SHORTENING THE TIME A CLIENT COMING FOR DRUG REFILLS (ARVS AND / OR COTRIMOXAZOLE) TAKES TO EXIT MUTOLERE ART CLINIC
BY
DR. MUGISHA ROY JEROME, MBChB, MMed(OBS/GYN) (MU)
MR. NSEKUYE PASCHAL (Dip. Clinical Medicine; Dip. Opthalmology; Masters Health Services Management)
PROJECT DONE IN FULFILLMENT FOR THE REQUIREMENTS FOR THE MUSPHCDC MEDIUM TERM FELLOWSHIP IN CONTINOUS QUALITY IMPROVEMENT
MAKERERE UNIVERSITY SCHOOL OF PUBLIC HEALTH
JUNE 2009 TABLE OF CONTENTS
LIST OF ACRONYMS...... iii OPERATIONAL DEFINITIONS ...... iv DECLARATION...... v ACKNOWLEDGEMENTS ...... viii ABSTRACT...... ix CHAPTER 1: INTRODUCTION...... 1 CHAPTER 2: BACKGROUND ...... 2 CHAPTER 3: LITERATURE REVIEW ...... 6 CHAPTER 4: PROBLEM STATEMENT, JUSTIFICATION AND CONCEPTUAL FRAMEWORK...... 8 4.1 Statement of the Problem...... 8 4.2 Justification / Rationale of the Project...... 8 CHAPTER 5: PROJECT OBJECTIVES ...... 10 5.1 General objective:...... 10 5.2 Specific objectives:...... 10 CHAPTER 6: METHODOLOGY...... 11 CHAPTER 7: RESULTS ...... 15 CHAPTER 8: DISCUSSION ...... 17 CHAPTER 9: LESSONS LEARNT AND CHALLENGES EXPERIENCED ...... 20 9.1 Lessons learnt...... 20 9.2Challenges experienced ...... 20 CHAPTER 10: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ...... 22 REFERENCES...... 24 APPENDICES...... 25
ii LIST OF ACRONYMS
AIDS Acquired Immune Deficiency Syndrome ART AntiRetroviral Therapy ARVs Anti retroviral drugs CDC Centers for Disease Control CME Continuous Medical Education CQI Continuous Quality Improvement HIV Human Immunodeficiency Virus MUSPH Makerere University School of Public Health OPD Out Patient Department UCMB Uganda Catholic Medical Bureau
iii OPERATIONAL DEFINITIONS
Prepack To arrange and put goods (or drugs in this case) into packs ready for distribution Refill To fill something with the contents it had before Service points Different stations in the hospital where clients receive care. The care differs at each station Shorten Make something little or less in measurement as compared to what it was before.
iv DECLARATION
We, Jerome Roy Mugisha and Paschal Nsekuye do hereby declare that this endofproject report entitled “Shortening the Time a Client Coming for Drug Refills (ARVs and / or Cotrimoxazole) Takes to Exit Mutolere ART Clinic” has been prepared and submitted in fulfillment of the requirements of the Mediumterm HIV/AIDS Fellowship Program at Makerere University School of Public Health and has not been submitted for any academic or non academic qualifications.
Signed…………………………………………Date………………………………… Jerome Roy Mugisha, Midterm fellow
Signed………………………………………….Date………………………………… Pascal Nsekuye, Midterm fellow
Signed………………………………………….Date…………………………………. Elizeus Rutebemberwa, Academic Supervisor.
We hereby declare that the project mentioned above was done at St. Francis Hospital Mutolere with full support of the hospital management.
Signed…………………………………Date………………………… Mayunga Pontius, Institutional supervisor/Hospital administrator
v DR. ROY JEROME MUGISHA He is a specialist in Obstetrics and Gynaecology, team leader of the Quality assurance committee and the Medical Director of St. Francis Hospital Mutolere where he has worked for the last four and a half years. During this time he has always been challenged by the quality of service the hospital offers to all the patients, including the time patients take in the outpatient’s department. No solution has been forthcoming.
