Improvement Package: s to improve quality of data for management of malaria in Kayunga District in Uganda JANUARY 217 This change package was produced by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) and authored by Esther Karamagi, Martin Muhire, Herbert Kisamba, Mirwais Rahimzai, Victor Boguslavsky, Edward Broughton, and M. Rashad Massoud of URC and Mathias Kasule Mulyazawo and Jimmy Opigo of the Ministry of Health, Uganda. The malaria improvement collaborative in Mayuga District was supported by the President s Malaria Initiative (PMI) through USAID and its Applying Science to Strengthen and Improve Systems (ASSIST) Project.
IMPROVEMENT CHANGE PACKAGE s to improve quality of data for management of malaria in Kayunga District in Uganda Esther Karamagi, University Research Co., LLC Martin Muhire, University Research Co., LLC Herbert Kisamba, University Research Co., LLC Mirwais Rahimzai, University Research Co., LLC Victor Boguslavsky, University Research Co., LLC Edward Broughton, University Research Co., LLC M. Rashad Massoud, University Research Co., LLC Mathias Kasule Mulyazawo, Ministry of Health Uganda Jimmy Opigo, Ministry of Health Uganda DISCLAIMER: The contents of this report are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Acknowledgements This change package on improving the quality of data for management of malaria in Kayunga district was developed by United States Agency for International Development (USAID) -Applying Science to Strengthen and Improve Systems (ASSIST) Project. It describes changes implemented at five health facilities in Kayunga district to improve the quality of malaria data and processes followed to harvest improvement. The authors would like to acknowledge support provided by the Uganda Ministry of Health- National Malaria Control Programme, USAID for the strategic guidance during the design of the intervention, District health office of Kayunga District Local Government and health facility staff of; Bbaale HC IV, Lugaasa HC III, Wabwooko HC III, Kakiika HC II and Nakyesa HC II for their involvement in coaching and actual implementation of the intervention. Specifically, we are grateful to facility participants for their contribution during the harvest meeting in compiling changes as presented and discussed in this change package document. This work was funded by USAID through USAID ASSIST project and the U.S Centre for Disease Control. It is part of a research study titled: Improving the quality of health facility data to monitor trends in malaria burden: Effectiveness of the Improvement Collaborative Approach. The USAID ASSIST Project is made possible by the generous support of the American people through USAID s Bureau for Global Health, Office of Health Systems. The USAID ASSIST Project is managed by University Research Co., LLC (URC) under the terms of Cooperative Agreement Number AID-OAA-A-12-11. URC's global partners for USAID ASSIST include: EnCompass LLC; FHI 36; Harvard University School of Public Health; HEALTHQUAL International; Institute for Healthcare Improvement; Initiatives Inc.; Johns Hopkins University Center for Communication Programs; and Women Influencing Health Education and Rule of Law (WI-HER), LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write assist-info@urc-chs.com. Recommended citation Karamagi, E., Muhire, M., Kisamba, H., Rahimzai, M., Boguslavsky, V., Broughton, E., Rashad, M., Kasule, M., Opigo, J. (217). s to improve quality of data for management of malaria in Kayunga district, Uganda, Improvement change package. Published by the USAID ASSIST Project. Bethesda, MD: University Research Co., LLC (URC)
Table of Contents 1. Acronyms... ii 2. Introduction... 3 2.1. Background to the change package.... 3 2.2. Achieving the collaborative objectives... 3 3. The Implementation phase... 3 3.1. Coaching... 4 3.2. Harvest Meeting... 4 4. Package for Improving Data Quality... 4 4.1. Intended Use... 4 5. Inputs... 5 6. Illustrative results... 6 6.1. Improving completeness and accuracy of records... 6 6.2. s that improved completeness and accuracy of records... 7 6.3. s that did not improve completeness and accuracy of records... 7 6.4. Concepts to improve completeness and accuracy of the OPD register... 7 7. Adherence to test and treat policy... 8 7.1. s that improved testing suspected malaria cases... 9 7.2. Concepts to ensure suspected malaria cases are tested for malaria using microscopy/ RDT... 9 7.3. s that ensured that patients treated for malaria had a positive malaria test.... 1 7.4. Concepts to improve to ensure that patients treated for malaria had a positive malaria test.... 1 8. Improving concordance of OPD and HMIS reports... 1 8.1. s that improved concordance of malaria records in the OPD register and the HMIS monthly report.... 11 8.2. Concepts that decrease discrepancy between OPD and monthly report form -15... 11 9. Improving concordance of test results between Laboratory and OPD register... 11 9.1. s that improved concordance of malaria test results in the laboratory and the OPD registers.... 11 9.2. Concepts to improve concordance of malaria records in the laboratory and OPD register... 11 1. Improving concordance of positive results in laboratory and OPD registers... 12 1.1. s that improved concordance on malaria test results in the laboratory and the OPD registers... 12 1.2. Concepts to improve concordance of positive malaria test results in the laboratory and OPD register. 12 11. Improving concordance of pharmacy and OPD records... 12 11.1. s that improved concordance in the pharmacy and OPD registers... 13 11.2. s that did not improve concordance of records in the pharmacy and OPD registers.... 13 11.3. Concepts to improve concordance or records in dispensing log and OPD register... 13 12. Recommendations... 13 13. Appendices... 14 Appendix 1: s that improved performance... 14 Appendix 2: s that did not work... 22 Appendix 3: Participating sites and their quality improvement teams... 24 Appendix 4: List of other facilitators for the harvest meeting... 25
