CFIR in LMIC settings

• CFIR was useful in assessing implementation across

multiple countries and contexts

• Some issues in implementation
• Prospective use with Likert, did not hold together
• Explore binary scales
• New, need to reinforce the added value of the CFIR

framework to participants prior to use

• Due to time, HR restraints, intent—use parts of the CFIR

most relevant to intended application

Obrigada, merci, thanks