A QI Team Approach to Scale Up Provision of TB Isoniazid Preventive Therapy (IPT) at Outapi ART Clinic

Author(s):

Outapi Quality Improvement Team

Topics: Isoniazid preventive therapy, Documentation/data collection, HIV-TB

Region and Country: Namibia

Organization: HIVQUAL-Namibia

The Report

Problem:

A routine review of performance data by the Outapi provider team revealed that of the 11 quality indicators regularly monitored by the QM program, the IPT performance rate was 22% - the lowest in that review period.

Intervention:

Outapi clinic staff determined to improve the provision of TB IPT to eligible patients from 22% to at least 50% within 6 months. To accomplish this goal, a QI project team was established to coordinate improvement activities. The team included a medical officer who also served as the team lead, a registered nurse tasked as the project secretary, a sister-in-charge, a pharmacist, data clerk, community counselor and an expert patient.

To systematically address TB IPT performance, the team investigated the current process to inform implementation of potential strategies. Data from the previous six month review period was analyzed, including data from all previous quality indicator performance scores.

In addition to reviewing the data, staff conducted process analysis using a fishbone and evaluated qualitative data from a previously completed focus group discussion addressing client views on IPT.

After careful review and analysis, the team considered potential interventions and parallel rationale for implementation:

A doctor gave a presentation to reinforce screening for IPT eligibility and prescribing practices for all clinic nurses
A screening tool for TB was placed in all consulting rooms to increase likelihood of its use
A screening tool for IPT was availed to all providers to boost identification of eligible patients
The data clerk gave a presentation on documentation in the patient’s file to improve this critical practice
The expert patient provided intensified health education to patients on IPT and TB to clear myths and misconceptions on IPT identified during the focus group discussions

With the selected interventions established, the team set out to implement proposed tests of change. Interventions were initiated over one month between January 15 and February 15, 2010, for patients registering with the ARV clinic.

Data was collected during the one month intervention period to monitor the number of patients:

eligible for IPT
eligible for IPT started on IPT during the intervention period
from previous cohort who returned for IPT refills
from previous cohort who failed to return for refills
stopped by providers owing to side effects
cumulative number of patients on IPT at the clinic

Results:

Use of Data to Study Results

94 patients were newly registered for HIV care between Jan 15 and Feb 15, 2010
80 patients were started on IPT in that period
This translated to a performance of 85%
From Feb 15, 2010 IPT was offered to all eligible pre-HAART patients by all the nurses
Given the success of the pilot phase, the project was further expanded to include patients on HAART from March 15, 2011

Lessons:

Future Plans:

A red sticker was placed on passports of patients on IPT for ease of identification and follow up on adherence and to monitor completion rates
During health education patients were shown samples of IPT and CPT for differentiation
Staff were encouraged to record in the patient file if IPT had previously be taken (e.g. IPT 2006)
The pharmacist on the QI team will continue updating the team regularly on IPT progress during staff meetings

* This improvement project report was adapted from a poster presentation presented at the 2011 All Country Learning Network in Windhoek, Namibia, and originally appeared in the May 2011 HEALTHQUAL International Update.

Year:

2011