List of tables Table 1: Rank- ordered changes to improve percentage of patients with malaria registered in OPD register whose details are complete and accurately filled... 7 Table 2: Rank- ordered changes to improve the percentage of suspected malaria cases that are tested for malaria in the laboratory using microscopy or RDTm in a given month.... 8 Table 3: Rank - ordered changes to ensure patients treated for malaria had a confirmed malaria test... 9 Table 4: Rank- ordered changes to improve concordance between OPD register and HMIS monthly report... 11 Table 5: Rank- ordered changes to improve concordance of records in the laboratory and OPD registers... 11 Table 6: Rank- ordered changes to improve concordance of positive results in the laboratory and OPD registers... 12 Table 7: Rank -ordered changes to improve concordance of records in the pharmacy and OPD registers... 12 i
1. Acronyms ACTs ANC ART ASSIST BP CDC CME HC HMIS HSD Ht IPD MoH MUAC NEG OPD PEPFAR POS QI RDTm URC USAID USG VHT Artemisinin-Based Combination Therapy Antenatal Care Antiretroviral Therapy USAID Applying Science to Strengthen and Improve Systems Project Blood Pressure U.S. Centers for Disease Control and Prevention Continuing Medical Education Health Center Health Management Information System Health sub-district Height Inpatient Department Ministry of Health Mid Upper Arm Circumference Negative Outpatient Department U.S. President s Emergency Plan for AIDS Relief Positive Quality Improvement Rapid Diagnostic Tests for Malaria University Research Co., LLC United States Agency for International Department United States Government Village Health Team ii
2. Introduction 2.1. Background to the change package. This collaborative was implemented in five health facilities; Bbaale HC IV, Lugaasa HC III, Wabwooko HC III, Kakiika HC II and Nakyesa HC II in Kayunga district. The collaborative objectives were: 1) Improve completeness and accuracy of malaria data. Data completeness means all components of the data tools are filled in. Accurate data meant that filled in information is as prescribed by the national guidelines. 2) Synchronize health facility malaria data tools. 3) Increase adherence to test ant treat policy for malaria. The test and treat policy requires that all patients presenting at the health facility are screened to identify those with fever. All patients with fever are tested for malaria using microscopy or RDT. Only those who are positive for malaria are confirmed as malaria cases and treated with antimalarial drugs. 2.2. Achieving the collaborative objectives The initial phase involved preparations for the collaborative including site selection, developing implementation plan which was a phased approach where each improvement objective was focused on every quarter. Sites were supported to improve completeness and accuracy of records in the first quarter October December 215. In the second quarter- January March 216, sites implemented changes to improve adherence to test and treat policy. Figure 1: The Improvement Collaborative at 5 Sites in Kayunga District Concordance of data in various facility tools was introduced at the end of the second quarter. The implementation plan was agreed upon by the USAID ASSIST implementation team. This was followed by development of materials for the stakeholders meeting and first learning session. 3. The Implementation phase Three learning session and seven coaching visits were conducted over the entire implementation period between the first and third learning session. figure1. Prior to the first learning session (first week of November 215) a baseline assessment was carried out to ascertain and document existence of gaps on level in completeness and accuracy of malaria data. Gaps identified were on missing information on: address, next of kin, malaria test done and the results, details on referral in or out of patients. The baseline findings were shared at the stakeholders meeting on November 11 215. The findings further formed basis for the discussion and action planning during the learning session. During action plan session, each site came up with specific activities to implement and ensure patients information in the OPD register would be complete and accurate. The meeting offered an opportunity to build consensus on key activities to improve the quality of malaria record by Ministry of health, Kayunga district and health facilities participants. The implementation plan was Picture 1: MoH staff demonstrates how to complete the OPD register. Photo by Martin M. URC shared at the learning session, participants introduced to quality improvement methods and guided to form site quality improvement teams 3
3.1. Coaching Coaching was conducted monthly to provide support to teams so they achieve their improvement objectives. Coaching in between first learning session and the second focused aimed at guiding site teams to improve completeness and accuracy of records, while one between the second and third learning session, was meant to guide site teams improve adherence to test and treat policy and concordance of records. The period was longer given that teams focused on two improvement aims. Coaching was usually conducted with staff from the National Malaria Control Program Picture 1 and district health team to help address sites challenges such as logistics. Seven rounds of coaching aimed at improvement were conducted in the entire collaborative life span. Figure 1 3.2. Harvest Meeting The changes tested throughout this collaborative were written down by the quality improvement teams in Documentation Journals during the intervention period. These journals are Ministry of Health tools and are also used by the USAID ASSIST project in other countries. 1 To complete compilation and analysis of changes tested so as to come up with this change package, we conducted a harvest meeting. For two days, we brought together 16 people, including seven QI team members, one coach, two Kayunga district leaders, and six QI experts from the ASSIST project staff. The harvest meeting followed the following order: Participants sat according to the five participating health facilities and used the documentation journals to generate a list of changes tested for each improvement aim at their facility. This list of changes was compiled into a master list representing all changes tested at all sites; The run charts in the documentation journals were used to provide evidence on whether the change led to improvement in performance, decline in performance, or had no effect on performance. This information was used for the ranking process in the next step; All changes tested by all five facilities for each improvement aim were then scored by the participants to generate ranking. The ranking was according to the magnitude of improvement observed after the change was tested, the relative importance of the change, the scalability, and the affordability of the change from the perspective of the improvement team members. The ranked changes are detailed in tables 1-7. Only changes that had evidence of improvement were evaluated beyond this point. s that did not lead to improvement are listed in section e below. The harvest meeting participants grouped the Picture 2: Participants grouping changes into concepts. Photo by changes that led to improvement into concepts Martin Muhire - URC (Picture 2). A detailed how to guide was written for each change, as shown in the changes tables Appendix 1: 4. Package for Improving Data Quality 4.1. Intended Use This change package is written for quality improvement teams working to improve malaria data quality in settings similar to Kayunga district. The changes may be adapted to improve the quality of data in areas other than malaria. 