Data Management Collaborative - Uganda | USAID Health Care Improvement Portal

Author(s):

Robert Kyeyagalire

Sponsors/partners:

USAID Health Care Improvement Project, University Research Co., LLC

Topics: HIV/AIDS

Region and Country: Africa, Sub Saharan, Uganda

Date improvement activities began:

August, 2009

Aims/objectives:

The overall objective of the data management collaborative is to strengthen practices of documentation, analysis, utilization and sharing of data generated at facility level; and for HCI to synthesize a package of the most robust, effective and efficient changes that can improve data management across QI teams. Topics covered in the collaborative include:
• Use of the MoH patient monitoring tools
• Storage and retrieval of patient files
• Compilation, analysis and utilization of medical data in HIV care
• Periodical HIV care and ART summary reports to districts and MoH
• Synthesis of interventions that have led to improvement and those that have not

Implementation package/interventions:

In order to improve data management in health facilities offering HIV care and ART services, HCI is implementing the following strategies:
o During the 1st learning session, sites analyzed their data management systems, identified problematic areas that could be improved and developed possible solutions. In subsequent learning sessions, sites will share lessons learned and further analyze their systems, identify pending problematic areas develop further solutions. Sites implement the developed solutions during action periods between learning sessions.
o During periodical coaching visits, site teams work with coaches to review their understanding and use of the MoH patient monitoring tools are trained on use of the MoH patient monitoring and demonstrated to on how they should be used
o Introduced the documentation journal in which sites document and track their QI interventions to improve data management, and link it to as evidence that the intervention worked or did not
Through-out the implementation of the collaborative, the most robust and effective changes will be synthesized from the participating sites and outlined into a change package that can be spread to other sites.

Measurement:

Indicator #1 Percentage of sites within the collaborative completely filling-in the patient HIV care card on every clinic visit
Indicator #2 Percentage of facilities documenting their QI interventions and resulting data in the documentation journal in a month
Indicator #3 Percentage of facilities producing time-series charts illustrating QI data on a monthly basis
Indicator #4 Proportion of facilities that submit quarterly reports on HIV care and ART to the district health office
Indicator #5 Percentage of facilities submitting cohort analysis and cross-sectional HIV care reports to MoH on a quarterly basis

Spread strategy:

HCI will periodically synthesize results from the sites and compile a change package of best-practices that will be distributed and implemented in sites while the collaborative is on-going. Best practices will be compiled on an on-going process.HCI is now compiling best practices on storage and retrieval of patient files.

Number of sites/coverage:

The total number of facilities participating in the collaborative is 17 consisting of 07 District Hospitals, 04 NGO general hospitals and 06 Health Center IVs out of a total of 4,639 health facilities in Uganda. These facilities cover 13 out of 80 districts and are located in 3 of 12 MOH regions. The estimated population covered by these sites is 5,400,000 people and 318,600 PLHIV.

Coaching:

At the start of the HCI ART Collaborative, a group of coaches, known as the Core Team, was formed at the national level from Ministry of Health and HCI staff to support sites and develop technical strategy for the project. The Core Team build capacity of MOH regional staff, called Regional Coordinators to conduct trainings and coaching sites in quality improvement and clinical treatment. Regional Coordination Teams were set up in 12 health regions of Uganda with 5 members each representing data, laboratory services, pediatric HIV, and 2 for general HIV care. For the Data Management Collaborative, sites are being coached by HCI staff, Core Team members and Regional Coordinators responsible for data once per months

During the on-site coaching visits, coaches review the previous work plans drawn up by the site QI teams to determine level of completion. Coaches then work with the team to identify gaps in processes of care, analyze the root causes and develop possible solutions. A new action plan is then drawn that is to be implemented by the site QI team in the subsequent action period, including collection of data to link changes introduced to improvements observed. Technical support in other areas of HIV care is also provided.

Coaches also work with site teams to synthesize evidence based practices that have resulted in significant improvements. Such practices are then compiled and spread to other sites.

Learning sessions & communication among teams:

Learning sessions will be held every after a 6-months action period and will be attended by 2 to 3 representatives from the collaborative sites, preferably in-charges of ART and data management at sites or others involved. Learning sessions are facilitated by HCI staff, core team coaches and regional coordinators.
General topics covered include technical aspects of HIV care and ART, implementation of QI in HIV care and data management
In preparation for learning sessions, sites use synthesis forms to summarize their improvement efforts highlighting key interventions that were effective (or not) in improving data management. Participants then make poster and PowerPoint presentations of the synthesized results of their work, while linking changes introduced to data observed. Participants gather in groups to brainstorm, compare and share notes on what works and what does not in different settings. Copies of synthesis forms are obtained by the facilitators for compilation into a change package.
Technical topics are presented by facilitators through PowerPoint presentations and copies handed out to participants. Any new guidelines, policies and/or publications from the MoH are also handed (or communicated) to participants at this forum.

Results:

At the 1st learning session in October 2009, all sites identified poor documentation practices in use of the patient monitoring tools as the primary problem affecting the quality of care. Others included poor storage systems for patient files that affect clinic efficiency, limited skills in data analysis and in compilation of HIV care reports. In the last 4 months, most sites have worked on improving documentation in the Patient Monitoring (PM) tools, and improving storage and retrieval mechanisms for patient files. Operational changes have so far included: - • formation of QI teams with team members assigned a role that contributes to the site’s objectives (all 17 sites have QI teams) • Use of the revised MoH standard patient monitoring tools that include the patient HIV care/ART card, the pre-ART register, the ART register and the quarterly report form (all 17 sites are using some of the tools) • Adoption and use of the documentation journal as the standard tool to capture and record interventions being implemented and the resulting data (10 of 17 sites are documenting changes in journal) • Reviewing the data storage systems currently used by sites so as to determine how file retrieval time can be reduced to reduce on patient waiting time and improve clinic efficiency (all 17 sites have started work on this) o 100% of facilities in the collaborative are using the HIV care/ART card for patients in care o 59% of sites are documenting QI interventions in the journal o Less than half the facilities have time-series charts on facility based indicators for quality of care It is worth noting that sites have just started implementing changes and have had only 2 coaching visits since the 1st learning session, better results are expected in the next quarter as sites appreciate QI more and gel together as a team. Graphical results on use of PM tools and on storage of patient files are shown below (For graphs and Tables please see document attached below)

Best practices/conclusions:

As illustrated in figures below:
i. In order to fast-improve complete and accurate filling-in of the HIV care/ART card, QI teams have assigned different fields of the card to be filled-in by different people on a clinic day. The triage nurse fills-in some, the clinician some and the nursing counselor some fields as the patient flows through the clinic. In addition, the team leader plays reviewing and supervisory role to ensure all the fields are filled-in. Figure 1 below illustrates results of such work in Nyenga hospital.
ii. Storing patient files in clearly labeled shelves, separated into pre-ART and ART and having a staff member manage the system lessens the time taken to retrieve a patient’s file on a clinic day. Table 1 below illustrates results from sites that have efficient storage and retrieval systems and those with poor ones.
(For graphs and Tables please see document attached below)