One of the QI teams from the collaborative.

The success of a QI collaborative depends largely on developing dedicated QI teams at facilities through training, coaching, and mentorship. However, conducting regular site-level coaching and face-to-face meetings with the whole team is a big challenge, especially in resource-constrained settings. Difficulties include lack of time, lack of resources such as finances to support site visits, and inadequately trained QI advisors. In a recent collaborative on HIV/AIDS care, my team used virtual QI coaching to help achieve results.

The Blantyre Early HIV Treatment Initiative (BETHI) collaborative was implemented in Blantyre district in the Southern Region of Malawi. BETHI collaborative had 29 health facilities. It focused on five indicators:

• Antiretroviral Therapy (ART) initiation: Proportion of patients with HIV initiated on ART, a combination of medications to treat HIV, on the same day as and within 2-7 days of diagnosis.
• Loss to follow up: Proportion of patients with HIV on ART with more than 60 days since their last visit or medication pick-up.
• Viral load monitoring: Proportion of eligible patients on ART who received a viral load test to measure the number of HIV copies in a milliliter of blood.
• Viral load suppression: Proportion of patients on ART whose test result shows a suppressed viral load (fewer than 1,000 copies per milliliter).
• Isoniazid preventive therapy (IPT): Proportion of patients newly diagnosed with HIV who are initiated on IPT, which reduces the risk of tuberculosis infection.

Why Virtual Coaching?

The collaborative faced two major challenges which prompted use of a popular, free application for messaging and calls to do virtual QI coaching. First, I was the only QI advisor assigned to conduct coaching and monthly data review meetings with all 29 health facilities. As such, there was not enough time for bi-weekly site visits to each facility. In addition, the collaborative faced financial challenges, and due to delayed funding, it was difficult to follow the schedule for site visits. To mitigate these issues, we formed a group in the application connecting the facilities and provided virtual coaching and support through this platform as a backup to onsite QI meetings.

Coaching Structure

We added three people – QI team leader, facility in-charge (manager), and data person – from each team to the virtual group. We encouraged facilities to post their challenges and conduct follow-up discussions in response. The collaborative also used the virtual group for scheduling in-person coaching visits and sharing monthly project data at the district level.

Excerpts from discussions in the virtual group.

When we discovered that it was difficult for teams to understand written conversation, leading to discussing the same issue over and over again, we introduced a new step. At the end of each discussion, facilities requiring further explanations sent me a note through the app, and we scheduled a voice call using the app. Normally I could call a team leader during their facility QI team meeting. The phone was put on loud speaker so that everyone could hear, comment, or ask questions. This was found to be a more powerful approach to communication.

Structure of the virtual coaching system.

Most discussions focused on how to use Plan-Do-Study-Act (PDSA) cycles to test change ideas and implement on a large scale. For example, one facility struggled to differentiate between outcome measures and process measures when using the Model for Improvement. At another facility, team members had different understandings of PDSA cycles. Some thought that the cycle was used as a general project management tool. After discussing these issues on the group and in voice calls, most facilities were able to test, implement, and document change ideas.

Improved documentation of change ideas to improve HIV/AIDS care at a collaborative facility.

Some participants posted group messages not related to the collaborative’s QI work. We set the guidelines and purpose of the group and shared them with the teams. Anyone posting unrelated materials was cautioned in the group and individually. These changes helped to maintain focus of the group on QI.

Adaptation Lessons for QI

Last year, I was awarded the Annette J. Bartley Memorial Scholarship to attend the IHI National Forum. I took home several important lessons that contributed to the BETHI collaborative work:

• Share knowledge and skills: The first keynote speakers illustrated this idea by discussing how innovations invented in Scotland reached the whole world. This inspired me to share QI knowledge and skills with likeminded people working in health care. Other sessions taught me ways to mentor people who are new to QI.
• Adapt the model for your context: Another speaker talked about making practical adaptations to the Breakthrough Series Collaborative model of learning in order to achieve results. At the end of the session, I pictured all the challenges I was facing in my collaborative and came up with realistic adaptation of using a virtual application for coaching instead of relying solely on site visits.
• Make use of data: The forum provided interventions to ensure that QI teams used their facility data for improvement. These included a monthly data review in which we present monthly performance on each indicator to the QI team.
• Network: Making connections is paramount to doing QI work.

 Successes and Next Steps

The BETHI collaborative kept motivation and momentum high despite irregular site visits. 22 out of 29 facilities scored 4.0 (significant improvement) out of 5.0 on the Collaborative Assessment Scale, a measure of progress. After design and baseline assessments in 2017, and launching the intervention in 2018, by March 2019 the project achieved 3 of the 5 indicators across the facilities:

• Same day ART initiation improved from 58 percent to 95 percent
• Viral load monitoring at six months improved from 12 percent to 45 percent
• Viral load suppression moved from 78 percent to 88 percent

Looking ahead, we plan to sustain the BETHI collaborative by continuing virtual coaching, sourcing funding for quarterly site visits and learning sessions, and providing technical support to district leadership. In January 2019, we also started running a virtual group to share knowledge among QI leaders across Malawi. We are exploring the best digital platform for the group, which includes members of a previous collaborative run by MaiKhanda Trust, district coordinators, and project officers from several non-governmental organizations (BETHI collaborative was facilitated by MaiKhanda Trust and the Blantyre District Health Office in partnership with HEALTHQUAL, with funding through the US President’s Emergency Plan for AIDS Relief, as part of the Health Resources and Services Administration’s Quality Improvement Capacity for Impact Project). In addition, discussions are underway to provide volunteer QI support for the maternity unit at a district.

Our work shows that while regular onsite visits are vital to provide detailed coaching in context and build strong relationships, virtual coaching strategies can provide a key source of support in developing frontline capacity. Collaboration with other partners doing similar work maximizes the use of available resources and ensures sustainability of initiatives.

Reserve your spot today to attend the 2019 IHI National Forum.

Moses Enock is a registered nurse midwife at a MaiKhanda Trust and an Improvement Advisor with MaiKhanda Trust for health care improvement collaboratives.