1 USAID Health Care Improvement Project. (29) The HCI Standard Evaluation System (SES): A learning and improvement system for strengthening documentation, analysis, and synthesis of learning by quality improvement teams. 4
5. Inputs The inputs to the improvement collaborative intervention included: Three learning sessions were held and 7 rounds of coaching conducted. Training on quality improvement during the learning sessions so participants acquire quality improvement skills to lead the intervention Participants were trained and mentored on quality improvement during learning session and coaching Materials such as registers were collected from district offices, WalterReed Project and printed and distributed to the health facilities. Other examples of data tools are the documentation journals distributed to site teams for documentation of the improvement process at all the sites. Technical assistance from experienced improvement experts within ASSIST through conference calls and other mechanisms. 5
13th 2th 27th 3rd 1th 16th 22nd 3th 8th 14th 2th 26th 1st 13th 19th 25th 3th 4th 1th 16th 2th 28th 5th 9th 14th 2th 13th 23rd 1st 9th 15th 21st 31st 11th 19th 13th 2th 27th 3rd 1th 15th 2th 25th 3th 4th 11th 16th 21st 27th 2nd 7th 12th 24th 29th 13th 18th 23rd 26th 3th 3rd 8th 11th 16th 19th 22nd 25th 28th 31st 3rd 6th 9th 13th 16th 11/13/215 11/15/215 11/17/215 11/19/215 11/21/215 11/23/215 11/25/215 11/27/215 11/29/215 12/1/215 12/3/215 12/5/215 12/7/215 12/9/215 12/11/215 12/13/215 12/15/215 12/17/215 12/19/215 12/21/215 12/23/215 12/25/215 12/27/215 12/29/215 12/31/215 1/2/216 1/4/216 1/6/216 1/8/216 1/1/216 1/12/216 1/14/216 1/16/216 1/18/216 1/2/216 6. Illustrative results 6.1. Improving completeness and accuracy of records Percentage of patients with malaria registered in the OPD register whose details are completely and accurately filled at five facilities in Kayunga district 1 9 8 7 6 5 4 3 2 1 Median Bbaale HC Lugaasa HC 1 9 8 7 6 5 4 3 2 1 1 9 8 7 6 5 4 3 2 1 Nov-15 Dec-15 Jan-16 Feb-16 Nov-15 Dec-15 Jan-16 Wabwooko HC Kakiika HC Nakyesa HC 1 8 6 4 2 1 8 6 4 2 1 8 6 4 2 Nov-15 Dec-15 Jan-16 Feb-16 Nov-15 Dec-15 Jan-16 Nov-15 Dec-15 Jan-16 6
Table 1: Rank- ordered changes to improve percentage of patients with malaria registered in OPD register whose details are complete and accurately filled Evidence from Pilot Relative Importance Simplicity / Scalability Afford ability Total rating Tested change idea Assign an OPD numbers before laboratory investigations are done 5 5 5 5 2 Assign a focal person to monitor completeness of OPD register daily and fill the gaps. 5 5 5 5 2 Establish a registration / prescription area 5 5 4 4 18 Develop a checklist of commonly missed parameters 5 5 3 5 18 Assign a linkage facilitator to take measurements and 3 record in the OPD register 4 5 5 17 Assign a focal person to monitor completeness of the OPD register 3 4.5 3.5 5 16 Orient staff to fill the OPD register through CMEs 1 4 5 5 15 Assign someone to pick patients books from the laboratory,record in the OPD register and take the book to the clinician 2 5 3 5 15 Mentor VHTs to complete the OPD registers 2 5 3 3 13 Redesign OPD patient flow 3 2 2 4 11 Assign a person to transfer patients information from patients books to the OPD register before leaving the 2 2 2 3 facility 9 6.2. s that led to maximum expected improvement in completeness and accuracy of records. Assigned focal person to monitor completeness of OPD register daily and fill the gaps. Establish a registration / prescription area Assign an OPD number numbers before laboratory investigations are done Develop a checklist of commonly missed parameters 6.3. The change that did not improve completeness and accuracy of records Orientation of the staff on filling of the OPD register through CMEs 6.4. Concepts to improve completeness and accuracy of the OPD register Increasing knowledge on correct way to complete the register Adjust patient flow Review register and correct data gaps Role assignment Display OPD parameters at the facility 7
Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 7. Adherence to test and treat policy Percentage of suspected malaria cases that are tested for malaria in the laboratory using microscopy or RDT in a given month in five health facilities in Kayunga district Aggregate- 5 health facilities 1 5 of suspects malaria cases that are tested for May-15 Aug-15 Nov-15 Feb-16 May-16 Total number of suspects malaria cases tested for 2 15 1 5 May/15 Jul/15 Sep/15 Nov/15 Jan/16 Mar/16 May/16 Jul/16 Wabwooko HC 1 9 8 7 6 5 4 3 2 1 Bbaale HC Kakiika HC 1 9 8 7 6 5 4 3 2 1 Nakyesa HC Lugaasa HC 1 9 8 7 6 5 4 3 2 1 1 9 8 7 6 5 4 3 2 1 1 9 8 7 6 5 4 3 2 1 Table 2: Rank- ordered changes to improve the percentage of suspected malaria cases that are tested for malaria in the laboratory using microscopy or RDTm in a given month. Tested change idea Evidence from pilot Relative Importance Simplicity Scalability Affordability Total rating Assign a triage nurse or a VHT to send all patients with fever to the laboratory 5 5 5 5 2 Display of test and treat policy 5 5 5 5 2 Create various testing points like ANC, OPD and IPD during weekends and nights 5 5 5 5 2 Conduct CME on test and treat policy 4.5 5 4.5 5 19 All malaria suspects get a laboratory request form filled by a clinician. 4 4 5 5 18 Manage RDTm stock daily 4 4 4 4 16 8
Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 7.1. s that led to maximum expected improvement in testing suspected malaria cases Assign a triage nurse or a VHTs to send all patients with fever to the laboratory Display of test and treat policy Create various testing points like ANC, OPD and IPD during weekends and nights 7.2. Concepts to ensure suspected malaria cases are tested for malaria using microscopy/ RDT Assign role of sending suspects to the lab to one cadre Improve access to RDTs Closing knowledge gap on test and treat policy Indicator 3: Percentage of patients treated for malaria with a positive malaria test in a given month. Aggregate- five health facilities Bbaale HC Lugaasa HC 2 1 5 of patients treated for malaria that had a positive malaria test in a given month Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Total sample of patients treated for malaria in a 1 9 8 7 6 5 4 3 2 1 1 9 8 7 6 5 4 3 2 1 Jul/15 Sep/15 Nov/15 Jan/16 Mar/16 May/16 Jul/16 Wabwooko HC 1 9 8 7 6 5 4 3 2 1 1 9 8 7 6 5 4 3 2 1 Kakiika HC 1 9 8 7 6 5 4 3 2 1 Nakyesa HC Table 3: Rank - ordered changes to ensure patients treated for malaria had a confirmed malaria test Evidence from pilot Relative Importance Simplicity/ Scalability Affordability Tested change idea Total rating Tick to indicate the patient is treated with a positive malaria test 5 5 5 5 2. Health educate patients about test and treat policy 5 5 5 5 2. Conduct CME on test and treat policy 5 5 4.7 5 19.7 Avail RDTm to ANC 5 4 3 5 17. 9
Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 7.3. s that led to maximum expected improvement in ensuring that patients treated for malaria had a positive malaria test. Ticking on the patients books to show that the patients particulars have been entered into the register Health educate patients on importance of test and treat policy Conduct CMEs on test and treat policy and guidelines 7.4. Concepts to improve to ensure that patients treated for malaria had a positive malaria test. Improve access to RDTs Closing knowledge gap on test and treat policy Quality of data of the OPD register 8. Improving concordance of OPD and HMIS reports Decrease in the discrepancy between number of malaria patients registered in the OPD register and those reported in the HMIS 15 monthly report to the district. Aggregate-5 health facilities 3, 2, 1, Total # malaria cases registered in the OPD register in a month Total # malaria cases reported in the monthly report 1 8 6 4 2 Bbaale HC Total # malaria cases registered in the OPD register in a month # malaria cases reported in the HMIS 15 8 6 4 2 Lugaasa HC Total # malaria cases registered in the OPD register in a month # malaria cases reported in the HMIS 15 May-15 Sep-15 Jan-16 May-16 Wabwooko HC Kakiika HC Nakyesa HC 8 7 6 5 4 3 2 1 Total # malaria cases registered in the OPD register in a month 5 4 3 2 1 Total # malaria cases registered in the OPD register in a month # malaria cases reported in the HMIS 15 6 4 2 Total # malaria cases registered in the OPD register in a month # malaria cases reported in the HMIS 15 1
Table 4: Rank- ordered changes to improve concordance between OPD register and HMIS monthly report Evidence from Pilot Relative importance Simplicity/ Scalability Affordability Total rating Tested change idea Crosscheck daily summaries with monthly totals in the HMIS 5 5 5 5 2 Introduce daily tally book to generate daily summaries of malaria diagnosed patients 4.6 4.6 4.2 4.2 17.6 Second person recounts number of malaria cases in the OPD register 4.5 4.5 4 4 17 Check daily to ensure the word malaria for diagnosis is not abbreviated 3 5 4 4 17 Generate weekly summaries of all patients diagnosed with malaria 3 3 4 4 14 8.1. The change that led to maximum expected improvement in concordance of malaria records in the OPD register and the HMIS monthly report. Cross checking daily summaries and monthly totals in the HMIS 8.2. Concepts that decrease discrepancy between OPD and monthly report form -15 Conduct review meetings Crosscheck the monthly report Daily/weekly totals Assign roles 9. Improving concordance of test results between Laboratory and OPD register Table 5: Rank- ordered changes to improve concordance of records in the laboratory and OPD registers Evidence from pilot tests Relative importance Simplicity /Scalability Affordability Total rating Tested change idea A VHT or a health worker collects patients books from the laboratory to the clinician 5 5 5 5 2 Redesign OPD clients flow 4 4 5 5 18 Assign compulsory OPD numbers before laboratory investigations are done 4 5 3 5 17 Involve VHTS and facility linkage facilitators in recording results in the OPD register 3 3 4 4 14 9.1. The change that led to maximum expected improvement in concordance of malaria test results in the laboratory and the OPD registers. A VHT or a health worker collects patients books from the laboratory to the clinician 9.2. Concepts to improve concordance of malaria records in the laboratory and OPD register Involving VHTs Improve patients flow in care Crosschecking the two registers 11
1. Improving concordance of positive results in laboratory and OPD registers Table 6: Rank- ordered changes to improve concordance of positive results in the laboratory and OPD registers Evidence from pilot Relative importance Simplicity/ Scalability Affordability Total rating Tested change idea Tick the patient book to indicate patient details have been entered in the OPD register 5 5 5 5 2 VHT/ health worker collects patient books from OPD and laboratory to clinicians 5 5 5 5 2 Orient new staff on how to complete the OPD register 4 4 5 5 18 Spot check the OPD register to ensure all patients have test results recorded 4 4 3.5 4.5 16 Prescribe patients medication only within the clinicians room 4 4 3 4 15 from ticking to writing POS and NEG for malaria results 3.5 4 3 3.5 14 Shift staff who are unwilling to record well in the OPD register to another department 3 3 2 2 1 1.1. s that led to maximum expected improvement in concordance on malaria positive results in the laboratory and the OPD registers. VHT/ health worker collects patient books from OPD and laboratory to clinicians Tick on the patient books to indicate that patients details have been entered in the OPD register 1.2. Concepts to improve concordance of positive malaria test results in the laboratory and OPD register Checking patients records regularly Role assignment Knowledge on completing OPD register Follow instructions on how to fill OPD register Shift uncooperative staff 11. Improving concordance of pharmacy and OPD records Table 7: Rank -ordered changes to improve concordance of records in the pharmacy and OPD registers Evidence from Pilot Relative Importance Simplicity /Scalability Affordability Total rating Tested change idea Cross check the dispensing log every morning by the first staff to arrive on duty 5 5 5 5 2. Record in the dispensing log whenever there are stock out of ACTs 5 5 4.7 4.7 19.3 Report early for duty to check for gaps 3 5 4 5 17. Tally number of ACTS dispensed with malaria positive patients in the OPD register daily 4 5 3 5 17. Assign one person to record at a given period 4 4 5 5 17. Mentor staff on filling the dispensing log 3 3 3 3 12. Improvise the first column in the dispensing log for ACTs 1 1 1 1 4. 12
