PROJECT TO IMPROVE AVAILABILITY OF STAFF ON DUTY TO PROVIDE QUALITY ART SERVICES AT RAKAI HOSPITAL

BY

MAYANJA ROBERT & KITYO ALPHONSE MEDIUM TERM FELLOWS

2009 PROJECT TO IMPROVE AVAILABILITY OF STAFF ON DUTY TO PROVIDE QUALITY ART SERVICES AT RAKAI HOSPITAL

BY

MAYANJA ROBERT, MPH KITYO ALPHONSE, MB chB MEDIUM TERM FELLOWS

JULY, 2009

ii Table of contents

Table of contents ...... iii

List of tables...... v

List of figures ...... vi

List of figures ...... vi

Declaration...... vii

Declaration...... vii

Fellow’s Roles in Project Implementation ...... viii

ACKNOWLEDGEMENTS...... ix

EXECUTIVE SUMMARY ...... x

ACRONYMS AND ABREVIATIONS ...... xii

1. Introduction and Background...... 1

2. Literature Review...... 1

3. Statement of the problem...... 2

3.1 Problem Statement ...... 2 3.2 Justification...... 2 3.3 Conceptual Frame Work / Fish Bone Analysis...... 3

4. Project Objectives...... 4

General objective ...... 4

iii Specific Objective ...... 4

5. Project Description...... 4

5.1 Detailed project description with current situation ...... 4 Monitoring and Evaluation...... 7 Project Outcomes / Results...... 8

Public Health Impact ...... 11

Lessons Learnt from challenges ...... 11

Conclusion and Recommendations...... 12

Conclusion ...... 12

Sustainability Plan / Future plans ...... 12 Appendix 1 ...... 15 Appendix 2 ...... 15 Appendix 2 ...... 15

iv List of tables

Table 1 Multivoting ...... 5 Table 2: Theme Selection Matrix ...... 5 Table 3: Implementation Methods / Counter Measures...... 7

v List of figures

Figure 1: Flow chart of ART clients in Rakai ART clinic ...... 6 Figure 2: Availability of staff in Clinic...... 8 Figure 3: Availability of staff in Clinic...... 9 Figure 4: Clients’ Satisfaction ...... 9 Figure 5: Waiting time in the Laboratory...... 10 Figure 6: Waiting time: Clinician’s room & Pharmacy...... 10

vi Declaration

Dr Mayanja Robert and Dr Kityo Alphonse do hereby declare that this end­of­ project report entitled ‘PROJECT TO IMPROVE AVAILABILITY OF STAFF ON

DUTY TO PROVIDE QUALITY ART SERVICES AT RAKAI HOSPITAL’

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 academic or non­academic qualifications.

Signed……………………………………………Date…………………………

Dr Mayanja Robert, Medium term Fellow

Signed……………………………………………Date…………………………

Dr Kityo Alphonse, Medium term Fellow

Signed……………………………………………Date…………………………

Dr Zirabamuzale Christine

Signed……………………………………………Date…………………………

Dr Rutebemberwa Elizeus

vii Fellow’s Roles in Project Implementation

Each Fellow participated in developing the proposal, data collection, analysis, sensitization of health workers on the project and standing orders for the availability of staff on duty.

Dr Kityo A together with CQI team conducted internal supervision and regular

CME sessions with HIV/AIDS Clinic staff on Quality improvement topics. Dr

Mayanja R conducted regular external supervision and attended some of the CME sessions.

Both fellows conducted training of staff in Kalisizo Hospital and Kakuuto HSD as the activities were being scaled up in other Health sub­districts.

viii ACKNOWLEDGEMENTS

We hereby acknowledge the Rakai Hospital staff who accepted to participate in this quality improvement project and made it a success.

We thank Rakai district administration for giving us the permission to do this course.

We are grateful to Dr Zirabamuzale C and Dr Rutebemberwa E for their technical­academic advice and facilitation.

We would like to appreciate SPH­CDC HIV/AIDS Fellowship program for offering us the opportunity to do this course and CDC for funding the project.

Last but not least, we thank our families for the emotional support during the course.

ix EXECUTIVE SUMMARY

There was low availability of staff of 15% in ART clinic in the month of August

2008 which led to delay of patients for about 4 hours before getting a service, inadequate assessment and caused client dissatisfaction to 50% of clients.

The objectives of the project were to increase the availability of staff, the clients’ satisfaction, reduce the waiting time in the Laboratory and increase the time of assessment for HIV/AIDS clients by Clinicians.

A quality supervision team was put in place to monitor the progress on a weekly basis through collection of data on staff arrival time, client satisfaction, clients’ waiting time. In addition sensitization of health workers on standing orders on working­hours, bi­weekly staff meetings to give feedback on collected data, new duty roster deploying more staff on duty per day was done.

The Availability of qualified staff during the day increased by 100%. The staff arrival time improved from 13% of staff arriving on duty before 9 a.m.to 70%.

There was improvement in clients’ satisfaction from 50% to 80% of patients perceiving services as good.

