Spread Collaborative for Tuberculosis Management in Cochabamba, Bolivia

Date improvement activities began: 
March, 2011
Date of end of collaborative: 
July, 2012
Aims/objectives: 

The collaborative sought to improve the quality and coverage of Tuberculosis (TB) control activities in Cochabamba, Bolivia, based on best practices identified during a demonstration phase collaborative in El Alto, Bolivia. Specifically, the objectives of the collaborative were to:
- Increase the capture of respiratory suspects and TB cases
- Reduce the percentage of unusable sputum samples
- Improve the cure rate among TB cases
- Reduce the abandonment rate among TB patients
- Increase the detection of MDR-TB cases
- Improve the quality of care and case management of MDR-TB patients
- Increase the detection of TB-HIV co-infections
- Increase conformity among quality control samples
In addition to objectives related to the quality of TB care, the collaborative also sought to strengthen the managerial capacity of the regional TB office and health networks.

Implementation package/interventions: 

The best practices identified in the demonstration phase served as the change package for this collaborative. As in the demonstration phase, the implementation package was organized around major issues in TB management identified in the needs assessment, such as the quality of sputum samples and logistical management of medication, among others. Key changes are detailed below.

Quality of sputum samples:
1. Educate patients about what a usable sputum sample looks like by building and using a sputum sample model for patient education
2. Give privacy to patients providing a sputum sample by designating a “Sputum Sample Unit,” a private area away from waiting rooms and other patients
3. Create a patient education video that demonstrates how to provide a proper sputum sample
4. Humidify the area where patients provide sputum samples

Logistical management of medication:
1. Introduce “DOTS boxes,” a dedicated complete treatment course for each patient stored in an individual box at the facility
2. Build and use a file organizer to manage patient files
3. Complete routine medication stock assessments and complete ordering on time to prevent stock outs
4. Regularly track and analyze indicators related to medication stocks and use

Maintaining patients in treatment to improve cure rates:
1. Assign a “godparent” to each patient, a staff member of the health facility to follow up with the patient throughout the six month treatment period
2. Incentivize staff by providing a half day of vacation each time one of “their” patients is deemed cure with a negative bacilloscopy
3. Hold patient-family meetings to involve families in patients’ care to increase support
Additionally, HCI and the MSD designed a CD-ROM training course on TB management for health care providers. Staff at participating facilities completed the course. HCI also provided support for laboratory personnel and worked to increase linkages between laboratories and health facilities.

Measurement: 

During the prior demonstration collaborative, the MSD and HCI selected 15 standards from the PNCT’s National Manual of TB Standards, then developed an indicator for each standard. Selected key indicators include:
- % of essential supplies, equipment and medications available to the health facility for the TB program
- % of identified respiratory suspects per number expected
- % of unusable sputum samples among all diagnostic bacilloscopies
- % of TB cases captured
- % of TB patients at a health facility that receive DOTS
- % of new TB patients at a facility who receive a rapid HIV test with informed consent
- % of new TB cases who began treatment who are cured

Spread strategy: 

This collaborative was a spread phase from a demonstration phase in El Alto, Bolivia. Based on the lessons learned in the demonstration phase and this spread phase, HCI compiled a guide to recommended changes that will be distributed to facilities in other departments of Bolivia outside of the context of an organized improvement collaborative at the request of the MSD and PNCT.

Number of sites/coverage: 

42 facilities in the Cercado health network of Cochabamba participated in the collaborative. This included 27 health centers, nine hospitals, and six laboratories. The facilities that participated encompass the highest TB treatment burden in the health network.

Coaching: 

Each facility received regular visits form a QI coach, to provide individualized guidance for their facility. Coaches visited each facility at least once between each learning session. During these visits, coaches helped facility staff tailor recommended changes for their individual facilities and determine service delivery issues impeded quality tuberculosis management.

Learning sessions & communication among teams: 

Four learning sessions were held for QI teams in Cochabamba. Participants learned about quality improvement and how to monitor and analyze indicators during the first learning session; in subsequent learning sessions, teams learned about the recommended changes part of each of four changes cycles, and strategies for implementing those changes at their facilities. Teams presented their results from the previous change cycle at sessions, and teams had an opportunity to discuss their experiences with implementation and exchange lessons learned. TB experts were present at the learning sessions to facilitate sharing and discussions.

Results: 

The changes implemented in Cochabamba under the improvement collaborative led to significant improvements in the quality of TB care, such as the following:
- The percentage of unusable sputum samples decreased from 42% to 21% in 2010, prior to the collaborative, to 9% in June 2012.
- Participating facilities detected 38% of expected respiratory suspects at baseline in March 2011. This increased to 78% in May 2012.
- The cure rate was 43% in March 2011 and was as high as 95% in February 2012 prior to a medical personnel strike. The cure rate to 78% in June 2012 over the course of the strike; however, this is still a significant increase over baseline.

Best practices/conclusions: 

The Cochabamba collaborative was an expansion phase from a demonstration collaborative in El Alto, another urban setting. The change package in El Alto had been adapted from a prior demonstration collaborative in 16 rural municipalities in Bolivia; while some of the best practices in that collaborative were successful in El Alto, others proved less applicable in an urban setting. The El Alto collaborative was an opportunity to determine the optimal change package for an urban environment, and was then scaled up to Cochabamba and Santa Cruz.

As in El Alto, the changes around collecting sputum samples were effective because patients more clearly understood how to provide a sample and were given a comfortable area in which to provide one, leading to more usable samples. This was important as it reduced laboratory supply and time losses; however, the overall capture of respiratory suspects remains a challenge. The use and monitoring of DOTS boxes were also key as they ensured patients received a full course of treatment, reducing the risk of drug resistance if patients’ supplies were interrupted. Facilities were better able to prevent stock outs and overstocks, so medication supplies across the health network were more balanced and medications were not wasted.

Finally, as in El Alto, the CD-ROM course was an important education tool for providers and other facility staff as it increased their knowledge about TB and permitted the involvement of all staff in active respiratory suspect searching, which led to a higher case detection rate.

 

Report Author(s): 
Jorge Hermida, Luisa Mendizabal
Organization(s): 
USAID Health Care Improvement Project (HCI), Ministry of Health and Sports of Bolivia (MSD), National TB Control Program of Bolivia (PNCT)
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