11.1. s that led to maximum expected improvement in concordance in the pharmacy and OPD registers Record in the dispensing log whenever there are stock out of ACTs Checking the dispensing log every morning by the first staff to arrive on duty 11.2. The change that did not improve concordance of records in the pharmacy and OPD registers. The first column in the dispensing log is meant for recording ACTs 11.3. Concepts to improve concordance or records in dispensing log and OPD register Bridge knowledge gap in completing the dispensing log Reserve a column in the dispensing log for ACTs Assign roles Double checking to identify and correct gaps 12. Recommendations Using time series charts, improvements were seen in completeness and accuracy of malaria data, adherence to test and treat guidelines for malaria, and concordance between the OPD, laboratory, and pharmacy registers, and the HMIS monthly report. The improvement collaborative and subsequent harvest meeting documented several changes and concepts associated with the observed improvement. We recommend the following strategies to improve malaria data quality in similar settings: Include data quality roles when assigning staff roles during shift changes or duty rotas, including roles for VHTs and other support staff or volunteers. Data quality related roles include; checking for gaps and inaccuracies in the OPD register and correcting them, transferring patient information from treatment notes into the OPD register, cross checking and harmonizing patient details in the laboratory, pharmacy and OPD registers, and making daily or weekly summaries of patient data. Periodically review primary data tools and summarize totals of key variables. This may be done daily or weekly. Totals should be recorded where they can be easily retrieved e.g. at the bottom of each page of the primary data tool such as the OPD register. To improve adherence to new guidelines like test and treat, ensure health workers know the content of the guideline, and make changes to improve frontline staff have access to necessary commodities like RDTm whenever needed. Improve connection between the laboratory, pharmacy, OPD, and clinical teams to improve concordance between the different data tools that contain data on the same patient. For example, adjust patient flow to ensure that patient data between these four teams is always recorded, and keep registers together to ease cross checking for concordance. 13
13. Appendices Appendix 1: s that improved performance Improvement indicator 1: of patients with malaria registered in the OPD register whose details are complete and accurately filled. Concept Mentorship on correct way to complete the OPD register Adjust Patient Flow implemented Mentorship of VHTs to complete the OPD register. Establishment of one registration and prescription area. Redesigned OPD patient flow successful? Yes/No. Evidence with data HC IV Improved from 15-9 HC III : Improved from -25 but HC III: Registration area improved from 48-1 performance sustained up to 88 HC IV: Improved from -9 How exactly was the change implemented (where, Who, When, any resources VHTs from the HIV clinic after a QI meeting and decided to invite the VHTs working in the HIV clinic and assigned to support in filling the OPD register. They were 2 VHTs trained. A rota was drawn so that one fills the register on a specific day- alternate days A knowledgeable staff notifies the rest of the staff about the CME. Staff is gathered in the meeting room and addressed about the gap and importance of completing the register. Demonstration on how to complete the register by the trained staff. A registration table was carried from the injection room to the waiting area. Prescription to patients in the corridors areas rather than the clinician's room were stopped. During a monthly performance review meeting no patient had complete information in OPD register. The QI team decided to register all patients on the triage table prior to the clinician and lab investigation by giving OPD numbers unlike before where patients were registered in OPD at the end Assigning OPD numbers before Lab investigations. HC IV: Improved from 9-1 and maintained A notice is developed and displayed with content: "No testing any patient without OPD number" This helps to capture all patient information in both lab and OPD register. Review and correct data gaps Assigned focal person to monitor completeness of OPD register daily and fill the gaps. HC III: maintained at 1 HC II: Improved from 55-1 HC II: Improved from - 1 The QI team leader at the end of the clinic day, cross checks the OPD register daily for completeness. When gaps are identified, they are completed A member of QI team was selected and mentored on what to look for. A guide designed on how to award marks. Selected dates for supervision and communicated to staff. When the date reaches, the supervisor checks in the OPD register, gives feedback to responsible staff to make corrections. Arrive early before patients start to arrive. Check the work of the previous day. Fill gaps if any. HC II: - Improved from 58 9 - and has been maintained During staff meeting 2 staff volunteered to check gaps in the OPD register. After 2 days checking by the supervisor they had not checked. Supervisor decided to choose one staff at a time -per week, to check gaps and complete them each of the two staff was assigned a separate day for checking for completeness and fill the gaps 14