Following the announcement of the availability of fellowships at Makerere School of Public Health, he applied, selecting to undertake a course on Continuous Quality Improvement in HIV/AIDS service delivery. Upon being admitted to the course, he undertook to do a special project on decreasing the waiting time for clients who come for Antiretroviral and/ or Cotrimoxazole refills. This was premised on the observation that such clients had known conditions and come only to replenish supplies in a predictable way unlike other patients who need to be thoroughly evaluated. He took a leadership role when the other members of the quality assurance team identified this problem during the theme selection matrix. He, after the initial training from MUSPH, guided the team members in the process of identification of the root causes of these delays. He designed tools for getting baseline data on average waiting time for the clients coming for drug refills. After identifying the countermeasures, he went further to lead the team members in the implementation of the project, designing a tool for studying the effects of the countermeasures as well as analyzing the data. He has been at the forefront of organizing all meetings and CME sessions. He prepared all power point presentations and has written this final report.
vi MR. PASCHAL NSEKUYE. He is a clinical officer/Cataract Surgeon who also holds a Master’s degree in Health Services Management. He is the incharge of the Outpatient department that handles HIV clients who come for drug refills. He has attended numerous trainings in HIV/AIDS care. One problem that had remained an enigma was the long waiting time for clients who only required drug refills. He constantly argued that people even delay to get drugs like Cotrimoxazole that is found in drug shops and so can be obtained over the counter with no prescription, what the medical fraternity call “The class C drugs”. He never envisaged how they could be assisted to quickly exit the outpatient clinic.
However when an opportunity arose to accompany the medical director for this training, he did not hesitate. Upon training he participated in the development of the continuous quality improvement project. He was the main clinician who attended to the clients especially after the departure of his colleague. He ensured that drugs were prepacked before every clinic day. He was responsible for collecting baseline data on waiting time and the data on the waiting time after the countermeasures. He organized and ensured all meetings took place including the quality assurance meetings and the continuous medical education sessions that enabled the staff understand the gist of the continuous quality improvement project.
vii ACKNOWLEDGEMENTS
We greatly acknowledge the support and cooperation of the management of St. Francis hospital Mutolere which enabled us carry out the project in the hospital to completion, as well as allowing us do the implementation in the hospital. We appreciate their patience, which allowed us to be periodically away from the place of work.
We wish to extend our sincere appreciation to the following staff of Mutolere hospital for their contribution, teamwork and maximum cooperation during the implementation period: Mr. Ngabirano Moses,clinical officer who was responsible for clerking the HIV clients; Ms. Katto Justine, Coordinator Public Health Program who was responsible for ensuring that any clients her program caters for had their administrative issues addressed before coming to the reception of the outpatients department; Ms. Nyiramugisha Winnie, palliative care nurse who was also responsible for arranging and keeping the records of the HIV clients; Ms. Nyiramugisha Vastine who was responsible for triaging; Mr. Ntibanyendera Stanslaus, counselor, who was responsible for arranging the records a day prior to the clinic day; Ms. Nkinzehiki Bonny, the nurse responsible for PMTCT but in this project she helped to review client records before their drugs were prepacked and Mr. Nzabalera Fideli the incharge pharmacy who was also responsible for prepacking the ARVs.
We sincerely thank our supervisor, Dr. Elizeus Rutebemberwa, for his commitment. His visits to the hard to reach Mutolere hospital, located in the hilly Kisoro district, enabled us lay new strategies when the going got tough during the initial stages as well as at the implementation phase. To all the lectures/facilitators, thanks for molding us into people capable of developing concepts and pursuing them to a conclusion. To all the other staff of Makerere School of Public Health, thanks for your support that has enabled us to successfully complete this fellowship in time.
viii ABSTRACT
Introduction: Mutolere HIV/AIDS care activities are integrated in the other hospital activities. This, from anecdotal information, has led to delays in getting drug refills for HIV/AIDS clients. A time and motion study has also shown that clients take on average up to 105 minutes to get Antiretroviral and Cotrimoxazole (Septrin) refills. This project aimed at reducing this time by at least 30% in four months.
Materials and Methods: Root causes to the delays were identified using the fish bone analysis. Interventions, with more focus on the pharmacy which had the longest delay, were introduced after sensitization of the top hospital management and the staff. These interventions included assigning triage to a nurse on clinic days, altering client flow, eliminating the need for clients to move back and forward within the hospital and introducing a new dispensing area for anti retroviral drugs in the clinician’s consultation room. Another time and motion study was conducted four months later on a busy clinic day.
Results: Clients were now spending on average 59.9 minutes (a reduction of 43%) to have drug refills. The highest reduction was between the time a client is seen by the clinician and receiving their drugs (from 52.5 minutes to 25.3 minutes).
