LARC presentation on the Continues Quality improvement

LARC Presentation

1. LARC Updates
Creating a Leak-
Proof Viral Load
Cascade via Clinic-
Laboratory Interface
(CLI) OptimizationLARC
03/08/2023
Katy Yao, PhD
LARC = Laboratory African Regional Collaborative

2. 2
Through rigorousapplication of a
structuredQuality Improvement
methodology and relentless focus on
results and data, LARC has
demonstrated measurable results
and scalability.
LARC is one of the few initiatives that
bring laboratorians and clinicians
together for problem solving and
process improvement.
Key Message
A
R
C
L

3. Presentation
Outline
LARC 1.0 and 2.0
(2016-2019)
LARC 3.0 (2019 –
Present)
Q&A
What is LARC?

4. Presentation
Outline
LARC 1.o and 2.0
(2016-2019)
LARC 3.0 (2019 –
Present)
Q&A
What is LARC?

5. What is LARC?
A data-driven, process
improvement program designed
to enhance healthcare service
delivery through multidisciplinary
teamwork using the DMAIC
methodology
Program Goals:
•To strengthen the viral load
cascade to achieve better
patient result (i.e., viral load
suppression)
•To improve institutional
capability for viral load scale-upLARC

6. Demand
Creation for
Testing
Specimen
Collection and
Processing
Sample
Transport
Laboratory
Testing
Result
Reporting and
Patient
Management
Clinic-Lab Interface Clinic-Lab Interface
Viral Load Cascade
LARC focuses on Demand Creation, Result
Reporting, and Client Management in the
viral load cascade.
Clinic-Lab Interface

7. DMAIC
Data-driven framework for processimprovement
Roadmap for Six Sigma and Lean

8. Structured DMAIC curriculum covers >30 QI
tools.
3 learning sessions + one workbook
WORKBOOK
(30+ tools)
8

9. Subscription
to the IHI*
Open School
on-line
courses
complements
the LARC
curriculum.
QI 101: Introduction to Health Care
Improvement
QI 102: How to Improve with the Model of
Improvement
QI 103: Testing and Measuring Changes with
PDSA Cycles
QI 104: Integrating data: Run Charts, Control
Charts, and other Measurement Tools
QI 105: Leading Quality Improvement
QI 201: Planning for Spread, From Local
Improvement to System-wide Change
L 101: Introduction to HelathCare Leadership
*IHI=Institute for Healthcare Improvement

10. Program implementation usually spans 9-
18 months but can be shorter.
10
May
201
8
Aug
201
8
Aug
201
8
Introductory
Webinar
Smart
Start
(on site)
Learning
Session I
Learning
Session II
Learning
Session
III
Final
Meeting
Action PeriodAction PeriodAction Period
LARC Program Implementation Model

11. LARCcqi.org
LARC website: A deposit of CQI tools and resources

12. Why Do We Need Another CQI Initiative?
Haven’t We Been Implementing CQI All Along?
ContinuousQuality Improvement
Define AnalyzeImproveControlMeasure
CQI

14. Presentation
Outline
LARC 1.0 and 2.0
(2016-2019)
LARC 3.0 (2019 –
Present)
Q&A
What is LARC?

15. The Viral LoadCascade
MalawiMozambique SwazilandTanzaniaUgandaKenya
↑ Patients
with high VL
whoreturned
for1
stEAC
↑ VL tests
orderedfor
eligible
patients
↑ VL samples
collectedfrom
eligible
patients
LARC 1.0 (2016-2017) tested the concept in 6
countries.
Demand
creation
Sample
collection/
transport
Laboratory
testing
Result
reporting
Patient
management
↑ VLresults
placedin
patientfiles
↑Patients
with highVL
calledfor
returnvisit