Role assignment Display OPD parameters at facility Assigned a person to transfer patient information from patients books to OPD register before leaving the facility. Assign a Linkage facilitator to take measurements and record in the OPD register Assign someone to pick patients' books from the lab, fill the data into the OPD register and take the book to the clinician Developed a checklist of commonly missed parameters. HC IV: Improved from -9. HC III: The change was implemented with other changes and improvement was from -8 HC III: Improved from 15-9 HC IV: Improved from 95-1 HC III: Improved from -1 HC IV: Improved from - 9 HC III: Improvement was from -8 During a meeting 2 staff assigned to check for completeness and accuracy of OPD register at the end of the day. It failed because at the end of the day, patients would have been taken the treatment book. So we changed to collecting all books from patients before they leave the facility. Health unit in charge organised a meeting with VHTs. Identify gaps in the register. Assign a staff to work with a VHT to transfer patient information. Develop a guide basing on the MOH guide (register). Request the VHT to continue updating the register One linkage facilitator selected from the ART clinic and taught on how to record in the OPD register. The Linkage facilitator is asked to take the measurements such as- weight, height and then record them into the OPD register. First they would record up to parameter 14 (patients demographic information) leaving the clinical details to the health worker to fill in after the patient has had treated. In a monthly QI meeting members agreed upon collecting patient books by another person other than the patient from one point to another to avoid loss of patient information, for example, picking books from the lab to clinician and to OPD register. Explain the change to the person to be assigned - either a VHT or a health worker. Ask the same person to carry the patients books to the clinician after picking results/books from lab to clinician and back to triage. Initially, missed parameters were filled by a trained staff. The parameters are written on a paper into a check list of such parameters missing in the OPD register like: B.P, test results, weight, height then displayed. The checklist reminds staff at registry to complete the register.. All parameters found in the OPD register were copied on a manila paper and displayed at the registration area so the staff on the registration table can refer to it when completing the register. 15
Improvement Indicator 2: of suspected malaria cases that are tested for malaria in the laboratory using microscopy or RDTs in a given month Concept Assign role of sending suspects to the lab to one cadre implemented All malaria suspects get a lab request form for a malaria test - Assigned a triage nurse/vht/ to send all patients with fever to the lab successful? Yes/No. Evidence with data HC III: 77 at baseline then 87-1 and this has been sustained HC IV: Improved from 65-78 HC II: maintained at 1 How exactly was the change implemented (where, Who, When, any resources Before the intervention, clinicians used to treat patients clinically except when there are obvious signs of malaria. A QI team member carried out health education about the new policy of going to the lab with the request form from the clinician. Clinician takes history and screens suspects with a fever and orders for a lab malaria test A lab investigation request is written in the patients book by the clinician, and patient directed to or taken to the lab for a blood test by the clinician was either implemented by a Triage nurse or a VHT. There is a psychiatric nurse who was redundant on the ward since there are a few mental patients and so was requested to come to OPD and assigned as a triage nurse so he can sort patients.- identify patients with fever write a malaria test request and send them to the lab to avoid delays and accompanying malaria complications. VHTs were requested from the HIV clinic to OPD on days that the HIV clinic does not run so they could work with the psychiatric nurse - Identify a staff or a VHT, In charge teaches the VHT or a staff on duty danger signs and assigns a VHT at OPD and offers a thermometer Improve access to RDTs Creating various testing points like ANC, OPD, and IPD during weekends and nights. HC IV: 68-8,improvement HC III: 83-1 improvement In an orientation meeting, staff agreed to create more testing points for malaria especially at night and on weekends when OPD is closed. The lab assistant supplies estimated RDTs to OPD, IPD, and ANC and emphasizes on proper documentation. - After education of staff about need to test all OPD patients presenting with fever, make request for RDTs from the store. Distribute RDT to ANC and OPD, provide an improvised register to the two departments for use in recording the test results so you are able to track work done. Trained staff record the RDTs used. Teach all staff on how to conduct malaria test using RDT Manage RDT stock daily Get RDTs from other lower facilities in case of threatening stock outs HC II: 82 to 1improvement HC IV: Improved from 8-1 Distribute to ANC/OPD staff on duty should request for the RDTs to be used for that day after work do a physical count to find out the balance of tests always record in the stock book and stock cards The in charge and lab person quantify the RDT stock balance When there is need, a request is made to units with enough stock by calling on phone, the in charges of those units to avail some stock 16
Closing knowledge gap on test and treat policy Conducted CME on test and treat policy. Displaying of test and treat policy. HC III: was at 77-1 improvement HC II:- Maintained at 1 HC II: 82-1 improvement : In charge reminds health workers about the CME on need to stick to test and treat policy by putting up a notice. Hold the CME and ensure there is a monthly schedule. - In charge calls for a staff meeting at the end of the month. I/C teaches and demonstrates the importance of screening for malaria among all fever cases Discuss during a staff meeting to display the test and treat policy, select a staff to do the display in an appropriate place, Find a manila and a maker and write the policy extract, after which it is displayed on the clinic walls. Improvement Indicator 3: of patients treated for malaria that had a positive malaria test in a given month Concept Improve access to RDTs Closing knowledge gap on test and treat policy Quality of data of the OPD register implemented Availing RDTS to ANC. Conducting RDT on other departments- ANC and wards Conducted CME on test and treat policy. Health education of patients about test and treat policy. Ticking to indicate patients treated with a positive