Assessing Quality Improvement Team Performance on the HIV/AIDS Service Improvement Collaborative in Cote D'Ivoire

 High-perfoming quality improvement teams are the cornerstone for identifying and testing local strategies to improve care. This study was conducted in the context of a collaborative improvement initiative launched by The Ministry of Health of Cote d’Ivoire and its National Program for HIV Care and Treatment (PNPEC) and the USAID Health Care Improvement Project (HCI) in December 2008 to study the performance of quality improvement teams.

The main objective of this study was to assess the performance of teams in four areas of quality improvement. a) documentation of QA activities; b) analysis of the effectiveness of the changes tested; c) sharing results and lessons learned, and d) institutionalization of the care process. Insights from this study can be used to devise strategies to improve QI team performance and thus achieve greater gains in improvement.
This cross-sectional study measured QI team performance in 33 sites in the demonstration phase of the PMTCT/ART improvement collaborative. Data was collected through interviews with QI team members, compiling QI team monitoring data, and a coach’s assessment of team performance.  
In the 33 sites surveyed, for 63% of the tasks, there were at least three people in the QI team who knew how to perform the given QI task. Of the 33 teams, there were only three teams where there wasn’t at least one person competent enough to complete all 14 activities. The most challenging tasks were: implementing a PDSA cycle; and drawing, annotating, and interpreting time-series graphs.
Overall, the level of team commitment, team collaboration, and resource availability was found to be relatively high. General Hospitals often reported having more resources than other health facilities, but they showed a relatively lower level of collaboration. There was no difference between those providing PMTCT services and those providing ART in these areas.
Only 7% of sites can document the problem and improvement targets, record the indicators, make a plan of action and note the changes tested at the site in a complete and consistent manner. Forty-three percent of the sites did not use time series charts to monitor data and 68% of the sites did not annotate key changes on the time series charts. But most sites (68%) were able to discuss the factors that were behind the trends in the indicators and 64% of the sites were able to discuss next steps based on the data at hand. About half the sites were able to assess the impact of recent changes in care. Although most sites (96%) reported sharing their changes and results, more than 50% of the sites did this at a below satisfactory level. This was reflected in the finding that use of information received from other sites to improve care was satisfactory only in 25% of the sites.
The degree of institutionalization was found to be low. Although almost 80% of the sites had developed some mechanism to orient new staff, more than 60% of the sites had not developed standard care processes including continuous quality improvement; a strategy to ensure resource availability, or a system for recognizing good performance. In each of the topics (Documentation, Analysis, Sharing, Institutionalization) PMTCT sites have relatively higher scores than ART sites.
Conclusions and Recommendations
Overall the level of documentation and sharing was fair but analysis skills and development of mechanisms to enable institutionalization was low. This study identified specific areas of weakness in team performance. According to these results, it is desirable to give sites further support in working towards institutionalization of quality improvement activities. Also, coaching visits and learning sessions should provide greater training in drawing and annotating time series charts and also in analyzing data. Coaches can focus their efforts on the areas of weakness identified by this study during future site visits and learning sessions.


Report Author(s): 
J Nguessan | L Jennings | Alain Ackah | Lynne Franco | Victor Kouassi
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