Change Package: Improving treatment of under five children with fever in

accordance with standard guidelines in the Lake Zone of Tanzania, 2012-2014

Tibu Homa Dissemination Workshop,

13th – 14th November, 2014Dr. Festus M. Kalokola

Introduction

• Tibu Homa Project: 5 year project supported by USAID working in the Lake Zone of Tanzania.

• Has been working with Ministry of Health and Social Welfare (MoHSW: National Malaria Control Program (NMCP) and Reproductive Child Health (RCH)) at national level, and the Regional and Council Health Management Teams (R/CHMTs) at field level with the following goal and objectives:

Introduction (cont’d)Goal:

To reduce morbidity and mortality of children under five years of age due to severe febrile illness in the Lake Zone of Tanzania.

Objectives:1. Increase availability of and accessibility to fundamental

facility-based curative and preventive child health services.

2. Ensure sustainability of critical child health care activities.

3. Increase linkages within the community to promote healthy behaviors thereby increasing knowledge and use of child health care services.

Introduction (cont’d)Health facility level based objectives

1. Ensure all under fives (UFs) with fever receive correct diagnosis and treatment.

2. Ensure constant availability of medicines and supplies.

3. Ensure all health providers have adequate information to guide them in decision making.

Introduction (cont’d)

Desk Review Facts: (at the beginning of the project, 2011):

• UF morbidity and mortality rates in the Lake Zone: above national average

• Compliance to IMCI care guidelines was poor

• Deficient comprehensive supportive supervision .

• Frequent stock out of essential medicines and supplies .

• Lack of clinical mentorship.

• Documentation of patient information was inadequate.

• Presumptive malaria diagnosis (over-diagnosis), irrational treatment, missed opportunities to detect and treat other causes of febrile illnesses in children (Tibu Homa desk review, 2011).

TH/partners and health facility accomplishments

TIBU HOMA PROJECT Health Facility PQIT

- Between 2011 and 2012:Formed 3 improvement

collaboratives and trained 580 HCWs in updated

case management guidelines, using an approach

that combines QI methods and SCM, and formed

183 health facility PQITs in three regions.

- Trained and mentored 267 QI coaches, logistic and

clinical mentors among the R/CHMTs.

- Conducted monthly coaching and mentorship in

collaboration with R/CHMTs and documented

effective changes made by PQIT.

- Conducted 3 learning sessions organized quarterly

for each wedge collaborative for each region.

- Conducted 2 harvest and synthesis workshops for

Mwanza and Kagera regions.

- Prepared a change package that consolidates the

key learning and recommendations for how to

implement changes in care.

- Redesigned case management flow maps that

resulted in improving clinic efficiency, tested and

documented changes on the SES journal.

- Improved compliance to case management

guidelines (IMCI and RCM) from 3% in Jan. 2013

to 34% in June 2014.

- Improved diagnosis of malaria and other causes

of fever, malaria testing rate from 46% in Jan.

2012 to 95% in June 2014.

- Improved health facility stocks of essential

medicines and supplies by an increase in % of

facilities stocked with more than 10 tracer items

from 42% in Feb. 2012 to 98% in June 2014.

- Improved Health Management Information

System (HMIS) and using data for decision

making as shown by an increase in % of facilities

using data from 46% in Jan. 2013 to 69% in June

2014.

Change Package

Definitions

• A change package is an organized summary of strategies and solutions which have been tested and proven to improve care in a given context.

• A change concept is a category of changes or solutions that are similar and have a common underling thought.

• A change idea is a specific way that may be applied in the implementation of a given concept in a particular situation.

Change Package (cont’d)

• After 2 years of implementation of the improvement program, a selection of teams that formed a cluster of best, middle and poorly performing PQITs from the first and the second wedge health facilities were invited to a final learning session of the implementation phase which was designed as a harvest workshop.

• THP technical team synthesized and harmonized results from the 2 regions and regrouped the change ideas around the change concept (the underlying thought behind the change).

Change Package (cont’d)• Change Packages have most effective changes and guidance

on how to implement them as good practices that can be used in new sites.

• Ideas and changes recommended are backed by data

– Improvements in patient waiting time

– UFs receiving mRDT/Malaria microscopy testing before treatment

– UFs with fever who received appropriate diagnosis and treatment

– Improved availability of medicines and supplies, and

– Making use of data in making decision for further improvement in the care of under-fives at the health facilities.