Conclusions and recommendations: The significant reduction in time required to have drug refills was achieved by involving staff and top management, altering client flow in the clinic and concentrating on areas where it had been shown that clients were delaying the most. Triaging and reducing the number of stations to be visited by the clients reduced the overall time spent in the clinic. We recommend prepacking of the ARVs and arrangement of client’s records before the clinic day, triaging of the HIV clients on the clinic day and dispensing of ARVs in the clinician’s consultation room to reduce on the time required for drug refills at Mutolere ART clinic.
ix CHAPTER 1: INTRODUCTION
Clients on long term medications, like those on ART are a special group of people because they know their diagnosis and their medications. They are predictable users of our services and are often in the know of a lot of details of the events occurring in the units from where they get care. Whereas special handling of these clients may not be prescribed, there is also no justification for them to be subjected to the same repetitive processes year in year out.
Prolonged waiting time to have drug refills, once experienced over and over again, is enough reason for these clients to default, dishonor appointments and have general feeling of despondency about the care they get, a factor that does not favor compliance to long term/life long medications. There is also loss of income as people set aside their other duties to regularly attend the clinic. This, coupled with increased expenses on meals while within the hospital is enough reason for the strong hearted clients to change the clinic while weak ones default outright.
Mutolere ART clinic has had the problem of prolonged waiting to have drug refills ever since ART was introduced in the hospital. The clients have always waited in long lines to have drugs yet the process could be simplified especially if they have no complications at the time of seeking drug refills. This deplorable situation has been a consequence of integrating these services among other hospital activities due to limited staffing and other logistics. As a result, ART clients have been handled in precisely the same way as the rest of the patients, negating the fact that after all they do not have to be handled in a constant manner year in year out. In any case, those coming for drug refills often do not need any laboratory investigations and their prescriptions hardly change. It is because of these considerations that we set out to find the root causes of the delays and design practical countermeasures that are feasible within the Mutolere hospital context.
1 CHAPTER 2: BACKGROUND
St. Francis hospital Mutolere is a 210bed PrivateNotForProfit facility located in the hilly and mountainous Kisoro district, about 500 km from the capital city of Uganda Kampala. It has been in existence since 1957. Since it was founded, it has increased in complexity, initially acting as a small dispensary but progressively offering complex curative, preventive and promotive health services. The bulk of its funding for recurrent costs comes from patient fees and primary health care conditional grants from the government. There are also limited external donations mainly for capital developments. The hospital’s funding and staffing are generally limited and this has always translated into cautious scale up of various health interventions.
The Antiretroviral therapy (ART) clinic started in May 2005 following Uganda government scale up of HIV treatment to district and general hospitals. Prior to that, Mutolere hospital HIV/AIDS activities were limited to offering counseling and testing, care for the orphans and vulnerable children as well as outreaches. Today the services are more extensive, and they in addition involve voluntary counseling and testing, provision of antiretroviral drugs, follow up on adherence and side effects, prevention of the maternal to child transmission of HIV among others. With the exception of this last package and outreaches, the rest of the services take place in the outpatient department. This scale up of ART services has created additional burden to the hospital, with a substantial increase in the work load in the outpatient’s department. The hospital’s out patient complex is congested on Mondays and Thursdays, two days in the week when there is easy access to the hospital. The transport on these days has been made easy by the availability of passenger vehicles and trucks that bring people to the nearby market in Kisoro town on those days. This readily available transport is also exploited by the other patients, which makes those days extremely busy with an out patient turn over of 100 120 patients against three dispensers and 23 clinicians (excluding the few nurses). It is no wonder that the increase in the workload dictated by introduction of ART at Mutolere faced some resistance from the management owing to the envisaged challenges emanating from this additional package. Need for extra staffing to run ART services and independent space to handle clients under ART featured prominently during the preparatory phase of ART scale up (Mutolere hospital, 2005/2006), yet such demands could not be met in the foreseeable future. Thus recourse to integration was the
2 only feasible way to handle this additional package. The clients coming for drug refills, just like other patients register, then go to a clinician, then to the cashier, then to the pharmacy before they exit (Figure 1)
Figure 1: Flow chart showing flow of clients who have come for ART refills.
Enter Reception Cashier
Pharmacy Clinician Exit
This implies ART clients, despite their unique known problems are handled in precisely the same way as other patients, notwithstanding the fact that some of the stations visited/ activities may be adjusted to make acquisition of drugs a lot easier.
