COMPLETE INTEGRATION OF TB ASSESSMENT IN HIV/AIDS CARE AT BUSESA HC IV

 

Problem: 

Background to the problem addressed

Busesa is a government rural Health Centre IV located in Iganga district offering a range of in and out-patient services ranging from MCH, TB, HCT, HIV prevention and treatment services including ART and community outreach services. ART services are offered once a week by a team of 13 health workers who equally share responsibilities in all other clinic departments. Following a training of some members of the team in quality improvement, the team embarked on identifying and prioritizing gaps in service delivery. TB assessment was one of the challenges faced by the clinic, and it was ranked the top priority problem.
 
The gap
Only 64 % of the clients seen on every clinic day could receive a complete TB assessment. 36% of clients seen in the clinic were not assessed for TB. The performance of the centre was far below the National target which is “100% of HIV positive clients should be assessed for TB at every visit” Our gap was 36%.
 
Problem causes
1.      Lack of awareness about client assessment for TB especially by some of the staffs who had not been trained in comprehensive HIV care.
2.      Failure to document TB status after assessment especially by the clinicians who are charged with recording in the clients’ ART/Care cards.
3.      Some clinicians attributed failure to assess to the workload during the clinic days given the small manpower at that time.
 
This was followed by a gap/problem analysis whereby the clinic team through a series of meetings came up with strategies to ensure achievements of the National target of 100% assessment of HIV positive clients for Active TB.

 

Intervention: 

1.      The trained health workers in comprehensive HIV care and HCI strategies were asked to arrange and orientate the other staff in TB assessment through Continuous Medical Education sessions and mentorship.

2.      Clinic flow charts were drawn and staffs as well as expert clients were allocated duties regarding TB at the different client flow points.
3.      Clinicians were asked/called upon to be vigilant on clients’ assessment especially for the WHO clinical staging and active TB.
The above strategies were tested for a period of six months with continuous assessment of their effectiveness.
In a period of 6 months (March 2009 – September 2009), the percentage of clients assessed for active TB at every visit increased from 64% to 71% but this was still far below the National target.
 
Additional strategies laid to help achieve the target included;
1.       Reminder strikers were introduced in the clinicians’ rooms so they could remember to assess clients and record in their cards. They were also put at the different client flow points reminding staffs to check the cards for full assessment.
2.       Enhancement of client health education on the importance of TB assessment so that they could actively participate in improving this indicator.
3.       An expert client was assigned a role of triaging/ensuring that clients with coughs are seen first and assessed for active TB by the clinicians on every clinic day.
4.       Physical referral of TB suspects to the laboratory to ensure that a sample is taken off and to reduce on the waiting time at the laboratory which was a big hindrance before (the role of escorting clients is done by an expert client).

 

       
Results: 

Table showing TB assessment in HIV positive clients at Busesa HC IV between March 2009 – September 2009

 

Period
March
April
May
June
July
August
September
Numerator
88
96
104
102
133
94
98
Denominator
138
143
150
136
177
122
127
Percentage
64
67
69
75
75
77
77

 

Results achieved
With all the above changes combined, TB assessment increased to 98%, an achievement which greatly motivated the team, made them more determined and indeed by August 2010 we hit the target of 100% and this has been sustained since.
 
Lessons: 
·        Team work helps in improvement of quality of care/service delivery.
·        Division of labor helps a lot in promoting team work, accountability and effectiveness
·        Regular review meetings help to assess performance and therefore giving ample time for the team to plan do study and act in time.
·        Involving other committed community support agents reduces on the work in resource limited setting.
·        Using a specific targeting model to assess a given condition can always be a success e.g. the use of intensified case finding forms (ICF) and INH prophylaxis model.
·        Continuous medical education is very key in performance improvement.

 

Report Author(s): 
Kaggwa Ali, Nangobi Phoebe, Balwanyi Charles, Violet Gwokyalya
Organization(s): 
Strengthening TB and HIV&AIDS Responses in East Central Uganda
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