AIDSRelief consortium (AR) supports health facilities in Nigeria to rapidly scale up and deliver life-saving antiretroviral therapy. With challenges impeding  best outcomes, AR continually identifies for improvement, factors influencing treatment success . AR strengthens structures that provide solutions to challenges patients face while accessing treatment.

The work was done across 16 AIDSRelief hospitals as listed below. The units were HIV/AIDS Care Units and the Staff were Doctors, Nurses, Laboratory Scientists, Monitoring and Evaluation Officers, Pharmacists and Auxiliary Health Workers. 

Acknowledgements: Staff and Management of the 16 Hospitals:

1. Bishop Murray Medical Centre, Makurdi, Benue State
2. St Mary’s Hospital Okpoga, Benue State
3. St Vincent’s Hospital Aliade, Benue State
4. St Anthony’s Zaki Biam, Benue State
5. Faith Alive Foundation Jos, Plateau State
6. St Camillus Hospital Uromi, Edo State
7. St Catherine’s Hospital, Iwaro Oka, Ondo State
8. Holy Rosary Hospital Onitsha, Anambra State
9. Mother of Christ Specialist Hospital, Enugu, Enugu State
10. Annunciation Specialist hospital, Emene, Enugu State
11. St Monicas, Adikpo, Benue State
12. St Thomas Ihugh, Benue State
13. St Josephs Adazi, Anambra State
14. St Patricks Hospital Mile 4 Abakiliki, Ebonyi State
15. Our Lady of Lourdes Hospital Ihiala Anambra State
16. Faith Mediplex Hospital Benin, Edo State

Dysfunction – Poor Documentation

Inadequate information was being used to arrive at clinical decisions affecting outcomes
Goal - Improved Medical Documentation (MD)




We reviewed 10 CQI indicators on medical documentation initially and then some months later; for 16 facilities between 2008 and 2009.

Hospital staff were engaged & sensitized on CQI concepts relating to Medical Documentation - they had periodic technical assistance visits where didactic sessions and hands on training were done; with periodic review of selected indicators on medical documentation; collection of feedback on performance and suggestions on the way forward, improvement planning and continuous review with the aim of achieving the standard for documentation as part of quality of care.  


QI Resource Persons – trained and experienced QI Specialists who provide routine support to the facilities

Facility Based QI Focal Persons – trained hospital staff who ensure compliance at the facilities with respect to the indicators

Training Sessions & Materials – Site based didactic Sessions on Quality Improvement & Medical Documentation, Regional and National Trainings on the same topics as well as training manuals, review checklists & Standard Operating Procedure manuals.

Tools for evaluation – abstraction tools

Focus Group Discussions – these sessions look at improving clinic flow, medical record documentation and the quality of information that goes into the Patient Management forms. It’s an open discussion between hospital staff, the Site QI team and the QI Resource Persons.



Methods used:
Essentially used repeated abstractions and reviews to ascertain the effects of planned changes
Microsoft Excel was used in analysis of results for patterns and distributions

A review of the results of CQI initiatives on MD, reported for 16 facilities in North Eastern, Southern and Eastern Nigeria between 2008 and 2009 was done.
The Initiatives: Facilities were sensitized on CQI with periodic technical assistance visits. An initial chart review of selected standardized and validated indicators on MD was carried out. Feedback on performance was done leading to suggestions on ways to achieve recommended standard for documentation as part of quality of care. Suggestions were implemented. Subsequent reviews were done.
Implementation of proposed change – we ensured training and retraining, availability of tools and resources, management buy-in and targeted technical support
Staff or Other Groups involved – Technical Program Area Specialists, Program Management Team, Health Supply Chain Team, Strategic Information Specialists
Dissemination of results and plans for change – Routine Reports, email correspondence, phone calls
Timetable for change – quarterly, bi-annual, annual
Effects of the changes: Better documentation, staff coming up with innovative strategies to ensure sustainability of these changes, patient data can now be analyzed to produce reasonable information which is useful for policy decisions
The changes resolved the problems as shown in the results, with nearly two thirds of the hospitals showing an improvement following the institution of the initiatives
Patient care is now predicated on objective information and decisions can be made earlier instead of later e.g. changing regimens because of CD4 results etc
Problems encountered included our inability to visit the hospitals in question quarterly as we had initially planned. This was as a result of unplanned for events which arose in the course of the work year and needed to be attended to. Also, some of the staff at the hospitals in question showed some resistance to change. In addition staff attrition retarded already achieved progress as the new staff would have to be again trained and mentored.



Lessons learnt: 
Solutions have to be site specific
Staff at sites have the ability to develop innovative strategies for solving problems
Rewards improve performance
Support has to be more regular to result in substantial improvement

Do differently next time: 
Don’t set site plans in stone
Ensure early management understanding and Buy In
Attempt to focus capacity building efforts on staff that show potential for long term stay at the facility

Messages for others: 
MAIN MESSAGE: Quality Improvement techniques can work in Resource limited settings and produce favourable results

Improved care and attention to detail, leading to concise documentation of findings provides the foundation for improved outcomes as a result of sound clinical decisions

Technical Assistance is important and necessary but has to be focused, tailored to facility needs and regular


Report Author(s): 
MARGARET W GANI-IKILAMA, Nguhemen Tingir, Adiba Ukpaka, Mercy Niyang, Michael Obiefune, Bola Gobir, Ayodotun Olutola, Alice Osuji, Flora Epoupa, Ngozi Uzogor, Angelina Toluhi, Judith Adimorah, Adedotun Omitayo, Maureen Ugochukwu, Genevieve Eke, Augustina Usiere
Nigeria AIDSRelief Program University of Maryland School of Medicine-Institute of Human Virology
ASSIST publication: 
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