A simple baseline study was conducted to authenticate clients’ concerns that there are significant delays before one can finally have drug refills at the pharmacy. All HIV (+) clients, totaling twenty two, who attended one Thursday clinic day, were followed up from the time they registered at the reception to when they had drug refills in the pharmacy. The time they were served at the different stations shown in the flow chart was noted. Then the time taken between the different stations that the clients visited was calculated. The results are shown in the table and summarized in the graph (Table 1 and Figure 2):
3 Table 1: Table showing the time spent between stations Client Time between Time between Time between Total time No reception and Cashier and Clinician and spent by each cashier (mins) clinician (mins) pharmacy (mins) client (mins) 1 2 43 60 105 2 15 33 22 70 3 2 18 31 51 4 7 12 185 204 5 9 9 47 65 6 20 45 60 125 7 13 25 7 45 8 6 4 33 43 9 8 12 13 33 10 3 9 28 40 11 8 2 35 45 12 9 28 26 63 13 29 4 40 73 14 13 17 75 105 15 19 9 86 114 16 13 82 100 195 17 14 6 55 75 18 82 68 95 245 19 84 70 85 239 20 155 15 10 180 21 66 14 10 90 22 20 30 53 103 Total 597 mins 555 mins 1156 mins 2308 mins time Average 27.1 mins 25.2 mins 52.5 mins 104.9 mins time
4 The table shows on average a client took 105 minutes to have drug refills, with the longest time spent between the clinician and pharmacy (52.5 mins). The 105 minutes required to have drug refills are distributed between the different stations according to the bar graph below (Fig 2)
Figure 2: Graph showing average time (in minutes) spent between stations
Graph showing average time spent between stations
60
50
s) 40 n i m
e( 30 Average time m i t
v. 20 A
10
0 DF AC CD Stations
Station A=Reception Station C= Cashier Station D= Clinician Station F=Pharmacy The graph clearly indicates that on average the time the client is seen by the clinician to when they get drugs doubles the time they move through reception to the clinician. It was thus envisaged that reduction of the waiting time would be best achieved by obliterating the need to go to the pharmacy for the drugs.
5 CHAPTER 3: LITERATURE REVIEW
Mutolere HIV/AIDS activities started in the early 1990’s as a response to the increasing destruction caused by the pandemic. They were and are still largely donor funded and were initially limited to outreaches, counseling, and care for the orphans and vulnerable children among others. Provision of drugs for the HIV/AIDS patients was introduced after a decade of relentless battles to offer assistance to the infected and affected people.
Whereas ART was seen as a step ahead in the care of HIV/AIDS patients, its rapid scale up by the Uganda government seems to have underrated the challenges that lay ahead. The Uganda Catholic Medical Bureau (the technical arm of the Episcopal Conference of Uganda) warned affiliated hospitals about the challenges of scale up of HIV/AIDS care (UCMB, 2005). Yet the Uganda Ministry of Health requested all general hospitals to scale up HIV/AIDS activities within the existing resources, save for the drugs that the ministry was expected to provide through donor support. Mutolere hospital being a PrivateNotForProfit (PNFP) unit heavily relies on user fees from patients and government subsidies in form of the Primary Health Care Conditional grant (PHC CG). Due to the limited funding, the hospital chose to take an integrative approach to contain the extra workload without increasing on the space or staffing. Thus all patients, HIV clients inclusive, are handled in the same premises following a dictated chart. However to some extent some of the stations visited may not add too much meaning to the clients, yet they consume their time. Anecdotal information indicates that HIV/AIDS clients coming for ARV and/or cotrimoxazole refills, and whose diagnosis and required drugs are already known and have only come for drugs, stay long in the outpatient clinic. This was confirmed by a baseline study as already alluded to in the preceding section.
Whereas ARVs themselves are not charged even in paying hospitals, overstaying in the clinic definitely affects a client’s other activities resulting into decreased production. In addition, there are other expenses like the need to have a meal while attending the clinic, and some clients may be impoverished to afford these additional requirements (Hardon et al., 2007). There is also a concern that that some people do not want to over mix with nonHIV (+) clients, for, after all many clients do not want to disclose their serostatus to people either consciously or subconsciously. Many clients
6 are often seen exiting the clinic hiding their medications. Yet bottlenecks to smooth client flow, obviously obstruct effective ART scale up, can be minimized through staff allocation to clinic duties as some studies have shown (Glenn et al, 2007).