16. 45%
73%74%74%
0%
20%
40%
60%
80%
100%
Dec-16 Jan-17 Feb-17 Mar-17 Apr-17
May-17
Jun-17
Jul-17
% VL samples collected from
eligible patients
Malawi
To increase the percentage of viral load
tests ordered for eligible patients from 0%
(July 2016) to 80%by June 2017 in CPN,
CCR, and ARV clinics Kenya
To increase the percentage of patients
with viral load results placed in their files
from 4%(October 2016) to 80%by June
2017
4
7072
51
78747674
0
20
40
60
80
100
Oct-… Nov… Dec-… Jan-… Feb-… Mar… Apr-… May… Jun-…
% Hard Copy VL Results
Filed
Monthly VL Results Filing
Progress
% VL in Files Target
Nationwid
e HCW
strike
To increase the percentage of high viral
load patients with documented timely
follow-up from 12%(average from
Dec’15 to June ‘16) to 80%by June 2017
To increase the percentage of high VL
patients with a documented return visit
from 35%(Oct 2016) to 100%by June 2017
To increase the percentage of high VL
patients 1) contacted ≤ 1 week after results
receipt from 27%to 90%, and 2) initiated
with IAC ≤ 1 month from 6%to 90%
between June 2016 and June 2017
Swaziland Tanzania Uganda
12
100
75
100100100100100100100100
80
0
20
40
60
80
100
Bas… July Aug… Sept…
Oct… Nov… Dec…
Janu… Febr… Mar… April May
Percentage
Month
% called within 2 days for return
visits
(June '16 -May '17)
0
60
73
100
96
35
48
73
86
96
0
20
40
60
80
100
OCTNOVDECJANFEB
Percentage
Months
High Viral Load Clients` follow up
MkurangaCTC
%HVL followed up by…
%HVL followed up by call…
27
60
91
82
91
100
92
6
53
91
73
86
100
92
90909090909090
0
20
40
60
80
100
JunNovDecJanFebMarApr
Percentage
Monthly Progress (June '16 -Apr '17)
% HVL patients contacted
HVL register
implemente
d
HVL stickers
on patient
files
IAC forms
implemente
d
Baseli
ne
Mozambique
To increase the percentage of viral load
samples collected from eligible patients
from 45%(Jul 2016) to 80%by Aug 2017
0
85
3333
45
28
77
9594
73
6
0
36
20
27
48
94
7474
78
9998100100100100
0
20
40
60
80
100
JulAug
- Oct
NovDecJanFebMarAprMayJun
2016 2017
% of Eligible Patients with VL
Ordered
Month
BagamoioLARC
% of Eligible HIV Patients with Viral Load
Ordered
MCH CCR
LARC Project
spread to
all Clinic
Clinician
Educati
on
began
Clinician
Education
All Clinic
Clinic
Director
Follow-up
The pilot resulted in measurable
improvement in 10 months.

17. LARC 2.0(2018-2019) implemented a
structured curriculum and delivery model in
Kenya.
Standardized Portable Replicable

18. 11
sites
4
partners
2
models
Kenya implementation
Direct Assistance ModelRemote Assistance Model
UMB (Nairobi) -5 sites
▪GIS (Western Kenya) –4 sites
▪FHI360 site (Rift Valley) –1 site
▪Amref (Eastern/Coastal) –1 site

19. Impressive improvement was documented.

20. One site reduced the number of missed
appointments for viral load testing by 19
percentage points.
22%3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Demand Creation
Decrease in missed appointments for viral load testing
BeforeAfterTarget
Site A1
20

21. Seven sites improved viral load result
documentation (in EMR, green cards, patient
files) by 33-97 percentage points.
*Direct Assistance Sites
21
0%
0%
23%
23%
42%
54%
66%
97%
95%
100%
100%
87%
95%
99%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Result Reporting
Increase in result documentation in tracking logs, patient files,
and EMR
BeforeAfterTarget
Site B1
Site B2
Site B3
Site B4
Site B5
Site B6
Site B7

22. Two sites reduced the number of patients not
attending EAC within 30 days of receiving
results by 48 -60 percentage points.
48%
60%
0%
0%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Patient Management
Decrease in missed EAC appointments
BeforeAfterTarget
Site C1
Site C2
EAC = Enhanced Adherence Counseling
22

23. LARC Capability Maturity Model (CMM) measures
improvement in organizational capability related
to the Viral Load Cascade.
12345
23

24. All 11 sites improved their institutional capability
for VL scale-up. Patient management seems to be
the hardest capability to develop.
24
Patient
Management
Result
Reporting
Demand Creation
2
1
2
1
1
2
1
1
2
1
2
4
5
5
4
4
4
3
3
3
3
3
CMM before and After Scores
BeforeAfter
A
B
C
D
E
F
G
H
I
J
K

25. Presentation
Outline
LARC 10 and 2.0
(2016-2019)
LARC 3.0 (2019 –
Present)
Q&A
What is LARC?

26. LARC 3.0(2019 -present) focused on
scalability in Zimbabwe.

27. Phase I (Oct 2019 –Dec 2020)
12 Clinics & 3 VL Testing Laboratories were Enrolled.
Smart Start &
Learning
Session #1
Oct 2019
Learning
Session #2
Jan 2020
Global Pandemic
Mar 2020
Action Period
Action Period

28. Smart Start
& Learning
Session #1
Oct 2019
Learning
Session #2
Jan 2020
Learning
Session #3
Sept 2020
Virtual
Despite the Pandemic, We Adapted And
Marched On.
Action Period Action Period

29. Zimbabwe
LARC Phase I
Results
16
%
Points
The 12 Enrolled Clinics Improved Result
Documentation by 16 Percentage Points.