The waiting time in the laboratory now ranges between 30 minutes and 1 hour 30 minutes, while before: time spent at laboratory ranged between 30 min & 4 hours.

x The minimum time spent by clients at the clinicians’ room increased from 2 minutes to 10 minutes. However, minimum time spent by clients at the pharmacy increased from 15 minutes to 30 minutes.

In conclusion, increasing availability of staff in Rakai ART clinic reduced waiting time and improved clients’ satisfaction with the services provided. Thus the district decided to scale up activities started at Rakai ART Clinic in the other 2 health sub­districts.

xi ACRONYMS AND ABREVIATIONS

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral Therapy

ARVs Antiretroviral Drugs

CDC Centre for Disease Control

CIPA Community Initiatives for Prevention of HIV/AIDS

DHO District Health Officer

DHT District Health Team

HCT HIV Counseling and Testing

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HSD Health Sub­district

HSSP –II Health Sector Strategic Plan – II

HW Health Worker

I/C In­Charge

MOH Ministry of Health

NGO Non­Governmental Organization

PLWHAs People Living with HIV/AIDS

PMTCT Prevention of Mother to Child Transmission

VCT Voluntary Counseling and Testing

xii 1. Introduction and Background

Rakai Hospital is in Rakai District. It is has a bed capacity of 100 beds. It started providing ARVs in March, 2004 with support from Uganda Cares and Ministry of health. When the number of HIV clients reached 200, the hospital authority decided to separate the HIV care services from out patient services by building

Rakai HIV/AIDS clinic. However, the patients still use laboratory services of the general hospital. The total number of HIV / AIDS patients on ARVs at Rakai HIV

/ AIDS clinic was 660. Generally, one health worker was deployed on a daily basis in each section of ART clinic (Clinical assessment room, Counseling room,

Laboratory & pharmacy) to serve these clients on working days.

2. Literature Review Full time availability of health workers at health facilities to provide minimum health care package services to the population is stressed by Ministry of Health in its Health Sector Strategic Plan II and Concept paper of Health sub­district as a means of increasing access to quality services to the people. In an effort to ensure quality services provided by the staff, quality of care standards (Yellow Star) were developed by Ministry of Health and given to districts for implementation.

Waiting time is one of the key quality standards highlighted in yellow star.

Ministry of Public Service standing orders state that unless it is otherwise provided in the terms of his or her appointment every Public Officer is employed on the understanding that the whole of his or her time is at the disposal of the

Government, and if the usual office hours are insufficient to deal with the pressure of work it is his or her duty, whenever it becomes necessary to work outside office hours without extra remuneration. An officer may not be absent from his or her station at any time without the consent of the officer in­charge of his or her department on the station. Office working hours are from 8 am to 5 pm.

In a Study done by Community Initiatives for Prevention of HIV/AIDS (CIPA) on magnitude and dimension of limited access to anti­retroviral therapy services in 3 sub­counties of Rakai District, 2007. It was found out that some health workers attached to ART behave in non­professional manner. They are irregular at their work place, abuse patients, ask for money and don’t care for them. This not only discourages PLWHAs from accessing ART services but determines the quality of services offered at those facilities.

3. Statement of the problem

3.1 Problem Statement The low availability of staff of 15% in the ART clinic in the month of August

2008 led to delay of patients for about 4 hours before getting a service, inadequate assessment and caused client dissatisfaction to 50% of clients.

3.2 Justification

The project was to increase the availability of staff at work during the day so that

HIV/AIDS clients get improved quality of ART services and hence live a long productive life.

2 3.3 Conceptual Frame Work / Fish Bone Analysis

FISH BONE ANALYSIS

Health worker issues

Nobody has been Many health workers are following up time of given off duty at same time arrival

Absenteeism Late coming of Health workers Low Availability Of staff during Working Lack of knowledge on hours standing orders

Poor communication on standing orders Poor Irregular external & internal No sensitization on motivation supervision standing orders

3 4. Project Objectives

General objective To improve the quality of ART service provision through ensuring adequate number of staff at Rakai ART clinic during working hours.

Specific Objective 1. To increase the availability of staff at Rakai ART clinic during working

hours from 15% in August 08 to 30% by January 2009.

2. To increase the clients’ satisfaction with ART service delivery at Rakai

ART clinic during working hours from 50% in August 08 to 75% by

January 2009.

3. To reduce the waiting time in the Laboratory from 4hours to 1 hour in four

months time of the project implementation.

4. To increase the time of assessment for HIV/AIDS clients by Clinicians in

Rakai ART clinic from the minimum of 2 minutes in August 08 to a

minimum of 15 minutes by January 2009

5. Project Description

5.1 Detailed project description with current situation In August, 2008, several problems on quality of care issues were identified by the hospital staff and fellows that needed to be addressed to improve ART service delivery at Rakai hospital.

The staff used multi­voting and theme selection matrix to prioritize the problem to focus on.

