Nzara Hospital Site Presentation IIT-QIC_LS4.pptx

Nzara Hospital LS presentation

1. Nzara Hospital QIC_LS 4 Preventing Interruption in Treatment (IIT)

2. AIM What are we trying to accomplish? MEASUREMENT How will we know if a change is an improvement? CHANGE What changes can we make to result in improvement? Act Plan Stu d y Do - Langley G, Nolan T, Norman C, Provost L (1996) The Improvement Guide Tests of Chan g e The Model for Improvement

3. Plan : investigate the current situation (problem statement), fully understand the nature of any problem to be solved (Root cause analysis), and to develop potential solutions to the problem (selecting the change ideas and developing the plan for implementation, documentation and time period- Action plan). Do: implement the action plan. The change idea are implemented and documented according the plan PDSA Cycle

4. Study: this stage is when the collected data must be organized and analysed. Determine whether an improvement was achieved. Determine what lessons have been learned. Was the intervention a success? Were only some elements of it a success? If so, why? It is imperative that the team conducts a thorough and rigorous analysis of the data and agrees on lessons learned, as these lessons will directly affect the next stage. Act: determines whether to adopt, adapt, or abandon the change idea. If the data is positive, consider scaling it up and implementing it more widely. PDSA Cycle This is why we are here!

5. QIC Results: (FY22 March- FY23 June)

6. QIC 1: Percentage of newly enrolled clients linked to COVs Some clients refused linkage in July and Sept respectively. The position of CLO was vacant in Sept affecting effective linkage. In November 2022,the vacant position of CLO was filled, SOPS and mentorship training was conducted on linkage and lastly we intensified counseling on benefits of Client-COVs linkage to all new and old clients not linked to COVs and all clients accepted the service. This as constantly continued positive until date. QIC 1: Percentage of newly enrolled clients linked to COVs

7. QIC 2: Percentage of clients due for ART refills provided with reminder services through call, SMS or home visit In March 2022, some clients on appointment had no phone numbers and among those are clients who refused cov linkage. In April 2022, most clients had active phone numbers with updated landmark . From May 2022-August 2022 appointment call cark position was vacant. Knowledge gap in home visit COV reminder services from March 2022 to October 2022 In September 2022, the vacant position was filled, reminder service picked up effectively until date. In November 2022,Capacity building on home visit reminder services was done during IIT QIC LS3 and this as perfectly worked in tracing clients without active phone numbers. QIC 2: Percentage of clients due for ART refills provided with reminder services through call, SMS or home visit

8. QIC 3: Percentage of clients who missed appointments QIC 3: Percentage of clients who missed appointments In April 2022 to October 2022 , there was existing knowledge gap on early client reminder services, regular mapping of clients location, consistent mentorship and updating of COVs booklets and tracking for early drug refill that led to high miss appointment. on job training was done from May-July and missed appointment reduced. In November 2022, IIT QIC LS3 was done and the change ideas as eventually worked by reducing missed appointment to zero percent. QIC 3: Percentage of clients who missed appointments

9. QIC 4: Percentage of clients who missed their appointment and received calls From April –July 2022, some clients who missed appointments had no active phone numbers, those who had contacts were out of network to their farms (farming season) From August 2022 till date the facility picked the change idea of attaching COVs contacts to clients folders who regular map their clients location and the reminder is passed through COVs to clients with unreached contacts and it is perfectly working. QIC 4: Percentage of clients who missed their appointment and received calls

10. QIC 5: Percentage of clients who missed their appointment received calls and with dates of return From April-July 2022, Clients who missed appointment Called couldn’t be specific on their date of return due to farming then when it reached to August, farming was on a break, they began to point out dates of return In October 2022, some clients appointed their dates of return after miss appointment but didn’t turn up. From November 2022- March 2023, the few missed appointments had dates of retun .

11. QIC 6: Percentage of clients who missed their appointment, returned through phone calls and refilled From March – July 2022 the facility had logistic issues with procuring airtime to the facility phone and their was a knowledge gap on missed appointment tracking. From August 2022 – Feb 2023, the administration was flexible in providing airtime after the facility performance data review. In October 2022, on site mentorship was done and missed appointment tracking SOPs were availed. QIC 6: Percentage of clients who missed their appointment, returned through phone calls and refilled

12. QIC 7: Percentage of clients who missed their appointment and returned to facility through COV tracing QIC 7: Percentage of clients who missed their appointment and returned to facility through COV tracing From March 2022-July 2022, tracing by COVs was weak due to delayed incentives. From August 2022, some COVs were replaced creating knowledge gap in regard to client tracking and due to the change of COVs some clients had mixed trust in COVs making them to come to the facility by themselves.

13. QIC 8: Percentage of missed appointment clients traced and refilled through facility or community settings In march 2022, most of the missed appointment clients were children who couldn’t be refilled in the community due to the call for a clinical review. From April-December 2022, it became the desire of stable clients choosing to be refilled in HF or Community. Jan 2023, most of the missed appointment clients had efforts to be refilled in the HF due to opportunistic infections. QIC 8: Percentage of missed appointment clients traced and refilled through facility or community settings

14. Change I deas Implemented and worked Early appointment reminder services and tracking two weeks before their due dates. Regular mapping of clients location and updating of COVs booklet. True linkage of client-COVs and attachment of COVs contacts to clients folders without active contacts. Early drug refill to clients on travels, farming and hunting . Practice of community ART refill services to stable clients. Engagement with COVs in both community and facility services. Continuous mentorship and follow up of COVs. Improved client flow process map within the facility.

15. None!! Change I deas Implemented and did not work (with reasons why they didn’t work)

16. From FY23 Q2 till date, we have progressed to 100% reduction of IIT through early client tracking for refills. IIT reduction: Quarterly Progress Towards 60% IIT reduction

17. Lessons Learnt Early client reminder services reduces missed appointment. Provider failure to offer linkage services contributes to missed appointment. Client contact details updated at every clinic visit in the KYC reduces missed appointment. Daily tracking, monitoring and appropriate use of appointment logbook reduces the gap in eligibility assessment. Use of COV contact details in linkage forms for clients without active phone numbers is perfect in tracing clients for early refills. Availability of facility service SOPs reduces knowledge gap in delivering services. Unfriendly services e.g delay in reminder services and delayed response of community drug refill to consenting clients contributes to missed appointment.

18. Early appointment reminder services weeks upon due dates. Regularly update KYC form on every visit to the facility. Attachment of COVs contacts to clients folders without contacts. Regular updating of COV booklets. Facility monthly data performance review. Daily updating and monitoring of appointment logbook. Best Practices

19. Insufficient airtime and inadequate number of phones for call reminders. Isolation of Nzara Hospital in terms of support e.g essential supplies, WiFi and any other support. Poor staffs incentives and delayed payments. Ongoing challenges

20. Avail updated call reminder SOPs to service providers. Avail community reminder transfer forms and conduct on job mentorship on the use of community transfer forms. Avail dedicated mobile phones for reminder services. Update consent forms at every clinic visit and offer COV linkage to new and returning clients at every visit. Regular supportive supervisions. Fill the gaps in the system. mentorship and trainings of staffs in the system. Early reminder services weeks upon due dates. Continuous engagement with Community HIV service team to improve feedback mechanism. Scale up reminder services Provision of community ART refill services. Attach COVs Phone contacts to clients attachment forms for reminder services upon appointment due dates and it helps in tracing clients without active phone numbers. Proper and regular mapping of client’s location via NYF Recommendations and next steps .

21. Q&A