Effectiveness of a quality improvement collaborative to accelerate elimination of mother to child transmission:

Key outcomes and determinants, Eastern Cape Province, South Africa

Faculty of Medicine and health Sciences Academic Day 2016 August 11

N. Shingwenyana1, A. Chirowodza1, D. Williams1, C. Diergaardt1, O. Adetokunboh1, S. Gede2, N. Gobodo2, N. Makeleni2, N. Tuswa2, B. Green1, I. Oluwatimilehin1

(1)South to South Programme for Comprehensive Family HIV Care and Treatment, Department of Paediatrics and Child Health, Faculty of Medicine and Health

Sciences, Cape Town, South Africa, (2) Amathole District, Department of Health, East London, South Africa.

Presentation Outline

• Background

• Methods

• Results

• Conclusions

Background• South Africa has made substantial improvements in

prevention of mother-to-child transmission (PMTCT)• Reduction in vertical transmission from 8.2% 2008 to 5.8%

in 20091 and 3.5% in 2010 to 2.7% in 20112 in the recent past, 1.2% in 20163.

• Challenges remain in health programme implementation for key antenatal and postnatal services.

• We to describe impact and determinants for successful implementation of a quality improvement collaborative (QIC) approach as a method to accelerate the achievements of (eMTCT) goals in South Africa.

1Sherman et al, 2010 2Goga, Dinh, Jackson et al.; 2012, 3Motsoaledi 2016

S2S Quality Improvement Collaborative

Pilot Phase: Jan 2013 to Dec 2013 - 4 Facility QI Teams in 4

Facilities

Demonstration Phase: Jan 2014 to Mar 2015 - Maintain 4 QI Teams Established and Additional 10

Facility QI Teams

Learning Session 1: ANC

Learning Session 2: ANC

Learning Session 3: DEL

Learning Session 4: POST

Learning Session 5: POST

Learning Session 6:

Maint.

PDSA PDSA PDSA PDSA PDSA

Capacity building at Sub district, District, Province, Partners

QI COACHING, TRAININGS, PROGRAM TECHNICAL SUPPORT

Stakeholder Engagement and Ethics Clearance

Measure 1: 90 90 90 PMTCT Tracer Indicators

1. Antenatal 1st visit before 20 weeks rate2. Antenatal client HIV re-test rate3. ART Initiation rate4. Mother postnatal visit within 6 days rate5. Exclusive Breast Feeding rate6. Infant 1st PCR test positive around 6 weeks rate7. Child rapid HIV test around 18 months uptake rate8. Child rapid HIV test around 18 months positive rate9. Couple year protection rate

Methodology

• Measure 2: Quality Improvement Maturity– 41 interviews conducted and Key Informant Focus

Group Discussions• Sample (Different health system stakeholders)

– District/Sub district Managers– Facility managers/Operational Managers– Professional Nurses– Data Capturers– Lay Counsellors

Methodology

• Measure 3: Qualitative assessment– Key informant interviews

• District Management Team Members• QI Team Leaders

– Focus Group Discussion• Quality improvement team members

Methodology

Data Processing

• Compiled control charts using selected PMTCT indicators.

• Performed Wilcoxon signed-ranks test for differences between pre- and post-intervention medians.

• Descriptive analysis of quality improvement maturity surveys.

• Thematic analysis of qualitative interviews

Results• Improved performance in early booking rates (24 %; p<

.001). • Improved antenatal HIV retest rates (31%; p< .001). • Postnatal visit within 6 days rates improved (6%).• Exclusive breastfeeding rates improved (28%; p< .001).

The 18 month rapid test uptake rates improved (28%; p< 0.001).

• QI performance was influenced by baseline rates, facility type and size, quality improvement skills, leadership and buy in for quality improvement

Learning session

Learning session

Learning session

Examples: PMTCT Control Charts Results

Baseline versus post learning session median rates for PMTCT cascade indicators amongst S2S supported sites in the Eastern

Cape 2012 - 2015

*p<001 for difference between median rates for baseline vs post learning using Wilcoxon Signed-Ranks Test

Organisational Quality Improvement Maturity Scores amongst participating sites

High scores indicated role QI readiness and buy in for QI as

important dimensions for success

High scores for QI Methods and skills indicated role importance of training

in QI as important to success

Feedback about S2S supportImproved Knowledge of Data for Programme Monitoring

“They helped me track whether I’m going to meet our monthly targets. I never worried myself about that graph until S2S came, but now I can interpret that graph…for instance, when I realised that I’m not going to achieve my target, I decided to do an internal campaign” Focus Group Discussion, QI Team Member, EC.

Feedback: S2S Learning Network

Shared Learning

“I attended the first Learning Session. I was surprised. I did not believe that what they

presented was achieved as shown in the data in such a short space. I was so surprised at

how facilities were able to present as a group what they had achieved together”.

DMT Member, NC

Feedback: S2S QI ToolsProblem Solving using QI Tools to Reduce Waiting Times

“We did that fishbone and PDSA….our facility is normally full come 2 o’clock and the lines are still long. S2S saw this so they wanted to reduce waiting times…

we had to section like those on chronic; they made cards for us. If someone is going to the chronic side you give them a particular number and those going to ANC;

ART….to avoid that mish mash…we developed a strategy which saw other nurses coming in earlier so by the time the others arrive the influx of people would be

reduced” QI Team Member, EC

Conclusions

• The collaborative approach achieved rapid improvements in eMTCT program outcomes.

• Improvements observed in a wide range of contexts across facilities in the Eastern Cape Province.

• Performance variability may be attributed to contextual, organizational and system factors.