30. 5
%
Points
The 12 Enrolled Clinics Reduced Missed
Appointments (EAC) by 5 Percentage Points.
Zimbabwe
LARC Phase I
Results

31. 52
%
Points
BRIDHL Increased VL Samples Meeting
Targeted TAT (28 days) by 52 Percentage Points.
Zimbabwe
LARC Phase I
Results

32. 63
%
Points
PSI Lab Increased VL Samples Meeting Targeted
TAT (14 days) by 63 Percentage Points.
Zimbabwe
LARC Phase I
Results
*NMRL did not provide data

33. Phase II (Jan 2021 –Dec 2022): Expansion to 477
health facilities, 15 testing labs and 37 hub labs (with
plans to scale up to all 1600 facilities by 2025)
•The model switched from training facility workers to
capacitating the coaches
•Feb-May, 2021 –ECHO sessions led by US-based
consultant targeting coaches
•July 2021 –to date, the country team led the
implementation
Implementation Goals
▪To increase % VL samples collected from eligible clients to 95%
▪To increase % VL samples meeting the 14-day total TAT to 95%
▪To reduce VL sample rejection rates to <1%

34. “Although some sites were still lagging behind in CLI
implementation, the LARC initiative led to significant
improvement …in TAT and rejection rates.”
•By end of September 2022,
•>50% of health facilities implementing CLI had
increased their VL sample collection from eligible
clients to an average of 60% against a 95% target.
•During the same period, the average TAT decreased
from 70 days to 19 days.
•All hub laboratories and testing laboratories had
rejection rates of less than 1%.
•The National viral load coverage increased from 44%
(January 2020) to 72% (July 2022).
Data source: MOHCC

35. Country Implementation
•92 laboratory coaches trained (from 40 PEPFAR-
supported and 23 Global-Fund supported districts)
•257 IST riders trained on pre-screening of samples
on pickup and verification upon delivery at the
laboratory. (IST riders as “CLI change agents”)
•250 lab and clinic coaches trained in 6 joint learning
sessions
•A 5-day MOH-led TOT trained 23 trainers from 5
provinces
•Joint virtual and physical outreach/site visits (clinic
+lab) conducted
•Clinical and laboratory teams from national
(quarterly PMT, IPs), provincial (monthly), district
(monthly) and facility (bi-weekly) levels continuously
engaged in several platforms (Zoom, WhatsApp,
face-to-face)

36. Interventions that resulted in improvement
Reduced TAT:
•Increased bike saturation
•Introduced shift work for 24hr
testing
•Registered samples within 24hrs of
receipt
•Sorted samples and verified/printed
results daily
•Teamwork
Increased VL Sample Collection Rate
•Initiated monthly cohorts,
appointment register, sticker system
•Synchronized drug pickup and VL
sample collection
•Fast-tracked clients due for VL
•Sent SMS reminders
•Conducted health education
Reduced Sample Rejection Rate
•Trained riders on pre-screening fidelity
•Monitored rejections weekly and shared reports with mentors and IST team
•Distributed Specimen Acceptance/Rejection Criteria job aides
•Conducted joint site support and mentorship visits(Clinic+ Lab)
•Provided job aides on prescreening, triple packaging
Source: BRTI

37. Zimbabwe’s Approach to Sustainability
Political Sustainability –Zimbabwe MOHCC has a CQI coordinator
within their HIV department, who chairs the working group and
oversees all CQI and CLI efforts. CLI activities have been integrated
into national standards of clinical practice (National HIV Quality
Improvement Guidelines).
Programmatic Sustainability –The program capacitated CQI
coaches employed by implementing partners as well as MOHCC.
They integrated CLI mentoring and monitoring into their routine
site visits.
Financial Sustainability –For non-PEPFAR-supported provinces,
the country is using Global Fund to support the scale-up.

38. Cost Calculator
$700,000 for 500 sites
Source: BRTI

39. Presentation
Outline
LARC 1.0 and 2.0
(2016-2019)
LARC 3.0 (2019 –
Present)
Q&A
What is LARC?

40. Thank you