Grace Children's Hospital - TB Screening
Founded in 1967, Grace Children’s Hospital is located in Western Haiti, just outside the capital, Port-au-Prince. The hospital serves a patient population of approximately 67,489 people; 4,512 are HIV+, of which 1590 are on HAART.
GCH chose TB screening as the focus of their improvement project for several reasons: TB is the most common opportunistic infection and endemic in Haiti, national guidelines recommend a PPD test for all new HIV patients, and GCH has a history as a center of excellence in TB management.
Further, the hospital’s performance data indicated that only 23.4% of 375 patients had received TB screening as per national guidelines.
The TB QI project team included a team leader, a facilitator, a time keeper, a record keeper, and three additional team members comprised of a sputum analysis technician, a psychologist and a lab technician. Despite working under difficult circumstances due to the devastating earthquake earlier that year, the team nonetheless set an ambitious improvement goal to increase the TB screening rate from 23.4% to 60% from June to December.
The Team Approach
During their first meeting, the TB improvement team reviewed GCH HIVQUAL data reports from previous data collection periods, and conducted a root cause analysis using the “fishbone” exercise pictured here.
Through their process analysis, the TB team derived informative insight to guide improvement strategies. They learned that PPD was previously not conducted systematically for all new patients without active TB; patients lacked information about the purpose and importance of PPD testing; and PPD results were not systematically entered into the EMR.
Based on these findings, the team developed several strategies to address performance in TB screening. Each strategy involved a Plan-Do-Study-Act (PDSA) cycle to test small changes toward further improvement. Three primary strategies emerged: A) systematic PPD testing for all new patients; B) reinforcing patient counseling and education about the importance of PPD testing; and C) use of the PPD register to systematically update results in the electronic medical record (EMR). Each of these activities was measured against baseline data and compared to follow-up measures to guide further strategies and QI activities.
GCH staff met and exceeded their stated goals, achieving a 40.3% increase in performance on TB screening from June to December, improving from baseline - 23.4% to follow-up - 63.7%
This improvement project demonstrates the importance of team work, persistence to achieve high quality patient care on a daily basis, and improvement of provider/patient relationships which can have a significance impact on patient attitudes regarding treatment.
In their efforts to sustain a quality program, GCH staff recognize additional challenges, including a shortage of PPD tests, frequent power outages, and unexpected political and economic barriers that impact patients appointments.
Pressing ahead, GCH staff plan to reinforce quality by motivating staff to embrace an improvement approach in daily activities, routinely apply national guidelines for TB, and ensure results are entered into the EMR so that performance data can be continuously monitored and utilized to inform future improvement.
* 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.