Photo by Steve Johnson | Unsplash
The four-year Tuberculosis Quality Improvement (TBQI) project, supported by the Institute for Healthcare Improvement (IHI) in five districts in South Africa, was ending in December 2020. The project, largely aimed at increasing TB case finding, trained district health managers as quality improvement (QI) coaches to test, develop, and spread successful change ideas, and created sustainable change. To do this, Department of Health (DOH) district program managers and coordinators were steeped in QI theory and practice, attending leadership and facilitating QI training workshops, teaching at multiple learning sessions, and receiving intensive on-site coaching with facility QI teams. We, as technical leads, had produced nearly 150 pages of guides and tools to support them.
Then, with only a few months left to go, we were asked to include three more districts in the project with no additional resources and facing COVID-19 travel restrictions. Of greatest concern was a recent analysis of national laboratory data that showed that, despite the great engagement at all levels, the project had not increased TB case finding to expected targets. Two possible explanations came to mind. Maybe our technical assistance for QI coaches was too diluted, as their work suddenly grew to support more teams across vast geographical areas and multiple facilities. Or maybe an underlying assumption of the national TB protocol — that most TB patients can be identified through screening for symptoms — was questionable.
Perhaps both factors contributed. A few facilities in one rural district had done some small tests of change, routinely testing all HIV-positive antenatal (pregnant) clients and newly diagnosed HIV-positive patients for TB whether they had symptoms or not. They found that half of those testing positive did not have TB symptoms. This observation has recently been confirmed in a national TB prevalence survey, suggesting that symptom screening is not enough to detect TB.
Time, accessibility, and impact constraints challenged us to think creatively to design a new, lean project model. We created what we called a Sprint. A Sprint uses “just enough” QI content to make change. In this case, it was a set of only four change ideas focused on testing high-risk, HIV-positive groups for TB regardless of symptoms. It also uses just enough QI to get the change ideas implemented.
In a Sprint, QI theory is implicit rather than explicit, integrated into a series of eight practical exercises that guide engagement with the TB program at the facility. Each exercise is presented as a one-page worksheet. Managers still lead QI at the facilities, but only need to know how to guide the QI teams to use the simple, standardised, self-explanatory worksheets. Our TBQI curriculum has gone from 150 pages to 8 pages in the new districts
Facilities update the worksheets monthly and then post them to a dedicated cell phone chat group. This allows for real-time virtual coaching by the Improvement Advisors (IAs) and provides a dynamic peer-to-peer learning platform. Feedback from the IAs of facilities that have posted to the group chats adds some healthy competition and motivates facilities to participate. The districts also have their own higher-level District Learning Network platform, a virtual quarterly meeting hosted by the province, where they share progress on project implementation. The Sprint project currently has four districts with two more districts joining soon, and will continue through December 2021.
This project targeted wide coverage in a public health care system where it is impossible to have regular, direct contact with participants. Faced with a similar context again, we might suggest starting with a very small pilot project using conventional QI to deeply understand the system, and then figuring out how to “achieve the most with the least” in the spread phase. This way, limited coaching resources can be more easily and consistently leveraged for quick uptake and sustainable engagement. One highlight of the current format is the cell phone platform. It gives us great certainty about who is doing what and how frequently in the implementation of the project. If we are not making headway, we know it is the change ideas and not project implementation that is the problem.
Sometimes less is more. A Sprint is like reading someone a story, rather than teaching them to read. Each approach is valuable for different situations.
Maureen Fatsani Tshabalala, RNM, BBA, MPH, is Director for Regional Projects in Southern Africa at IHI. Michèle Youngleson, MBChB, is IHI’s Senior Improvement Advisor for the South Africa Tuberculosis Quality Improvement (SATBQI) initiative and an IHI faculty member.