Change Package - Intended use

• Capacity building at the site level

– Capacity building

• Ensuring all UFs with fever have correct diagnosis and treatment

– Capacity building, improving clinic efficiency

• Ensuring all UFs with fever are tested with mRDT/microscopy

– Capacity building, improving laboratory service efficiency

• Ensuring health HFs have no stock-outs of essential medicines and supplies

– Establishment of functional medicines and therapeutic committees

– Improving information and communications

• Ensuring healthy facilities have adequate information to guide decision making

– Improving efficiency of data management, data dissemination

Capacity building that cuts across all the improvement objectives

NChange Concept

Change Idea How to guide

1 Capacity Building

The health facility PQIT improve the skills of HCWs in case management by introducing job aids, guidelines, M&E and HMIS tools into routine health facility care.

Steps:

1. The PQIT after receiving training briefs the HMT/Board on

the improvement plan and budget.

2. The HMT/boards provides funds to support photocopying

guidelines, job aids, M&E tools and making time available

for orientation of HCWs.

3. The PQIT then:

- Identify staff to be oriented for target service identified- Prepare the materials- Make orientation schedule- Orient HCWs on each target service according to prepared schedule

Clinical care (IPD&OPD) Laboratory diagnosis SCM HMIS and data management Orphans and vulnerable children (OVC) care

4. PQIT identify staff that will provide mentorship in target

service areas.

Ensure all U5s with fever are receiving correct diagnosis and treatment

There are two change concepts under this improvement objective:

– Capacity building

– Improving clinic efficiency

Change Concept

Change Idea How to guide

1 Capacity Building

Conduct internal mentorship and supervision monthly to improve HCW performance

Steps: PQIT in collaboration with the facility HMT will do the following:-

1. Identify and assign mentors and supervisors

2. Prepare and display mentors/supervisors roster

3. Prepare a guide (checklist) for supervision/

mentorship

4. The supervisors/mentors supervise and mentor

HCWs, prepare and submit monthly supervision/

mentorship report to PQIT and HMT.

Introduce weekly case reviews and death audits

Steps:

1. PQITs and the HFMT assign staff to develop and

display timetable of topics and presenters of case

reviews.

2. Assign staff to conduct death audits, document and

store the proceedings.

3. Assign staff to analyze, prepare and share reports of

case reviews and death audits with PQIT and HMT

monthly.

2 Improving

Clinic

Efficiency

Change pattern flow to prioritize U5s care and treatment and provide for emergency care

Improving efficiency of services in care, involve

identification of areas with opportunities for

improvement, equipping HCWs with tools necessary for

result achievement.

Steps:PQIT review and redesign the current flow chart and request the management to include the following

1. Relocate/ establish pediatric OPD (POPD) services at

RCH.

2. Introduce emergence triaging assessment and

treatment (ETAT) at POPD.

3. Develop duty roster to cover all shifts.

4. Allocate clinician and triage nurse for U5s at RCH/

POPD.

5. Integrate dispensing and min lab services and

documenting registers at POPD.

6. Introduce a topic on early health care seeking in

health education topics at POPD/RCH.

Ensure all U5s with fever are tested with mRDT/microscopy

There are two change concepts under this improvement objective:

– Capacity building

– Improving laboratory service efficiency

Change Concept

Change Idea How to guide

1 Capacity

building

Incorporate importance of mRDT testing, proper documentation of mRDT results and other patient information in continuous medical education (CME)

Steps:

PQIT in collaboration with HFMT explain the importance and

validity of mRDT testing, proper documentation of mRDT results

and other patient information in CME by:-

assigning staff to prepare the schedule and do the orientation to relevant staff.

2 Improving laboratory service efficiency

Create more laboratory testing sites at POPD, RCH and IPD

Steps:QIT review the current flow chart to include the following depending on the care level of the health facility:

1. Relocate/ establish new testing sites for U5s at RCH/ IPD or

separate testing services for U5s at main lab.

2. Introduce lab roster of lab staff at all shifts, weekends and

public holidays.

3. In a situation where there is a shortage of mRDTs, give priority

to under fives and use microscope for adults.

4. In the absence of a lab technician in the evening and

weekends, use mRDTs only for children.

5. Introduce appropriate registers to document testing process at

all testing sites.

6. Assign a PQIT member to monitor documentation, evaluation

of the testing rates, results turnaround time and submit

reports to PQIT monthly.