It should be understood that long waiting time is one factor responsible for patient dissatisfaction among patients seeking care in the outpatient department (Eilers, 2008; Probst, 1997). The fellows were not able to access any documentation regarding the “acceptable” waiting time in OPD for HIV/ AIDS patients. We were however convinced that there is no justification for clients to stay close to 2 hours in the OPD in order to receive known drugs for a known condition, moreover on repetitive basis. It should be appreciated that Cotrimoxazole is actually readily available in the drug shops and pharmacies and is not restricted, therefore it should be easy to access for HIV clients. It has been shown that long waiting times results in the lack of respect for scheduled appointments resulting in not honoring return dates, which may interrupt drug adherence (Lucey et al, 2004). Yet interruption of adherence is potentially dangerous as it inevitably results into drug resistance.
7 CHAPTER 4: PROBLEM STATEMENT, JUSTIFICATION AND CONCEPTUAL FRAMEWORK 4.1 Statement of the Problem
At Mutolere ART clinic, in the month of September 2008, during the busy clinic days of Monday and Thursday, HIV (+) clients took on average 105 minutes to have drug refills (ARVS and/or Cotrimoxazole). The high numbers of HIV/AIDS and other routine clients who turned up on the clinic days that happen to be market days in Kisoro town caused this. Market days are usually preferred for the clinic days because that is when the means of transport for the people coming from far are available. However, when all these clients come, they are served concurrently yet unlike the routine clients, the HIV /AIDS clients know their condition and their drugs are known. They just came to replenish the drugs. Whenever they go through the entire process that the rest of the clients go through, it creates unnecessary delays both to them and to the other clients who also have to go in the same lines with them. The long period interferes with their other activities, can cause defaulting and creates or worsens stigma owing to prolonged mixing with curious non HIV (+) patients.
4.2 Justification / Rationale of the Project HIV clients, on known lifelong medications should not overstay in the outpatient clinic if they have only come for drug refills. Exception to this should be when they have complications or other disease conditions where reevaluation can be done. Only in these circumstances would they go through processes that nonHIV patients go through. There was thus a definite need to reduce total time taken for HIV clients who are devoid of complications to have drug refills.
8 4.3 Conceptual framework
Limited funding Lack of independent ART unit Hospital policy dictating defined client flow Staffs not carrying out triage Primary problem Clients coming on market days when transport is easy for them and other nonHIV (+) clients
Few staff to offer ART Clients move long distance to scattered service Consequences points Congested dispensing window Clients have to be served alongside other patients
Delay to get drug refills Effect on client
9 CHAPTER 5: PROJECT OBJECTIVES
5.1 General objective: The objective of this project was to reduce the time it takes a client at Mutolere ART clinic to get drug refills by at least 30%; from almost two hours in August 2008 to an hour in January 2009.
5.2 Specific objectives: 1. To decrease the numbers of service points clients go through when they come to get drug refills. 2. To eliminate the need for visiting the Pharmacy by pre–packing drugs before the clinic day
10 CHAPTER 6: METHODOLOGY
The fellows attended a MUSPH CDC module on Continuous Quality Improvement (CQI). This was one of the modules to be attended by the fellows. They made a report to the hospital management when they came from the training. This helped to get the management on board and embrace a change project, which was one of the requirements for the award of the fellowship. The management suggested that since there was a Quality Assurance team already in place, this could be incorporated in the project as the team to work with the fellows. This helped to make the project not look like an appendix to hospital activities but was incorporated into the hospital routine work. The team then met several times and during these meetings, the following was done: 1) Identification of the problems affecting ART clinic at the hospital: This was done during a meeting with all the team members who brainstormed on the various problems. After the brainstorming, there was multivoting to enable everyone’s views to be heard. 2) Selection of the problem that was seen to have the highest impact on the clients. This was done using a theme selection matrix whereby four main themes which came up from the identified problems were listed and members of the team voted as to which of the themes was the one that affected the clients most and which needed immediate improvement. Client’s delay in the process of getting drug refills from the ART clinic scored the highest. 3) Identification of the root cause of the clients’ delay using the fish bone analysis was made (Appendix 2). Major problem categories were identified and further analysis to reach the root causes was made. The actionable problems were identified as follows: • There is no independent ART unit so HIV (+) clients are served concurrently with other patients. This is a consequence of the desire to avoid extra costs accruing from the scale up of the HIV/ AIDS activities. • Triage of clients was not being done • The hospital policy dictates that all patients flow in a particular way, irrespective of their needs • That the hospital activities be integrated to contain the costs related to scale up of HIV care.
