A 2008 assessment of the quality of care and treatment for people living with HIV/AIDS (PLWHA) in Cote d’Ivoire revealed that there was a significant need for improvement in terms of adherence to standard of care and patient retention. As a result, Cote d’Ivoire’s Ministry of Health and its National Program for HIV Care and Treatment (PNPEC) and the USAID Health Care Improvement Project (HCI) launched an HIV collaborative improvement initiative in December 2008 in partnership with PEPFAR and implementing partners. This collaborative provided an opportunity to study the process of shared learning that occurs among quality improvement teams.
The main objective of this study is to better understand the methods and level of spread of ideas tested by a quality improvement team from one site to another, and the factors facilitating or limiting the spread of these ideas. This study therefore aims to assess sharing mechanisms available to teams during the demonstration phase of the collaborative and the factors that facilitate the sharing process.
The specific objectives of this study are to: 1) Describe the methods for sharing across quality improvement teams; 2) Examine the factors that facilitate sharing; 3) Obtain an inventory of the changes tested by the teams and identify the source of those ideas; 4) Examine factors facilitating or hindering the decision to apply changes; and 5) Identify strategies to improve the spread of ideas between quality improvement teams.
This cross-sectional study was conducted in January and February 2010 in the PMTC and ART sites that participated in the demonstration phase of the collaborative. The study included thirty four (34) health facilities out of a total of forty-one (41) sites of the collaborative demonstration phase: 5 regional hospitals, 12 general hospitals and 17 other health facilities. Data were collected by URC Cote d’Ivoire staff and three staff members from the Ministry of Health. Data collection tools included questions about sharing mechanisms used in the last quarter, factors facilitating or restricting their use, changes implemented in the sites and sources of ideas for change. Data were collected through questionnaires administered to quality improvement teams and group discussions.
The mechanisms for sharing ideas to improve the quality of services most commonly used are, in descending order: telephone communication (20 out of 34 sites), learning sessions (16 out of 34 sites) and visiting other sites (10 out of 34 sites). Few sites exchanged ideas through physical means (paper) or electronic media.
Quality improvement teams reported preferring telephone communication as it provides quick, discreet, practical, and direct contact. On the other hand, some reported that telephone communication is costly, and does not allow direct contact or enough time to share experiences.
With regard to learning sessions, sites believe that they are inexpensive and practical (i.e. the sites do not spend money to attend sessions), facilitate direct contact, provide an explicit mean of communication and allow more time to share experiences. Those who used learning sessions to share ideas reported that the “commitment of colleagues” is the main factor facilitating its use.
Quality improvement teams that opted to visit other sites reported that these visits allow them to have a better understanding of the change implemented as well hands-on application.
The majority of sites reported that the two main factors limiting use of a mechanism are: first, these mechanisms are not organized, and second, a lack of financial means or logistical support. Sites reported that external support played an important role in the use of various sharing channels and in the uptake of change ideas.
Overall, many changes have yet to be disseminated. Of the 9 changes for PMTCT care documented in this study, only four have been implemented in more than half the sites. For ART treatment, only 5 of 8 changes are implemented in the majority of sites. Changes with a low rate of implementation include daily stock inventory, accompanying patients to their homes and displaying the ART regimen.
Conclusions and Recommendations
This study is one of the few studies that have investigated the diffusion of new ideas within a collaborative. It has shown what sharing mechanisms are the most commonly used by demonstration sites to share experiences. Thus, to facilitate the dissemination of good practices, the following actions are recommended:
- Provide logistics support to sites in order to facilitate telephone communication
- Provide internet connection to facilitate sharing of experiences via the internet.
- Organize regional learning sessions.
- Develop a directory of contacts and create a forum for exchange.
- Encourage sites within the same geographical area to visit neighboring sites to share experiences.
Effective sharing of improvement practices among members of the health system can lead to rapid and effective improvement across all sites. It would be important to assess the changes that may have occurred since the end of this study and determine whether sites that have heard of the changes implemented in other sites, have tried to implement them in their own sites. The lessons learnt from this evaluation should be applied to the spread phase to ensure that the learning process is strengthened.