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How can someone with improvement knowledge support a QI project spread throughout a region or district? Working from a location within the district may enhance the ability to carry out the work.
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The Benefits of Local Improvement Support

By Nokuthula Portia Zulu | Tuesday, January 28, 2020

Senior leaders, including representatives from the National Department of Health, Zululand District, and IHI, gather for the introductory meeting at the district office.

I could not wait to be introduced as the new improvement officer (IO) who would be embedded in the Zululand district to provide direct support to district, sub-district, and facility leaders, as well as to facility QI teams. I would provide coaching and mentorship to support work to close gaps in care for a tuberculosis (TB) program.

This work is part of the South Africa Tuberculosis Quality Improvement (SATBQI) initiative, which has an overall aim of achieving a 50 percent reduction in TB mortality by 2025. In the district, this would represent a decrease from 2,891 deaths recorded during from April 2014 to March 2015 to 1,450 deaths per year. In the initial project design, an IO would make an appointment with the district to support district leaders and build capacity. This person did not stay within the district and was not an integral part of the district team.

We learned that it was difficult to do QI in this way. Facility QI visits were not prioritized by district staff as there were many competing activities. The limited number of visits were spread across numerous sites so QI “dosage” at individual facilities was low. Data was difficult to access from the subdistrict office. Improvement stories from the field could not be easily obtained and documented due to limited contact with the facilities.

It also became difficult to track which changes resulted in an improvement, as facilities did not routinely collect process data. Due to competing priorities and programs in the primary health care setting, although the change ideas selected would be tested after the IO visit, after a few weeks the focus would shift to other priorities. This resulted in inconsistent performance. These lessons led to the adoption of the new design, in which an IO would be located in the district. This person would reside in or near that district and be available daily. Sites with high TB burden would also be prioritized for intensive QI support so we could learn about the gaps in TB care and how to close them.


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The introductory meeting for Zululand District, in Kwa-Zulu Natal Province, included representatives from the National Department of Health and IHI. The meeting introduced the amended design of the project, which included the new IO, that is, me. The discussion also included scale-up plans for the district.

The district leadership appreciated this plan for direct support from the IO. The executive management immediately indicated that they would provide office space and support. Being embedded in the district system meant my office days would be spent at the department’s offices. I didn’t realize then that spending my days at the department’s offices was such a blessing. I learned that being fully part of the district team proved to have a lot of advantages:

1. Increased field visits — The department continuously has one priority issue to attend to after another, and requesting visit dates as someone who occasionally came from outside the district proved to be challenging. One of the advantages of being fully in the district space now is that I get to know the current district priorities and hear about events in different areas. It is easier to schedule visits to facilities without disrupting current activities at the district and facility level.

The increase in field visits means more time for coaching facility teams on QI methodology. As a result of this added support, the teams become more confident in implementing QI. This in turn improves the facility’s overall performance.

The increase also promotes joint visits with district leaders and sub-district leaders. This supports the leaders so that they can sustain these initiatives into the future.

2. Improved data access — Access to data can be very challenging in the district setting, as data is carefully controlled and individuals and organizations outside the department cannot easily use it. Being part of the district team makes this simple, with an awareness that data access is provided and used in mutual trust within the Department of Health data use policies. I can now engage directly with the Data Capturers at facilities and with Data Officers who collate information at the subdistrict and district level. Coaching on data quality that I provide also promotes that easy access to data, as the teams know they will receive data support.

3. Incorporated project learning in existing events — As an embedded IO, I have become a trusted resource within the district when it comes to quality improvement knowledge. This trust has led to opportunities to teach QI in different forums within the district and to share lessons learned in the SATBQI project.

At an existing bimonthly forum discussing HIV and TB, I can provide brief important project updates and share best practices. As a result of the use of 1-hour speaking slots at these meetings to showcase the power of QI, district leadership endorsed starting monthly SATBQI project meetings fully dedicated to the quality improvement work. Implementers come to these meetings as a peer-to-peer platform to share their QI work.

Every week the deputy manager meets with clinical program managers. I have a 30-minute slot during these times to teach QI and coach program managers on their QI projects to ensure that improvement culture is upheld in the district and across all programs. In addition, QI methodology is applied to the weekly nerve center meetings in which data is reviewed, which are mandatory for all facilities. Using QI assists the district to focus and track changes for nerve center indicators in a short meeting.

4. Enhanced leadership engagement — In Zululand district, there is high leadership engagement, and this has contributed to project success. When new priorities emerge in the district, it is common for everyone to focus on that venture. An IO within the district can easily learn of these changes and advocate for the project to be considered as a priority amongst others. It has been very interesting to note how leadership engagement and buy-in has promoted engagement of key implementers at facilities. This is also important as I am always visible and can provide updates on the project as required.

At district health management team meetings, all subdistrict and district senior leaders meet quarterly. The deputy director and the TB coordinator share project progress with the district leadership, and I provide support with data presentation. When senior leaders sharing QI activities in this forum with other leaders, it not only promotes leadership empowerment, buy-in, and engagement.

Senior leaders are always faced with many tasks and often do not even have time to read formal reports. The most effective method that I have found is to have short 30-minute weekly check-ins with the Deputy Director of Programs, a key leader, to discuss in person feedback and any challenges faced. Brief weekly updates on a popular, free virtual application for messaging and calls have proved to be very useful in cases where leadership is not available. In addition, we send formal reports each month.

Current Results

In May 2019, the project transitioned from the pilot phase to scale-up phase. Learnings from one pilot subdistrict were spread to the four remaining subdistricts within the Zululand district.

One of the project aims is to find patients with undiagnosed TB and treat them before they get very sick. The numbers of patients diagnosed with TB has increased as the IO’s support is spread across the subdistricts, indicating that facilities are improving detection of TB. Due to complexities of supporting five subdistricts, having an IO located in the district has proved to be an important part of the design as we scale up the project.

Graph tested positive

In Zululand district, the number of patients diagnosed with TB has increased following scale-up of the project.

Like any other approach, this approach is not without its challenges. The district setting is a busy one with multiple meetings and trainings. As part of the district, the IO is expected to take part. This requires me to make sure that I don’t lose the focus of the project priorities while ensuring that the relationships built are maintained. I aim to do this by regularly discussing feedback and sharing my schedule. The IO has a monthly planner that is shared with management, and beyond that I share weekly schedules as a reminder of upcoming tasks. To foster balance and sense of being part of the district, I allocate Mondays to time in the office when the whole district team meets to share updates and weekly plans.

Having an embedded IO also fosters a risk of dependency on the IO. This may paralyze current improvements if the IO leaves. To minimize this risk, I have focused on building capacity of by coaching leaders in two high volume facilities in each subdistrict. These leaders in turn are responsible for coaching in the remaining facilities. By including one facility supported by local leaders in my coaching visits, I can monitor the effectiveness of the capacity building work by observing the results of their independent coaching.

Portia Zulu is a project officer for the Institute for Healthcare Improvement.

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