To these challenges, countermeasures that focused on adjusting client flow were identified using the countermeasures matrix (Appendix 3). To avoid resistance and failure during implementation, the
11 countermeasures were subjected to the aids and barriers analysis so as to identify which factors may favor implementation and those that could retard the process (Appendix 4). We focused on the stage between the cashier and the pharmacy because that is where the longest delay was identified. Practically, the following were done: 1) Sensitization of the management and staff at Mutolere Hospital about the need to decrease waiting time at least for the HIV/ AIDS clients coming for drug refills 2) Reduction of the service points through which the clients go as they get drug refills 3) Prepacking the drugs the clients take and shifting the drugs from the pharmacy to the physician’s (clinical officer’s) room before the clinic day. 4) Amalgamating the visit to the clinician by the HIV/AIDS client with the acquisition of the drugs (i.e. ARVs to be dispensed by the clinical officer after the consultation if no complications have been reported). 5) Evaluation of the reduction in the client’s time at the ART clinic and then getting the lessons learnt to be passed on to the other areas of the hospital 6) Dissemination of the results to the entire hospital and medical fraternity through abstracts of the project and dissemination of the results workshop.
12 Photo showing cupboard for storing the prepacked drugs.
13 A client being served by the nurse in OPD. The nurse will also do the recording. The client has not moved to the pharmacy.
14 CHAPTER 7: RESULTS
The new client flow was agreed upon by the team running the ART clinic. In particular this client flow clearly indicates an amalgamation of the visit to the clinician by HIV/AIDS clients with acquisition of drugs, which negates the need to go to the pharmacy that is visited by all the other patients. This is illustrated in Fig 3 below. Figure 3: New client flow for patients coming for drug refills
Enter Reception Cashier
Clinician Exit + drugs
Hence the clinician’s consultation room is the same place where the clients receive their drugs that have been packed a day before the clinic day. The effects of the countermeasures, as described, were again subjected to evaluation in form of a time and motion study that was conducted on a busy clinic day. The findings were summarized in a table and the results have been compared to those before the countermeasures were instituted (See table 2).
15 Table 2: A comparison of time required to have drug refills before and after the counter measures
Before counter After intervention % measures reduction in time Reception Cashier 27.1 10.7 59% Cashier Clinician 25.5 24.3 4.7% Clinician Drugs 52.5 25.5 51% Av. Total Time (Min) 104.9 59.9 43%
Figure 4: Bar chart showing time between stations before and after counter measures.
Bar chart showing time between stations before and after countermeasures
120
100
) 80 es t u
n Before countermeasure i m
60 After countermeasure n i (
e m i
T 40
20
0 RECCASH CASHCLIN CLINDRUGS AV. TOT TIME Stations
RECCASH=Reception to cashier; CASHCLIN=Cashier to clinician; CLINDRUGS=Clinician to drugs; AV. TOT TIME=Average total time
16 CHAPTER 8: DISCUSSION
The table and graph show a comparison of the time clients used to take to have drug refills before the countermeasures were instituted and the situation after the countermeasures. In particular, the bar graph shows the time between the different stations visited by the clients with bars depicting the situation before the countermeasures standing against the bars depicting the situation after the countermeasures to give a graphic representation of the countermeasures’ effect. The effect of the countermeasures is more pronounced on the time spent between the clinician to drugs and then average total time required to have drug refills.
From the table and graph, the following are noted: • There was a 43% reduction in time required to have drug refills (from an average of 105 minutes to 59.9 minutes which surpassed the project target. • There was a 51% reduction in the time it takes a client to be seen by the clinician to when they get their drugs (from 52.5 minutes to 25.3 minutes). This is an indication that intervention in the area where clients delayed the most paid dividends. • With triage, clients quickly moved from the reception to the cashier before being seen by the clinician.
