Recommitment to Aims | There was a recommitment to the specific aims of the 20,000+ Partnership to reduce mother-to-child HIV transmission rates to <5% by 2011. A specific three-district target of preventing 7,000 infections annually was established. |
Simplification of the Indicator set and data capture | The indicator set used to track PMTCT was simplified to include six core process measures—reducing the measurement burden by 40% for each clinic. More emphasis was given to local data capture and tracing, allowing facility-based audits to double check the validity of data on clinics' performance that was tracked at the district level. The web-based database was abandoned and replaced with a paper-based auditing system supplemented by simple spreadsheets that could be tracked by any facility information officer. Continuous data monitoring and the use of statistical process control charts supplanted the traditional before-and-after analytic approach in order to provide study staff and external observers with knowledge about the effectiveness of the interventions. All key steps in the PMTCT cascade were monitored in close to real time (1–2 months delay), with feedback provided monthly to all facilities in the study. |
Standardisation of QI tools | A set of high-impact ideas for changing aspects of the PMTCT cascade and job aids to guide their implementation were developed. A facility-based guide to QI (available either as supplementary materials or on request) was developed to speed implementation. This allowed anyone in the public health system who wished to learn about QI approaches to rapidly be skilled up. Standardised district report-back presentations were created and routine data capturing tools (register books) were created and printed for mass distribution. |
Targeting Health System Leadership | Leadership in each of the three districts was more proactively targeted with monthly District Task Team meetings where results were reviewed, obstacles discussed, and key staff committed to activities for the next month. District data managers were assisted to develop robust reports on the PMTCT program progress that could be reflected on by the district leadership. |
Flexible local leadership of QI | Any willing and interested member of the health system could become the focal point for leadership of system improvement. The mantra of the study staff became “waste no will”—ie, engage with anyone who demonstrated interest in learning how to apply QI methods to their practice. |
Better understanding and use of existing system linkages | Hospital-feeder clinic referral units were important functional units of the health care system with pre-existing, built-in support structures (monthly perinatal meetings, clinic supervisors meetings, ARV referral sites, etc). The study staff adapted the study design to capitalize on these linkages to embed the QI approach into the health system. |