Table 1

Components of the quality improvement framework

Aligned aims, set goals	The 20,000+ Partnership relied heavily on the “Model for Improvement,” a sequential guide to improving health systems.22 This model encourages from the outset a clear statement of aims with highly visible metrics.
Used systems thinking	We conveyed to both leadership and to frontline clinical staff that the PMTCT results observed were the result of the delivery system at a local level, and that local understanding and reconfiguration of that system would produce a different result.22 23 To this end, the sequence of processes in the PMTCT care pathway was mapped and assigned measures and targets to track performance of each step.
Derived change Ideas from the front-line staff	20,000+ staff working with facility-based multi-disciplinary “improvement teams,” sought novel change ideas that could be tested on a small scale in facilities within a short span of time. All ideas were welcomed by the improvement teams.
Iterative, data driven improvement cycles	Ideas for changing the system were rapidly, systematically and safely tested on a small scale using the “Plan-Do-Study-Act” method.44 Tools to identify bottlenecks, develop change packages, implement, and then reflect on successes and failures were employed by the “improvement teams.”
Feedback on performance data	Core competencies were taught through PDSA cycles and active participation. Basic ideas were woven into the process of identifying problems and implementing changes by trained facilitators and mentors. Feedback of data connected facilities to each other and to the broader narrative of district and nationwide PMTCT program performance.
Multi-disciplinary “improvement” teams	At a facility level, process improvement and systems change were driven by multidisciplinary teams at multiple sites all tackling a common problem, sharing lessons learned and adopting best practices together. This approach engendered creation of a responsible “care team” and increased staff buy-in, will for change, and morale.
Communities of practice	Individual facilities were encouraged to create novel solutions and test them freely. As new ideas emerged with strong evidence to support their effectiveness at individual facilities, a platform for sharing these solutions with other similar facilities was needed. 20,000+ and the Department of Health created facility networks and opportunities to meet with each other to share successes and failures.
Focus on leadership engagement, purpose, and attention	The 20,000+ Partnership was created to respond to an urgent need identified by the KZN Department of Health leadership. In order to maintain focus on results, purpose and problem solving, the 20,000+ team created monthly opportunities to engage with District Health authorities to focus their attention on the PMTCT program, review data specific to the program, highlight key systems obstacles, and ensure continuous will-building for change.