Moses Enock, BSc, a registered nurse midwife from MaiKhanda Trust, Malawi, is the winner of this year’s Annette J. Bartley Memorial Scholarship, earning a free trip to the IHI National Forum. The scholarship, which is awarded to one nursing professional every year, includes a free registration to the Forum and covers for travel and lodging. 

Mr. Enock has worked as a maternal and child health coordinator and hospital matron. He is currently an Improvement Advisor with MaiKhanda Trust for health care improvement collaboratives and quality improvement (QI) capacity building in Malawi. He has spent seven years setting up and running QI initiatives, coaching and mentoring teams in health facilities and strengthening the use of data for quality improvement. Moses provides QI capacity building for health care works at all levels: health center, district, and national. He also provides technical advice and support to the Ministry of Health and partners who work on health care QI in Malawi.

A panel of judges — including Annette’s closest nursing colleagues and friends from IHI’s staff and faculty — chose this year’s Bartley Scholarship winning essay from dozens of excellent candidates. 

Annette J. Bartley, RN, BA, MS, MPH (March 21, 1962 – November 24, 2016) was a nurse and health care improvement coach for more than 30 years, which included several leadership roles in frontline clinical care and management. A beloved member of the Institute for Healthcare Improvement (IHI) community, Annette died in November 2016, leaving behind a legacy of kindness, compassion, and optimism.

Here is Mr. Enock’s scholarship-winning essay:

Using QI Methods to Improve HIV and ART Care in Blantyre, Malawi

Malawi has close to 978,482 people living with HIV (PLWH). Blantyre district accounts for 14 percent of all people living with HIV in Malawi. It is also estimated that Blantyre accounts for 32 percent of the national coverage gap in HIV care. It is estimated that, of 137,000 people living with HIV in Blantyre district, only 55 percent are on antiretroviral therapy (ART). This shows that diagnosis and initiation on ART are major challenges in the district. Similar gaps exist in retention on ART treatment, viral load monitoring, and viral suppression.

To improve HIV and ART care services, a quality improvement collaborative was initiated in Blantyre district with funding through the US President’s Emergency Plan for AIDS Relief (also known as PEPFAR). The project timeline was July 2017 to September 2018.

The project had five main goals:

• Achieve 90 percent same-day ART initiation
• Achieve 90 percent viral load monitoring
• Reduce default rate
• Achieve 90 percent viral suppression
• Use of Isoniazid Preventive Therapy

This was a QI collaborative with 29 health facilities in Blantyre. The project covered a population of more than 90,000 of PLWH in Blantyre. The project used a Breakthrough Series approach to manage the collaborative and used the Model for Improvement with PDSA cycles to test change ideas. The project started with a design meeting to define the project topic, goals, and identify partners and facilities. All participating facilities formed QI teams and were trained on quality improvement methods. These teams conducted monthly QI meetings and received month QI coaching from an improvement advisor. Each facility had a data dashboard to monitor and report monthly progress on each indicator and successful changes ideas tested. Each team also created a quality improvement board to display QI work in the facility.

Collaborative learning sessions were conducted every three months with three participants from each facility. The quality improvement coordinator was main lead at the district level. The improvement advisor provided technical guidance, coaching, and mentorship to the district coordinator and facility QI teams. The Ministry of Health, HIV AIDS Directorate, and other partners working in HIV were engaged during the design phase.

The following were high-impact change ideas to improve same-day ART initiation and viral load monitoring:

• Escort newly diagnosed HIV+ clients for ART initiation.
• Reduce waiting time for ART initiation by increasing room, clinic days, and start ART clinic early.
• Allocate a full-time ART provider every day to ensure that newly diagnosed HIV+ clients are initiated on the same day.
• Provide physical screening for viral load test eligibility at the beginning of ART clinic.
• Start viral load test for eligible clients before supplying ART.

The project was a success. Same-day ART Initiation increased by 33 percent (58 percent vs. 91 percent), rates of viral load monitoring increased by 11 percent (12 percent vs. 23 percent), and rates of viral load suppression increased by 10 percent (78 percent vs. 88 percent). There is a need to scale similar initiatives to other districts in Malawi.