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Reducing the waiting time for HIV/AIDS patients attending Mengo Hospital HIV clinic, an urban hospital in Uganda

Improvement Report
Suubi Henry Mubiru

Topics: Program design, HIV/AIDS

Region and Country: Uganda

Organization: Mengo Hospital a Urban Hospital in Uganda-Sub Saharan Africa
The Report

Mengo Hospital is a Non Government faith based private not for Profit hospital and the pioneer of modern medical practices in Uganda and has existed for a hundred and thirteen (113) years thus far. It was established by Dr. Sir Albert Ruskin Cook of the Church Missionary Society in 1897. It has the four main clinical disciplines of medicine; surgery, paediatrics and obstetrics & gynaecology, along with the specialised services in; eye care (ophthalmology), optometry and dentistry with state of the art facilities and services.

Mengo hospital exists with a Mission; “To provide excellent sustainable health care services that bear witness to Christ”.
The Vision “ to attempt to heal the suffering is much, to carry the water of salvation to thirsty souls is more, but to combine the two is the greatest work a man can hope.”
Mengo Hospital HIV clinic, started its activities in 1988 with approximately 69 HIV patients. Since its inception, the services at the department have greatly grown in scope and size registering several land marks, from just 69 clients to over 5000 registered in the clinic by the end of 2010, having over 2,300 clients receiving ART. The clinic also caters for children infected with HIV and by the end of 2010 there are approximately 240 child clients, of whom 130 are receiving ART.
By the end of 2010 Globally, 39.4million people(adults and children) said to be living with HIV/AIDS, of these 25.4million live in Sub-Sahara Africa,(HIV prevalence 7.4) of which 2,145,000 are living in Uganda,(HIV prevalence 6.5). Globally, 4.9 million new infections were detected by the end of 2010, out of which 1.9 million in  SSA, of which 120,000 were in Uganda with 2.3% registered HIV related deaths in Uganda in the presence of ARVs.
Mengo Hospital is located 3 km from Kampala a city with a population of 1,353189( 25 July 2010 population statistics). The HIV prevalence in this area is 6.5% and it is estimated to be having more than 87,957 living with HIV. A total of 2160 HIV new cases were diagnosed of those 1384 were enrolled for chronic care by 2010 in Mengo Hospital HIV clinic, along with 4000 patients who were existing in HIV care. It is the hospital policy to conduct RCT(Routine Counseling and Testing for HIV) on both In and Out patients and the HIV prevalence is 9.6% due to the hospitalized population.
Problem statement: HIV/AIDS Patients waiting for so long in the clinic before receiving services or being attended to.
Before the interventions, there was no well defined patients’ flow in HIV clinic and this led to chaos almost on every clinic day and unnecessary fatigue to patients and staff.
§ This was noticed by the quality improvement team members, in one of our monthly meeting and a survey was conducted to ascertain the average time a patient could spend in the clinic at various points and the observation showed the average time as 3hours and 30 minutes. This was not fair to our clients and staff, so improvements were suggested. Members identified the possible causes and among these included the following;
§ Absence of a well defined patient’s flow chart in the clinic.
§ Lack of categorization/segregation of major aspects of HIV care services e.g TB care, family HIV care, ART care leading to congestion and stagnation of patients’ flow hence increasing the waiting time and poor quality of services provided.
§ Low involvement of administrators in the running of HIV clinic to check the arrival time of staff and departure.
§ Delays to retrieve patients care files by the records staff.

§ Changing the numbering and the filing system, from coding basing on the year of registration e.g 120/09 to a more standard ID like 0001, and the filing could be based on ID numerical descending order and the shelves well labelled like(0001 – 0099).

§ Introduction of the appointment book to enable the records staff to compile a list of expected patients and retrieve patients’ files earlier.

§ Computerizing the reception to reduce on the writing as the demographic data was always the same and to reduce the contact time at the reception.
§ Categorisation/ segregation of the major aspects of HIV care services e.g HCT, TB, family care in order to decongest the clinic.
§ Classification of patients i.e stable (those who have been in care for more than a year with CD4cell counts >350) the unstable (those who are newly registered and the old ones with CD4 cell counts <350. The stable ones are put on a refill program either by a nurse or counsellor to relief the clinicians from attending to all patients.
§ Setting up two satellite clinics (outlets) where patients coming from these areas or tose who find it easy to access their treatment refills go and only come to the hospital for their HIV routine monitoring tests. 
§ Developing a well defined patients’ clinic flow chart.
  • - Improved staff client working relationship due to patients’ satisfaction with the services rendered as the average waiting time reduced from 3 and half hours to 40minutes.
  • -  Filing and retrieving patients' care file folders was simplified and the indexing by ID numbers was adopted to date.
  • - Patients’ general adherence to treatment which includes; Cotrimoxazole, ARVs and Anti TBs improved from 85% to 98%.
  • - Patients’ retention rates improved from 88 to 98.8%, and the number of patients honouring their clinic scheduled visits tremendously improved. This eased the tracing of the few who missed their appointment/scheduled visits and the defaultors are contacted earlier.
  • - When task shifting was introduced, staff burnout was checked, different cadres acquired new skills which is a  motivating factor, clinicians were relieved from workload yet even the patients are impressed with the little time they spend in the clinic.
  • - This intervention promoted the willingness of HIV positive patients to enrol for HIV care in this hospital as a result of satisfied existing HIV patients who talk well about the hospital services, hence reducing the HIV/AIDS coverage gap from 42% to 33%.

§ It is a good practise to develop patients’ flow chart as a team, to embrace several inputs and the flow charts create clarity in the clinic both for patients and staff as all the stages a well stipulated.

§ Developing a flow chart in the clinic does not only benefit the patients, but the staff as well as it checks on the staff burnout which promotes their morale.

§ Staff training and orientation is paramount for the success of every specific change, for when a purpose is not established, it becomes hard for people to embrace and implement a change promptly in the intended way.
§ Applying the PDSA problem analysis and solving approach applies to almost all situations and when followed and used promptly, it can help to identify gaps, suggest changes which are studied over a period of time, solutions are stipulated and resorted to objectively which leads to quality improvement.
§ Great acts are made up of small deeds, a journey of a thousand miles must begin with a single step. Documentation and willingness are cardinal factors for quality improvement health care.
§ The first step for the success of any improvement change starts by identifying and accepting a gap or a problem which exists, team work is the key for a successful program and every player is important regardless of the their respective roles.