From the time ART was introduced in Mutolere hospital, clients have been undergoing rigorous and time consuming and unnecessary processes to have drug refills. It is understandable that the initial visit should be comprehensive because it involves history taking, detailed physical examination, thorough investigations and preART counseling before the eligible clients are started on medications. The treatment, being a lifelong course, needs to be simplified in order for clients to own up the process of drug replenishment. For all the time that Mutolere hospital has offered ART, clients have undergone an agonizing, long experience to have drug refills. From the baseline study, we note some took a very short time but others took up to three hours or more to get drug refills. With technical assistance from MUSPH/CDC and team work from the hospital management and staff, the root causes to these delays were identified and the feasible countermeasures implemented.
17 At the end of the project, another time and motion study has shown a 43% reduction in the time required to have drug refills. This surpasses the target of 30% reduction at the beginning of project implementation. The objectives of the project have been achieved and the staffs working on the clinic days are happy with the effects of this intervention. Moreover the long waiting time to have drug refills has “collateral” effects on other patients and the staff. The former are made to delay in all service points to receive care because of additional patients from the ART clinic while the latter must serve all patients before they close business for the day. The findings and comparisons were presented initially to the quality assurance committee and hospital management team. They recommended that there was a lot to learn from this initiative and other staff members ought to share the information. Consequently, and in accordance with the budget/work plan, a CME comprising all staff was convened. The staff members too were happy with the work done by the fellows, which made it a lot easier for the staff to continue implementing the project even when there is no financial support. There are undocumented reports that clients are happy with the ease at which they get drug refills. It is already reported that getting drugs from the clinician’s consultation room not only makes the process faster but it also enhances further interaction and seeking for some clarifications before the client eventually exits the clinic.
18 Staff at one of the CME seminars organized by the fellows to share effects of the change project.
19 CHAPTER 9: LESSONS LEARNT AND CHALLENGES EXPERIENCED
9.1 Lessons learnt This project generated the following lessons: • Client delay in exiting the ART clinic has been a long standing problem, with many of our staff arguing that it may not be overcome. However, using the fish bone analysis, a technique we learned from Makerere University School of Public Health helped us identify interventions that are costeffective and feasible within our own circumstances. • By soliciting support from the top management of the hospital, the team was able to change hospital policy prescribing particular client flow • Triaging and drawing new client flow removed the need for clients to move forth and backwards within the clinic and the hospital • Triaging also removed the need for unnecessary waiting after registration • By involving senior staff members and the preexisting quality assurance team, there was no resistance to change. Rather the project was embraced by the staff members • Continuous medical education (CMEs) to the rest of the staff enabled the rest of the staff not involved in the project to acquaint themselves with what was going on. This increased co operation among all the stakeholders including those not involved in the project.
9.2 Challenges experienced We met the following challenges: • We received the financial support from the School of Public health a bit late. This some how affected the implementation of the project but we improvised by using a few existing resources within the hospital to ensure we did not lag behind. • We had movements to the School of Public Health to attend modules. Our absence might have stalled the progress of the project if we had not delegated to the remaining staff within the hospital • Some staff felt that, since there was some limited funding, it will continue even at the end of the fellowship. We have continuously sensitised them, through the CMEs, that that there is no extra funding. So as staff we need to own up the project so that the positive outcomes are not lost in due course.
20 • It is agreed that the fellowship office facilitated us to attend the modules but looking at the cost of living today, this was not enough to help us live within Kampala. However we were strongly motivated to pursue the course to completion. • Amidst limited staffing at the hospital, our absence while attending the modules, always created a significant vacuum. This was solved by task shifting and reorienting the staff left behind to handle the duties we directly used to do. We also had support from the top management who ensured that the hospital continued to run especially in absence of one of the fellows who happens to be the medical director.
21 CHAPTER 10: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
Majority of clients coming to Mutolere ART clinic for drug refills already have their diagnosis known. Traditionally they have been moving in the same lines as those used by other patients in the outpatient department. Because the clients come on Mondays and Thursdays which are market days (when there is easy transport) and there are other nonHIV patients, the clinic days have always been very busy, thus over delaying those who only need drug refills. The clients have always expressed displeasure at the long waiting time, a problem that was authenticated by a simple time and motion study done at the beginning of this project. We have always thought that reducing this waiting time is a Herculean task because we never had skills to analyze it. However, we were able to analyze it and design practical solutions thanks to the training from MUSPH.
Staff attending to ART clients have already reported that the clients who come for drug refills are happy that they have been saved the inconvenience of staying too long in the hospital only to receive known drugs. It is no longer necessary for clients to completely interrupt the day’s activities in order to come and receive their drugs.
