Why It Matters
By bringing together staff involved in diagnosing and treating patients with HIV, a clinic examined the care process and adapted the system to improve care.
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To Address Gaps in Care, Map the Process Together

By Azukile Nzuzo | Thursday, August 15, 2019

To Address Gaps in Care, Map the Process Together
Sr Thandi, the facility manager, holds an aim statement.

During my routine visit to Bedfordview clinic for clinical mentoring and quality improvement, a clinician who consults patients newly diagnosed with HIV was left with a patient file. As she looked around the clinic for the patient, she was unaware that the patient had already left. The clinician said this was a daily occurrence. She mentioned her frustration about being unable to link patients to care. Typically, after a patient is diagnosed as HIV-positive, the next step is to ensure they start on HIV treatment that same day; at the time of this work, a patient would first see a clinician for baseline bloodwork to assess their infection and use the results to determine when to start treatment. A nurse I spoke with noted that many patients were lost before seeing a clinician for bloodwork and treatment. She pointed out that managers often blamed the clinic staff for these occurrences, but that the staff felt like there was nothing they can do about it.

These conversations at Bedfordview clinic, in Ekurhuleni, Gauteng, South Africa, showed that the staff were stuck. They felt they had no control over the negative events happening in their environment. The clinic manager decided to call all key players (HIV counselor, nurse, etc.) involved in the process of diagnosing and treating patient with HIV. Their task was to map out the whole process from start to finish and then identify potential gaps in the process. The process map provided insights to what and who is involved in the process and the gaps that may result in losing a patient before they are started treatment.

Adapting a System Through Process Mapping

Mapping the process involved gathering everyone who plays a pivotal role, therefore fostering teamwork. By visualizing the process everyone could quickly identify the gaps, which included long waiting times, confusion around the location of the next service point, and long lines at service points where baseline bloodwork is collected for newly diagnoses patients. This meant that after testing positive, patients were not reaching clinicians for baseline bloodwork and treatment. Based on the analysis, the facility staff decided to focus their efforts on developing a more patient-centered process.

The team mapped out the old and new processes for patients.

The staff decided on a new way of doing things, which required counselors to accompany all patients newly diagnosed with HIV from the counseling that follows diagnosis to the clinicians. This adaptation helped the facility streamline the process of linking patients to care, thus improving the clinical management of patients. While some staff were initially skeptical of the change, after reviewing the baseline data they agreed there was a need to do things differently. In addition, once patients left the clinic, their file were now sent for data capture. Since this adaptation, each month, the staff review run charts of patients initiated on antiretroviral therapy for HIV in a facility meeting.

The clinic tracked progress in a run chart.

Taking a Bottom-Up Approach

Unlike the traditional problem-solving method, in which managers sit in the boardroom to make final decisions, the facility used a bottom-up approach that included all categories of staff. This approach allowed the staff to participate, broadened the knowledge base for the decision, and helped the staff to see the bigger picture.

As a first-born child, I relate to the traditional approach to decision making. My default is to be a parent to my younger siblings. Growing up, I would have to delegate tasks and make sure they were done otherwise – I would be the one getting into trouble. After being unlucky a couple of times when my mother came home to dishes still in the sink, I then tried a bottom-up approach, asking my siblings to unpack why they were unable to do dishes daily and what they thought the solutions would be. Instead of me punishing my brother and sister and getting the same results, my siblings drew up a roster for the dishes and they committed to it because it was their idea. This approach improves collaboration and open communication.

Partnering with Patients

During my coaching visits to the clinic, I observed the interactions between patients and providers. In these relationships, the patients often find it uncomfortable to be assertive about how they want to be served or even to complain if they have a bad experience. The clinic community committee (CCC), an initiative of the Department of Health, is intended to ensure community participation in the health care system. The involvement of the CCC, which consists of patients and community care workers, allows the needs of patients to be understood by including them in decision making. In this case, the CCC was involved in identifying problems in the process from the patients’ perspectives. Understanding the needs of the patients meant that the facility staff could now consider their preferences and patients could understand their voices matter.

Sustaining Improvement

The facility sustained this new process despite challenges. Recently, the clinic lost two HIV testing lay counselors who were part of the process when contracts were not renewed, meaning there was one counselor left. What kept the facility going was that the patients were well informed of the new process, and the facility staff reviewed the data to connect with it, knowing that behind each number is a patient.

Since this work began, the South African government has updated guidelines for antiretroviral therapy to introduce Universal Test and Treat, which means patients are initiated on treatment the same day as diagnosis regardless of their CD4 count, a measure from the baseline bloodwork. The facility adapted the process accordingly.

The key to change is collaborating with patients and guiding them through the system to minimize missed service points. The fundamental principle of quality improvement is putting the patient in the center. Systems must be designed not just for the service provider but also for the patient. Using quality improvement methodology, the facility managed to create services that support patients during their time of need.

Azukile Nzuzo is a Quality Improvement Coach at the Aurum Institute.org.

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