Uganda | Application of quality improvement and performance management approaches to improve pharmaceutical process
The collaborative aims to apply improvement and performance management approaches to strengthen pharmaceutical human resources and improve the availability and use of HIV care and TB medicines at health facilities, to ensure improved outcomes for patients receiving that care. QI teams are testing changes to improve medicines management and better patient outcomes.
While utilizing the existing structures in the district health system, HCI is working with the Quality Assurance Department and the Pharmacy Division in the MoH to prototype and evaluate QI and performance management interventions involving and engaging pharmacy staffs at 14 health facilities in 3 districts of Eastern Uganda.
A staggered design was employed to examine whether improvement at the facility level occurs with the onset of QI team activities. Such an approach would help to ascertain whether improvements seen are likely to be due to background variables or due to the interventions put in place by the teams. Health facilities were randomly assigned into 4 groups to form a phased model of introducing the improvement approaches.
Improvement teams at health facilities and at district level are supported to implement innovative interventions like analyzing and clarifying tasks, addressing competency gaps, establishing informal peer mechanisms to provide feedback on performance, improving coordination between HIV/TB clinics and pharmacy, involving pharmacy staffs in HIV/TB clinic based activities, optimizing inventory and improving documentation and stock management practices. Performance management interventions alongside process redesign have previously been successful in improving staff engagement, productivity and performance in other HCI supported countries.
Other interventions like engaging departmental heads while quantifying medicines orders, packing and labeling medicine envelopes in advance and checking patients’ understanding of dispensing instructions have been implemented to improve medicines management while ART adherence counseling and provision of OI medicines in ART clinics have been implemented to improve patient outcomes.
Improvement is continuously assessed in the areas of pharmacy staffs performance, medicines management and patient outcomes.
On a monthly basis, teams monitor the following indicators related to patient outcomes: Proportion of patients with 95% adherence to ARVs; Proportion of patients adhering to scheduled clinical appointments; and Proportion of patients demonstrating clinical improvement.
Bi-monthly, teams monitor the following indicators related to medicines management and use: Timely submission of medicines order forms to the National Medical Stores; Stock-out periods for selected medicines; and Proportion of patients who can ably explain correct dispensing instructions.
On a quarterly basis, teams monitor the following indicators related to capability for improvement: Proportion of staffs with improvement competency scores rated as “high,” and Improved communication and information sharing between clinic teams and pharmacy personnel.
Lessons learned from the application of improvement and performance management approaches in pharmaceutical processes will be useful to the Ministry of Health as it rolls out the National Quality Improvement Framework, which emphasizes application of QI to non-clinical areas in the health facilities. On-site coaching is provided to all health workers present, making it accessible to all those interested to learn about improvement. As a result, the competencies in improvement that health workers on the Improvement team acquire can be used to apply improvement approaches to antenatal care services, out-patient department, and male circumcision units among others.
HCI is also collaborating with another USAID funded project (SURE) that is supporting the MoH ensure health facilities consistently access essential medicines, lessons on medicines management observed in this collaborative are shared with the SURE team for possible spread to the facilities they support across the country. SURE coaches have been involved in on-site coaching sessions and can therefore learn the approaches.
The intervention is in all 14 HIV care health facilities in 3 districts of Eastern Uganda, out of 112 districts in the country.
Following the staggered design, for each month in the first quarter of implementation, 3 or 4 new sites received the initial QI orientation and were supported by coaches to identify areas for improvement. The coaching teams is led by the HCI QI Advisor and composed of Ministry of Health staffs, regional and district QI coaches who conduct on-site training and coaching sessions. Trainings targeted specific competencies each month and that those who were not part of the QI team were also invited to participate.
In August 2012, HCI organized district-level sharing sessions where representatives of Improvement teams from each of the 14 participating health facilities met at the District Health Offices (with the DHOs) and shared the progress made in this new area of application of QI in pharmacy practice. These sessions enabled health workers develop competencies in synthesis and sharing of data for improvement, enabled participants to share experiences and results observed during the implementation, and also got the MoH, DHO and health workers to identify and prioritize areas in service delivery that required improvement. Eighty three (83) health workers including clinical officers, nursing assistants, registered nurses, midwives, pharmacy technicians, store managers, counselors and expert clients attended the August learning session. The next learning session will bring together teams from all three districts and is planned for January 2013.
Beyond learning sessions, QI coaches often share changes that they have observed to be effective in one facility with teams at other facilities during the monthly on-site coaching sessions. That deliberate transfer of knowledge enables the spread of the most robust and effective interventions between teams, and provides enough detail for the recipient team to replicate the changes.
At the facility level, teams are trying to improve communication and coordination between clinics and pharmacy, and between pharmacy and districts offices or national medical stores
Since the start of the collaborative in March 2012, Improvement teams have been formed at all the participating sites, and all of them have received on-site training to develop basic Improvement competencies and are testing changes to improve medicines management and patient outcomes. Teams have reported improvements in the timeliness and accuracy of orders to the national medical stores, improvements in storage of drugs as per the manufacturer’s recommendations and many stores are applying the first-in/first-out approach when dispensing medicines. Patients’ adherence to treatment has improved partly due to adequate adherence counseling during dispensing, more patients are reported to be adhering to scheduled appointments and in a number of facilities ART patients are showing clinical improvement.
The collaborative is still on-going. Upon completion, best practices will be compiled and shared on application of quality improvement and performance management approaches to strengthen human resource and improve health care processes in non-clinical settings.