A PMTCT Quality Improvement (QI) Project in Ekurhuleni North Sub-District Craig Parker1, Elna Lock2, Lauren de Kock1

1. The Aurum Institute, Johannesburg, South Africa 2. Ekurhuleni Municipality

Craig Parker Cparker@auruminstitute.org

• The launch of the National Core Standards (NCS) for all health facilities in SA in 2012 has created an unprecedented need for Quality Improvement (QI) methodologies to address operational gaps identified in Primary Healthcare Facilities (PHCs).

• The Aurum Institute and Ekurhuleni North Sub-District have been working on a QI project

since February 2012 to capacitate HAST Management, Facility Management, Antenatal Care (ANC) Nurses and Data Capturers to employ QI techniques to improve their PMTCT programme.

1. Background

5. Conclusion and Recommendations

4. Results

2. Intervention

Conclusions The QI model adopted in Ekurhuleni North provides an effective and innovative entry point into addressing gaps and improving quality of public healthcare. • Through working systematically through the PMTCT care pathway it was possible to identify

highly specific gaps and use QI methodologies to test changes and share learning. • Instead of facilities feeling overwhelmed by the magnitude of improving every aspect of care

at once, facilities were empowered to focus on small scale changes to understand what worked and then scale up the initiatives.

• Once adequate progress at a specific step in the care pathway had been attained, the learning collaborative moved onto new topic areas while maintaining progress in previous topic areas.

Recommendations JHB Health District • The Learning Collaborative methodology can and should be applied to every care pathway

in the Primary Healthcare Setting and beyond. • This approach should be built into the core of quality strategies being pursued by

Johannesburg health district as well as the National Department of Health. • This is particularly relevant to the National Core Standards where facilities are required to

reach compliance across a multitude of criteria all at once. Without a systematic way of working through quality issues, facilities will remain demotivated and stuck in the spiral of low quality healthcare.

The QI project improved the use and accuracy of data. Data was successfully used by management to identify and address gaps. DHIS sub-district improvements include: HIV 1st testing improved from 60% - 100%; 32 weeks re-testing for HIV from 40% - 80%; ANC PMTCT CD4s done 80% - 95% and AZT initiation from 80% -95%. Furthermore, according to statistical rules of systems change, all of the identified improvements are showing signs that indicate change beyond natural variation 3+4. The Change ideas that have been tested include:

• Antenatal Care (ANC) management and validation Tool • Process rearrangements within clinics • Early booking messaging in the community • Screening women for LMP • Patient linkage between ANC and rest of the clinic • Scheduling and booking rearrangements in ANC • Sub-District management review sessions • Facility management sharing sessions • Data tracking at a facility level

The project is structured as a ‘’Breakthrough Series Collaborative” (BTSC), a QI model that promotes simultaneous change across large parts of the system 2. Twenty Seven participating PHC facilities are linked into a “Learning Collaborative” to accelerate peer-to-peer learning and collaboration through setting common aims for strengthening PMTCT services in their facilities. Instructive learning sessions are conducted on a 3 monthly basis, followed by intensive action periods of assisted QI implementation at the facility level. On-site mentoring is offered by Aurum mentors and municipality/DoH “HAST coordinators”. Groups of clinics are encouraged to come together in these actions periods to share the ideas that are leading to successful change. The PMTCT care pathway is broken down into constituent topic areas that tie in with DHIS indicators. Topic areas are grouped according to their place in the care pathway and each learning session deals with three to four topic areas starting from the front end of the pathway. For example the first Learning Session deals with Early ANC bookings, ANC HIV 1st testing and ANC CD4 testing. The participants therefore move systematically through each step of the pathway while applying QI methodologies. Visual management techniques are utilized at the sub-district and facility level to promote a culture of data for action while Plan-Do-Study-Act cycles are utilized to explore implement and scale up change ideas.

REFERENCES :

1. District Health Information System (DHIS) 2. Institute for Healthcare Improvement (2003) The Breakthrough Series 3. Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: a simple analytical tool for learning from variation in healthcare processes.

BMJ Quality & Safety, 20(1), 46-51 4. Rules are approved by Associates for Process Improvement (www.apiweb.org)

Graphic illustration of the Learning Collaborative Model used in the Ekurhuleni North QI Project

Aurum would like to acknowledge the Institute of Healthcare Improvement for providing technical support on this Project

Graphs of Antenatal Care DHIS Data showing statistical shifts towards improvement

Quick Facts about Ekurhuleni North: • There are 27 PHCs and 2 MOUs • The HIV Prevalence amongst pregnant women is 29.8% according to DHIS statistics from

March 2012 to March 20131

• Caters to a highly migrant population of approximately 989,145 people1

• Tembisa, Kempton Park, Benoni, Edenvale and Boksburg all fall in this sub-district

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