malaria test. successful? Yes/No. Evidence with data HC III: Improved from 48-1 HC IV: Improved from 68-96 HC III: improved from 77-1 HC III: Improved from 93-1 HCIII: tested it with other changes (availing RDTs to OPD and giving ACTs to patients who test positive) 48-1 How exactly was the change implemented (where, Who, When, any resources After education of staff about new policy, make request for RDTs from the store and distributed to ANC so they start testing mothers in ANC. Provide an improvised register to the ANC for use in recording the test results. RDTs are supplied to different departments ANC and wards, the staff on these departments carry out malaria tests when lab is closed., The lab staff checks whether the tests are done well and refills the RDTs. In charge reminds health workers about the CME on need to stick to test and treat policy by putting up a notice. Hold the CME and ensure there is a monthly schedule. Selected topics based on new facility policy Develop a rota. May use an improvised counter book. Assign a specific staff to do health education. The clinician and staff that attended the leaning session are first to conduct the education. Hold a meeting to discuss how to regulate patient disappearance and incomplete data. Identify a triage nurse to check the register gaps and complete it, follow up check for a tick on the patients book, and send back patients to triage in case a tick is absent. 17
Improvement indicator 4: malaria suspects with tests recorded in the lab that have their results recorded in the OPD register as well Concept Involving VHTs implemented VHT/health worker collect patient books from Lab to clinician successful? Yes/No. Evidence with data HC IV: Improved from 5-85 HC III: Improved from 5-62 How exactly was the change implemented (where, Who, When, any resources Before patients would be given books to go to the lab for malaria tests after which some of them would go home without the results recorded in the OPD register. Health workers had to alter the practice so patients take books to the lab and after lab tests are done, treatment books are piled. After a number of patients have been examined, they are called and their books handed over to a health worker or a VHT who takes them with the patient to the clinician but the patient remains waiting at the waiting area. After the clinician prescription, the patients details are recorded into the OPD register and patient is given the book to go and pick drugs 2-3 VHTs are allocated to seat around the registration table. They collect books from the lab so they can be registered at the OPD registration table. After registration, they are taken to the clinician and then to the Pharmacy by the same VHTs VHT or FLF from ART clinic are gathered and oriented on how to record in the OPD register Patient flow in care Crosschecking the Two registers Compulsory OPD no before lab investigations. Redesigned OPD client flow. Daily cross checking of the Lab and the OPD register HC IV Improved from 65 to 1 HC III: 77-93 improvement HC IV: Improved from 8-9 A notice is developed and displayed with content: "No testing any patient without OPD number" This helps to capture all patient information in both lab and OPD register Establish a registration table, register patients on arrival and give them an OPD number. Record the number on the treatment book. After being registered, the patients is seen by a clinician and goes back to the registration table so the test results data are recorded. Conduct meeting to harmonise data in Laboratory and OPD. Assign a staff to regularly crosschecking OPD and Lab registers to make sure information in the two registers tallies. 18
Improvement indicator 5: of malaria patients with a positive test result recorded in the lab register that are also registered in the OPD register Concept implemented successful? Yes/No. Evidence with data How exactly was the change implemented (where, Who, When, any resources Double Checking Patient flow Role assignment Ticking in patients books to indicate particulars of patients are been captured in the OPD register. Prescription only done in the clinicians rooms VHT/health workers collect patient books from OPD, Lab to clinician HC III: Improved from 61-1 HC III: Improved from 67-1 HC IV yes led to improvement from 62-1 Hold a meeting to discuss how to regulate patient disappearance and incomplete data. Identify a triage nurse to check the register gaps and complete it, follow up check for a tick on the patients book, and send back patients to triage in case a tick is absent. Staff oriented on new facility policy of having a specific one prescription area. All other prescription areas are stopped and only done in the clinician's rooms clearly labelled to indicate the clinician's room Before patients used to be given books after lab test in the lab and they could go home without being registered so the change was that from the lab, books are piled together and given to a health / VHT to move them and the patients to the clinician. A patient waits at the triage for the clinician to call one by one Knowledge on completing OPD register Orienting new staff on how to complete the OPD register. HC III: Improved from 81-1 HC IV: Improved from 63-8 A focal person who is a QI team leader checks the register for completeness and orients staff about the tools during monthly meetings., the triage nurse makes routine checks and fills in the gaps. It is done anytime of the day when the nurse has time Follow instructions on how to fill OPD register Shift uncooperative staff d from ticking to writing POS and NEG for malaria results Shifting of staff who are unwilling to record well in the OPD register to other departments. HC III. Improved from 61-1. HC III: Improved from 8-1 After checking for a tick and is not available, treatment books are sent back.d from ticking to writing POS, NEG and VHT allocated to carry patient books from the clinician to lab and back then to recording table) A staff member that doesn t complete the register well even after mentorship is re-allocated to the injection room by the in charge and replaced by one willing to complete the register. 19
