A continuous quality improvement(CQI) approach directed at improving HAART initiation for eligible pregnant women in the province of Kwa-Zulu Natal, South Africa 2012 SOMSA CONGRESS, ST GEORGES, TSHWANE 04 DECEMBER 2012 Mrs Otty Mhlongo PMTCT Manager - KZN

Background KZN Province is at the epicenter of the HIV pandemic, (highest antenatal HIV prevalence %(DOH, 2010) in SA). Problem statement: 43.7 % of maternal deaths in SA, is due to non pregnancy - related infections, primarily HIV/ AIDS. (Saving Mother's Report ). HIV positive women eligible for HAART are not initiated timeously, leading to high MTCT rates, and maternal deaths. In March 2010, 52% of pregnant women eligible for HAART (CD4<350 and WHO stages 3 and 4) accessed treatment.

Simple method to identify gaps in the healthcare system Systematic way to close those gaps and safely improving the process of care Principles (WILL, IDEAS, EXECUTION): Apply local wisdom Focus on the data (stop the blame game) Work “smarter” NOT just “harder” Partnership and teamwork is the only way forward “Quality Improvement” in healthcare

Regulation Standards Professional oversight Accreditation Performance review QA QA and QI Evidence Guidelines, protocols, SOPs Training Competencies CQI Aims: what are the “gaps” Measures: tools to measure the critical processes and outcomes Changes: frontline methods and activities to close the “gap” IMPROVED OUTCOMES

AIM To increase initiation of all (100%) of pregnant women who were eligible for ART onto treatment. Target population: All PMTCT/MCWH coordinators in the 11 Districts of KZN including operational health workers in all the public health facilities.

Intervention A Continuous Quality Improvement methodology, aimed at health systems strengthening, improving the reliable delivery of processes. A 'dashboard 'of key indicators was tracked. The 20,000+ partnership (made up of the KZNDOH, IHI and UKZN) used tools to identify root causes of process failure, iterative tests of change (Plan-do- study-act cycles), and local data to guide improvement. “Wedge” meetings – meetings between hospitals and feeder clinics, focusing on indicator performance

WHAT IS A DASHBOARD ?

DASHBOARDS Helps view the whole and guide the improvement team to whether changes are leading to improvements. Always in front of your eyes- helps team to focus A useful dashboard will have outcome, process and balancing measures

Results HAART initiation increased to>80% (Q1 12/13 -85,3%) Data -focused approach to improvement using Noticeable decline in Maternal mortality from 392 in 2010 to 353 in 2011, and quarterly trend of Q1 2011/ to Q1 2012/ Reduced MTCT Q1 2012/2013 = 2.6% MTCT – Collaborated with NHLS/MRC

Results (Cont…) Strong ties/collaboration with feeder clinics and mother hospital(Wedge approach) Team approach into solving problems Common shared aim- working towards achieving same goal Perinatal review meetings – CQI standing item

QI Project started

KZN Province ANC client Initiated on HAART (Raw numbers)

KZN Baby PCR Positivity around six weeks Changes Initiated

Maternal mortality 2010/2011

Maternal mortality

Implications of a QI approach on the health system Quality Improvement approach is a leveraged strategy to improve health system performance towards better health outcomes. A multi-faceted/ multi-disciplinary approach that effectively improves the working and coordination of the health system through engaging: -Leaders- Districts Programs / Data management team -Frontline workforce to be part of the solution -Data usage to guide improvement -Improved communication between hospitals and feeder clinics End-product: Better use of existing resources and closing feedback loop.

Recommendations and future actions A data focused quality improvement approach, mentorship/support by Provincial, District and support of Partners at all levels including systematic approach to improvement can facilitate rapid achievement of national PMTCT/MCWH targets, thus meeting the Millennium Development Goals

Conclusion Quality improvement approaches have helped to close the service delivery gaps for PMTCT interventions in KZN. The same replicable approaches can be applied to other areas of MCH care and other programs to help strengthen health systems. Applying same principles in working towards E- MTCT by Action Framework and achieving MDG 4, 5 and 6.

Acknowledgements  KZN DOH  Ms Pinky Phungula –MCWH Province  UKZN Partnership Team- PEPFAR CDC funded  All Partners