Why It Matters
Learn how an IHI team fell into the classic trap of implementing a checklist too quickly — and how, by regrouping to carefully test the tool, they are improving the quality of screening for tuberculosis.
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Avoid the QI Checklist Trap

By Pierre Barker | Wednesday, March 20, 2019

Sister Ostrich leads the QI team at Imbalenhle clinic.

When conducting quality improvement (QI) work, it’s easy to introduce a checklist and assume that a problem in the system has been solved. As IHI’s Dr. Pierre Barker was recently reminded, while checklists are an important tool for standardization, they must be tested and implemented correctly to be effective. When an IHI team and their partners implemented a checklist, tuberculosis (TB) screening increased, yet identification of patients with TB didn’t budge — until they recognized the trap and made key changes.

Since early childhood, I’ve been traveling from my home town Durban, South Africa, to the Drakensberg mountains, the best place in the world to hike. Along the way, we speed past a group of low buildings on the side of the highway through the provincial capital, Pietermaritzburg. Little did I know that these buildings are the EastBoom clinic, the largest community health center in the area and the heart of a local effort to use QI to fight tuberculosis (TB), a disease that kills over 125,000 South Africans each year. Recently, I traveled with the wonderful IHI South African improvement team members to this clinic and another just outside the city.

The concept for getting on top of the epidemic is simple: most undiagnosed TB patients regularly come to South Africa’s urban and rural clinics for routine primary care, but they are not identified and started on treatment. In theory, we should be able to use basic QI methods to increase the reliability of the steps of screening, testing, and treating TB patients who are already visiting the clinics. However, we’ve been struggling with the TB project since it started nearly two years ago.

When we received funding from the Bill and Melinda Gates Foundation, I confidently predicted — based on successful QI work we’d done with HIV care in similar South African settings over the past 15 years — that we would quickly see improvements in diagnostic and care processes. Well, I was wrong! After a year of efforts, clinics had successfully increased TB screening rates, but they had not seen any increase at all in identified patients with TB.

IHI South African team members Maureen Tshabalala, Hloli Ngidi, Celumusa Ndimande and Michele Youngleson outside the EastBoom Clinic, where new TB case identification increased by 40 percent.

We had fallen into a classic QI trap – not taking enough time and concentrated effort to learn about how to implement a checklist (in this case, a screening tool for TB symptoms). While clinics were hitting their screening targets, the quality of screening was so poor that no new patients were being found. Checklists are a tempting shortcut, but they require as much testing and learning as any QI tool. The team re-grouped and redesigned their efforts with a focus on a smaller number of clinics, with more testing of innovations to improve the quality of screening and initiation on TB treatment.

An annotated graph of TB cases demonstrates more than a 100% increase in identified new patients with TB who were given life-saving treatment as a result of the change ideas. These ideas and others are being assembled into a change package that will be scaled up in health districts across South Africa.

The next nine months made a dramatic difference. An inspiring group of clinic nurse leaders and district managers shared how they fanned out across their clinics, testing and honing better ways to ask the questions on the checklist, cross-referencing vital sign data with patient responses to questions, and finding potential TB patients in the extremely busy primary care clinics. The result: an increase in TB case identification across 6 of the 10 participating clinics. Some clinics more than doubled the median number of TB patients identified each month, with an overall increase of 38% across the 6 clinics that improved. This is the first critical step on the path to reaching the South African government’s goal of cutting TB mortality in half over the next three years.

Dr. Pierre M. Barker is IHI’s Chief Global Partnerships and Programs Officer.

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