Improvement Indicator 6 - of patients that were prescribed ACTs that were dispensed ACTS at the pharmacy Concept Reserve a column in the dispensing log for ACTs Assign roles Double checking to identify and correct gaps implemented Recording in dispensing log whenever there are stock outs of ACTs Assigning one individual to record at a time Tally no. of ACTs dispensed with malaria positive patients in the register and daily recording in dispensing log. Cross-checking the dispensing log every morning by the first staff to arrive successful? Yes/No. Evidence with data HC III: to 96. improvement HC IV: to 7 improvement HC II: 75 to 1 improvement HC III 19-6 and maintained HC IV -7 HC II Maintained at 1 HC II: improvement from -1 and maintained to date How exactly was the change implemented (where, Who, When, any resources At both facilities, During the weekly ACT quantification for the weekly report, it is realised that no ACTs recorded because the health facility suffered stock outs. Members agreed upon writing through stock outs of ACTs instead of leaving that column blank. All staff members were oriented on recording number of ACTs dispensed in the dispensing log. This was done on alternate days when a specific staff is on duty and is responsible for filling the dispensing log Identify an outdated register for use as a tally book assign nursing assistant to tally the ACT dispensed to positive patients. Follow up on daily consumption of ACT by the dispenser The clinician in charge and other staff who treat patients agreed in a meeting after coaching that they will always check with the dispensing log to ensure all patients are registered. The staff arrives in the morning and before any other activity checks the book and if there are any gaps, they are filled in and then the responsible staff communicated too about the gap Improvement indicator 7: Decrease the discrepancy between # of malaria patients registered in the OPD register and those reported in the HMIS 15 monthly report successful? How exactly was the change implemented Concept implemented Yes/No. Evidence (where, Who, When, any resources with data Review meetings Crosschecking Daily/weekly totals Second staff recounts malaria cases in the OPD register. Daily checks to ensure the diagnosis of malaria is not abbreviated Cross checking daily summaries and monthly totals in the HMIS HC III: Discrepancy reduced from 14 to 9 HC IV : discrepancy reduced from 4-4 HC II: Closed the gap between OPD and HMIS 15- reduced from 51-9 patients Wabwooko- QI team meets at the beginning of the month, recount the malaria cases in the OPD register and compare with the total counted by the records person before submission of the monthly report. Corrections are made in case of any discrepancy before sending the report to the district. Ensure everyone writes "Malaria" in full, not in abbreviations such as MAL. The HMIS focal person at the end of the month notes that staff were recording abbreviations and could mistake them for other diagnosis. So prescribers were asked to always write malaria, at a monthly staff meeting. - makes daily totals of malaria patients, record them at the bottom of the OPD register sheet. At the reporting time they sum up the end of month report and then compare with the daily totals in the OPD book. 2
Introduced daily tally book to generate daily summaries of patients diagnosed with malaria Generating weekly summaries of all patients diagnosed with malaria. HC II: minimised discrepancy from 14 to. Second HC II: reduced discrepancy from 19-3 HC IV: reduced discrepancy from 25 to 4 Conduct a meeting on the importance of having same data in HMIS and OPD Assign responsibility to nursing assistant to do daily tallying identify an outdated register to use for daily tallying. The clinician checks to ensure daily summaries are done. During a monthly data analysis meeting, variations are identified between HMIS 15 and OPD register. The records assistant suggests to the team to do weekly summaries so as to reduce work load, and sum up at the end of the month 21
Appendix 2: s that did not work Improvement indicator 1: of patients with malaria registered in the OPD register whose details are complete and accurately filled. implemented & Orientation of staff on filling the OPD register successful? Yes/No. Evidence with data HC III Improved from 8-78 then dropped to HC IV: improved from 31-94 then dropped to 22 HC IV: No didn t work because staff left work to those who attended learning session. HC IV: improved from -95 and dropped to after 3 days HC III: improved from 8-78 then dropped to How exactly was the change implemented (where, Who, When, any resources Organise for a meeting and choose a day for CME on completing the OPD register. A notice is put up as reminder About conducting the meeting. During the meeting identify and assign a staff responsible for regularly updating the OPD register, follow up on CME plans and continue to emphasize regular cross checking of the register. Orientation was done for new staff. After assigning a staff at the registry, new staff are taught on job, and asked to fill the register when trained staff is watching who may later demonstrate to the new staff. After the first learning session in Nov'15 QI team members gather other staff who didn't attend for CME on completeness and accuracy of OPD register. Now after gathering, they are briefed about the performance of the facility and develop a plan to improve. After the CME, selected staff are assigned responsibility of filling the register. A knowledgeable staff notifies the rest of the staff reminding them about the CME. Staff are gathered in the meeting room and addressed about the gaps and importance of completing the OPD register. Demonstration on how to complete the register by the trained staff is done. Organise a meeting, choose a day for the CME and the topic, inform the staff through a notice or conduct the meeting, assign responsibility to take on from the action plans of the discussions such as who to regularly update the OPD register. Schedule a follow up CME by fixing a date. Improvement Indicator 2: of suspected malaria cases that are tested for malaria in the laboratory using microscopy or RDTs in a given month implemented Conducted CME on test and treat policy. successful? Yes/No. Evidence with data HC III. Improved from 7-89 then dropped to 7 How exactly was the change implemented (where, Who, When, any resources A knowledgeable staff notifies the rest of the staff reminding them about the CME. Staff are gathered in the meeting room and addressed about the gaps and importance of completing the OPD register. A trained staff demonstrates to the rest how to complete the register 22