District TB Coordinators supported the TB Team at the facility.
At a health facility with challenges in patient flow, some clients were missing services. The facility had trouble identifying patients with tuberculosis (TB) symptoms – despite an increase in number of patients screened for TB from different care streams – in order to refer patients for testing, diagnosis, and treatment. In a new project, the team received continuous coaching on QI approaches and implemented changes that made critical differences for clients.
Imbalenhle Community Health Centre (CHC) in Imbali township, KwaZulu-Natal Province, South Africa operates 24 hours per day and serves approximately 25,000 patients per month. Although the staff of Imbalenhle CHC work under pressure with a low number of colleagues, extended hours of work, and limited resources, they dedicate themselves to providing quality health care services.
In 2017, the South Africa TB Quality Improvement (QI) project began in the uMsunduzi sub-district to ensure that all clients with TB are identified and started on treatment. For this project, the facility is supported by an Improvement Officer, an expert in QI approaches who assists the facility in developing solutions.
In November 2018, the project concentrated its focus on the 10 highest-burdened facilities in the sub-district, and Imbalenhle CHC was selected as a priority facility. Since the inception of the project, the facility has undertaken projects to improve the TB care cascade.
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Improving Screening Quality
First, the team discovered that most clients originate from the chronic care stream. To improve resource allocation, they identified the chronic stream as the target area for improvements.
During QI meetings, a team member presented the clinic’s data, and the group monitored results, identified gaps, and developed ideas for tests of change. By engaging with the data, the team found screening was performing well, but a low number of TB-positive patients were identified. The team champion emphasized that TB care involves a cascade of services, in which screening is vital to improve case finding, especially in a facility with a high TB burden.
Recognizing the need for stronger screening skills, the project provided an onsite staff training focused on quality TB screening. The training highlighted the importance of asking questions in detail, making sure clients understand the value of giving honest answers, paying attention to signs and symptoms other than coughing, and taking a proper medical history.
A Strong Commitment
Another challenge the clinic faced was that while some clients were weary of spending too long at the facility, limited resources were available to shorten the process time. However, the involvement of frontline staff rigorously tracking issues transformed challenges into drivers for improvement. Efforts to address differences and gaps in various units’ processes required teamwork and support from the TB team to build capacity in other units. Using problem-solving approaches, the team developed action plans aimed at improving patient care.
The TB team developed a strong commitment beyond their expected duties. After realizing most clients in the chronic stream arrive an hour before operations start, the team began arriving an hour before chronic stream staff to complete TB screenings for these clients. This step ensured all clients received screening and sputum collection before seeing the clinicians. As a result, the team completed more TB screenings and identified more cases.
Reducing Loss to Follow-Up
The team reversed the process flow to ensure the patient sputum is collected before the client reaches their final point. Patients went through these steps in order: vital signs, TB screening, sputum collection, doctor’s visit, and finally pharmacy.
At the end of the day, the team review the TB case identification registers, following clients’ journey through the TB care cascade to check whether anyone fell through the gaps. It is crucial clients remain in care to ensure successful treatment. Realizing some clients are lost to follow-up before they can complete care, the team brainstormed ideas to trace clients and provide proper care.
They decided to audit files at visits to ensure the lists are completed with traceable contact information. For clients with a new diagnosis, the team calls the number provided by client to verify contact details while the patient is in the clinic. If the phone doesn’t ring – a frequent problem before these changes – the team corrects contact details while the client is still present. If the client has forgotten their address on the day they are going home, a tracer driver drives them home to locate the address. As a result of these changes, the clinic has maintained a treatment success rate of 90 percent.
Throughout this process, leadership support has played a key role. The chronic stream operational manager, who acts as the QI Team leader, is fully engaged in and supportive of the work. This has led to the QI team receiving attention and support from the facility’s Assistant Nursing Manager. The district-level TB management partners with the team to regularly visit the facility and provide support.
A CHC Nurse Service Manager sits with the TB QI team.
Team Achievements and Takeaways
By reordering processes, the team has reduced overall waiting time. Staff from other areas, especially the chronic stream, are engaged in developing ideas for change. Working towards and reaching goals together has motivated the staff. Since implementing these changes, the facility has observed a slow increase in identified TB cases.
A TB QI team at Imbalenhle Clinic
The chart shows progress in TB case finding at Imbalenhle CHC. In November 2018, the Matron became more involved in the QI team (e.g., allowing staff to take time off for extra work hours from early arrival for TB screening and sharing the team’s successes with other units). In addition, the provincial office announced a change; now, patients diagnosed through x-ray had to be included in the total count of those testing positive. Note: EN = Enrolled Nurse.
This story demonstrates how to build momentum for QI in limited resourced settings, distribute resources effectively, remap patient flow to make the most impact, and engage support from leadership and management. To others doing this work, we would say: engaging staff in improving TB care processes is possible; however, feedback is needed for staff to see the impact of changes. Refrain from “blame games”; focus on changing the system, not attacking individuals. Shift from compliance screening to screening with purpose. When discussing work, talk about “us,” not “you,” because we are in this together. Lastly, know that every process failure can be an opportunity for improvement.
Celumusa Ndimande is an IHI Improvement Officer.