The hospital management has been impressed by the fellows’ ability to tackle this problem with minimum additional resources from the hospital and pledge to continue supporting all efforts to make the clinic run more smoothly. It is hoped that the momentum so far attained is not merely a response to the limited funding from MUSPH but will continue even as the funding is withdrawn. We recommend that: • The achievements so far attained be documented and shared with the neighboring hospitals offering ART. • The adjustments to client flow in the ART clinic be maintained even after closure of this project • That the quality assurance team continues to monitor the effect of adjusted client flow on a quarterly basis and report to the management of the hospital and the rest of the staff through CME. • Management continues to offer support to efforts aimed at improving the quality of care to HIV/AIDS clients
22 • That a follow up time and motion study should be conducted after 6 months to assess whether the momentum so far attained in reducing waiting time for clients has been maintained • That the School of Public Health assists in ensuring that the work done by the fellows is shared by the medical fraternity through abstract writing and publication.
23 REFERENCES
Eilers M. Gayleen (2008): Improving patient satisfaction with waiting time. Journal of American college of Health. Vol 53,No. 1 JulyAugust 2008
Glenn Wagner, Gery Ryan, Stephanie Taylor (2007): Formative efficiency of antiretroviral therapy scale up efficiency in SubSaharan Africa. In: AIDS patient care and STDs. 21(11): 871888.
Hardon, Akurut, Comoro, Ekezie, Irunde et al………. (2007): Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in Africa. In: AIDS care .19(5): 658665
Lacy N.L, A Paulman, M. D Reuter, B Lovejay: Why we don’t come: Patient perceptions on no shows. Annals of Family Medicine 2004 NovDec; 2(6): 5415
Mutolere hospital annual report 2005/2006.
Probst JC, Greenhouse DL, Selassie AW (1997): Patient and physician satisfaction with an outpatient care visit. Journal of family practice 45(5): 418425
UCMB Uganda Catholic medical Bureau bulletin Vol. 8 No. 1 July 2005.
24 APPENDICES
Appendix 1: Fish bone (Ishikawa diagram) analyzing the problem
Fish borne (Ishikawa diagram)
Congested Busy clinic day dispensing window Understaffing No specific ART Restrictive staff Routine establishment OPD day Low HW: Limited PT space Easy transport on same day Understaffing Limited funding
Budget Program not Market constraints anticipated day Clients at Mutolere ART treatment centre take long to Triage of ART have drug clients not No refills assigned Policy independ ent ART unit
Standard flow Concentrate on general points
Not Bureaucratic Scattered service process prioritised points No triage
Staffs Procedure Distance Appendix 2: The countermeasures matrix
Root Counter Practical Effectiveness Feasibility Overall Action Causes Measures Method
Limited Integrate Share tasks 12 Y funding activities and team 4 3 work
Delay of clients who 5 4 20 Y No Give Specify have come independen priority to responsible for ARV t ART unit ART staff on each and/ or clients clinic day. Septrin refills at Mutolere hospPirtobal lem Prepack Policy/bure Reduce the 5 5 25 Y ART clinic aucracy stations drugs and dispensing by clinician; change flow
Triage of Enforce Assign triage ART triage to a 5 3 15 Y clients not particular assigned. staff Appendix 3: The barriers and aids analysis.
BARRIER AND AIDS ANALYSIS TO THE PRACTICAL METHODS
PRACTICAL METHOD BARRIERS AIDS Share tasks and team work Competing priorities •Unpredictable circumstances •Cooperative staff •Some clients reporting late •Hard working staff •Enthusiastic staff •Obedient staff Specify responsible persons on Limited training each clinic day •Un cooperative staff •Clinic days known •Staff demanding special allowance •Staff can rotate •Over rotations not liked •Staff eager to assist •Some activities need no expertise Prepack drugs and dispensing by Increased workload to clinician due clinician; change client flow to required records •Tablets easy to pack •Standard doses •Hospital less busy on non market days •Clinician willing to dispense •Instructions already known by clients •Instructions easy to understand •Majority of clients on one regimen •Appointments kept by clients •Management support. Assign triage to a particular staff Understaffing •Demand for allowances •Available staff •Concerned staff •Diagnosis known •Known clients •Known client needs •Legible records Appendix 4: Members of the Quality Assurance Team with the MUSPH supervisor