Ensure all HFs have no stock out of essential medicines and supplies

There are two change concepts under this improvement objective:

– Establishment of medicines and therapeutic committees (MTCs)

– Improving information and communication

Change Concept

Change Idea How to guide

1 Establishment of functional medicines and therapeutic committees (MTCs)

Introduction of medicines and therapeutic committees (MTCs) guidelines in to routine services

Steps: The Health Facility Management team (HFMT): 1. Obtains the MOHSW guidelines and job aids2. Identify and orient committee members 3. Develop a MTC functionality monitoring checklist and

the schedule4. Assign a member to monitor MTC functionality

monthly and report to HFMT5. Develop a quarterly meeting schedule6. Assign a member to represent MTC at monthly PQIT

meetings

Introduction of stock-out monitoring form at all dispensing areas, physical stock counting and updating stock ledger into routine service

Steps:QIT review and redesign the current flow chart and request the management to include the following:1. Collect stock-out forms from the source/ District

Medical Officer (DMO) or reproduce own copies 2. Distribute stock-out monitoring forms to all

dispensing areas and orient users3. Allocate staff to monitor correct use of the stock-out

monitoring forms4. Assign staff to conduct monthly physical count and

update stock ledger

Change Concept

Change Idea How to guide

1 Establishment of functional MTCs

Introduce consistent recording of consumption data in the dispensing registers at each dispensing area

Steps:HFMT to:1. Obtain dispensing registers from DMO/ Medical

Stores Department (MSD)2. Orient staff on proper recording of consumption

data in dispensing registers3. Distribute dispensing registers in all dispensing

areas4. Assign staff to record consumption data in each

dispensing area5. PQIT to assign one of the members to monitor

correct recording of consumption data in the dispensing registers

Introducing assessment and verification of the quantity and quality of medicines

Steps:MTC to: 1. Identify and form a subcommittee on assessing

and verifying the quantity and quality of medicines

2. Introduce assessment and verifying procedures to subcommittee members

3. Assign one of the MTC members to monitor functionality of the subcommittee

4. Share the results of assessment and verification in the routine MTC and PQIT meetings

Change Concept Change Ideas How to guide

2 Improving information and communications

MTC provide updates on the availability of medicines during the clinical meetings

Steps:MTC should:1. Introduce updates on stocks of medicines and

supplies into routine clinical meetings2. Assign one of its members to inform clinicians

about the stock-out level during routine clinical meetings

3. Assign a member to document and monitor the frequency of updates provided during the clinical meetings

Communicate with DMO office/ MSD for follow up

Steps:The health facility in charge should use the results of stock out monitoring tool to:1. Communicate with DMO/ MSD about the

availability of out of stock items2. Follow up with DMO/ MSD on the requested

items

Ensure all HFs have adequate information to guide decision making

There are two change concepts under this improvement objective:

– Improving efficiency of data management

– Data dissemination

Change Concept

Change Idea How to guide

1 Improving efficiency of data management

Health facility information is provided from one source

Steps:HFMT to:

1. Identify and assign a data management focal person

2. Produce and display roster for supportive supervision on

data management to other HCWs

3. Organize and coordinate data management monthly

meetings

4. Attend and share data management report at the

monthly PQIT meeting

Monitoring availability of patient information, registers and other data collection tools weekly/ monthly

Steps

1. Health facility in-charge assign HCW to monitor

availability of patient information, registers and other

data collection tools

2. Assigned HCW to monitor and report on availability of

registers and tools monthly to health facility in charge

3. The assigned HCW to check regularly if the registers have

appropriate columns drawn and information

appropriately filled:

a. Collect and compile data from all registers weekly

b. Submit compiled data to the PQIT focal person and

the data management focal person

Change Concept

Change Idea How to guide

2 Data dissemination

PQITs analyze data, plot graphs and share data with health facility management and other HCWs, display data on notice board monthly

Steps:

1. PQITs to:

a. Prepare data collection, analysis and sharing protocols

b. Prepare and agree with the HF management on the results

sharing schedule

2. PQIT secretary sends out a notice of the meeting to HCWs 2

weeks before the meeting

3. PQIT focal persons send data to MTUHA officer who sends it to

HF in charge for onward transmission to DMO, RMO, THP

regional and zonal offices

4. PQITs identifies and prepares notice boards for posting results

5. PQIT focal person posts results on notice board monthly

PQITs use data to plan for further improvements (PDSA cycle: Plan-Do-Study-Act cycle)

Steps:

1. PQIT focal persons assigned responsibility for documenting

changes on the Standard Evaluation System (SES) form

2. PQIT secretary sends out a notice of the PQIT meeting 2 weeks

before the meeting

3. PQIT reviews progress made per each indicator:

a. Determine outcome of changes made

b. Determine changes that have given improvement results

c. Decide on what changes are required to bring further

improvement.

d. If no further improvement required, discuss with the HFM

to institutionalize the changes

Recommendations• R/CHMT/HFMT to establish HF PQITs by selecting

committed/willing HCWs.

• Use a training package of integrated QI, Case Management and SCM training.

• Introduce the Change Package during the training and assist them to develop an implementation plan.

• The HFMT should work closely with the teams and include their plans in HF plans / comprehensive council health plans (CCHPs) and orient the other HCWs.

• R/CHMT/HFMTs to support PQITs to document the improvements in the SES journal and share results regularly with HFMTs and other HCWs.

Thank you.