4 Table 1 Multivoting Multivoting Vote 1 Vote2 Late coming of health workers 30 16 Inadequate drugs for opportunistic infections &supplies 35 18 Irregular supervision by DHT &administrators 25 10 Lack of regular meetings to solve problems 20 Problems discussed, interventions not implemented 10 Lack of Health education / sensitization on availability of free 40 20 ARVs, clarifying misconceptions like ARVs kill you faster Low utilization of ART services (only 600 people on ARVs out of 41 21 the expected 4700 HIV expected eligible clients in Kooki) Team work is minimal 12 Limited number of staff at work during the day 41 20 Poor Planning 9 Poor HW/patient relationship resulting from poor communication 12

Absenteeism of health workers due many health workers being 28 14 given off at same time Poor handling of patients 30 14 Lack of follow up of patients who don’t turn up for more arvs 26 15 Lack of motivation / incentives 18 Poor working environment 8 Long waiting time by patients before getting a service 41 18

Table 2: Theme Selection Matrix

Problem area Impact on Need to improve Overall customer rating Low utilization of ART services (only 600 people on ARVs out 5 5 25 of the expected 4700 HIV expected eligible clients in Kooki) Long waiting time by patients before getting a service 4 5 20

Lack of Health education / sensitization on availability of free 3 4 12 ARVs, clarifying misconceptions like ARVs kill you faster Limited number of staff at work during the day 5 5 25

‘The limited number of staff at work during the day’ was the problem area

selected to be improved upon in the following months.

5 A quality of care team was selected to do internal supervision and monitor the progress of planned activities.

The team members included: Dr Kityo A – Team Leader Nakabiito Safina – Deputy I/C Nabukeera Betty – I/C Pharmacy Mbabazi Florence – I/c ANC Mujuzi.M. – Health Educator Milly Matovu ­ Counselor Nambale J.B – I/c Laboratory Dr Mayanja R – Ex Official A flow chart was drawn to identify the bottle necks in the flow of clients.

Figure 1: Flow chart of ART clients in Rakai ART clinic

No Register Treatment education Patient arrives Is patient patient critically

Yes Measure patient vitals Manage patient Clinical Examination& Drug prescription

Admit Lab investigation Is there any Yes other illness

No Dispense drugs Home

6 Table 3: Implementation Methods / Counter Measures

PROBLEM ROOT CAUSE COUNTER PRACTICAL ACTIONS MEASURES BASED ON SCORES Lack of knowledge on the No sensitization of HWs ­Sensitize HWs on ­Conduct a sensitization workshop standing orders on on standing orders on standing orders on for health workers on standing number of hours a civil number of hours a civil number of hours – orders servant works. servant works. civil servants are supposed to work Poor motivation of HWS Irregular internal & Form ­quality of care Quality of care team selected external support team to do internal DHO to make monthly supervision supervision supervision to art clinic ­DHT to increase no of supervision visits Absenteeism Many hws are given off Re­deploy hws thru Principal nursing officer is to meet duty making another duty all in­charges of sections to make a roster so that every new duty roster HW works a minimum of 8 hrs per day Late coming of hws No body has been ­Put a register for ­Ms is to request for funds to buy following time of arrival arrival of hws the registers within 2 weeks. ­Reward those hws Askari on duty to keep book after who come on time 8.30am+2.30pm continuously for 6 ­A budget line is to be created for months giving gifts to hws who come on time – budget committee to handle No leaving before Nursing officer on duty will ensure handing over & both all hws hand over to new ones hws should sign on when going off duty time of hand over

Monitoring and Evaluation

A quality supervision team together with fellows monitored the progress of the expected outcomes on a weekly basis through collection of data on staff arrival time, client satisfaction at exit interview, time clients spent at each service station in the patient client flow, number of staff deployed through registers signed on arrival for work every days. Client satisfaction was based on Clients’ perception and expectations. That is, whether quality of care offered to them in the ART clinic was considered ‘good’ or ‘bad’. The percentage increase of the clients who rated the service as ‘good’ was taken as a proxy indicator of increased client satisfaction.

Through bi­weekly staff meetings, a feedback was given to the staff to be able to discuss strategies for improvement. Specific tasks were assigned to individuals to ensure the work was done according to schedule.

Project Outcomes / Results

Figure 2: Availability of staff in Clinic (i) More staff was deployed during working hours

• The Qualified staff deployed during the day increased from 5 to 10

(ie:100% increase)

The PMTCT clinic & HIV clinic were merged – reducing client movement

3

2.5

2 Before 1.5 After 1

0.5

0 Clinicians Lab Councilor Pharmacy

8 Figure 3: Availability of staff in Clinic (ii) Late coming reduced

­The staff arrival time improved: When we began the project only 13% of

staff arrived on duty before 9 a.m. Final assessment: 70% of staff arrived

before 9 a.m. with about 45% coming before 8 a.m.

30

25 Before 20

15

10 After 5

0 < 8am 8 to 9am >9am

Figure 4: Clients’ Satisfaction • There was dramatic improvement in the way the patients perceived the

quality of services at Rakai Hospital. From 50% to 80% of patients

perceiving services as good during exit interviews.

80

70

60 Before

50

40 After

30

20

10

0 satisfied Not

9 Figure 5: Waiting time in the Laboratory • The time spent in the laboratory now ranges between 30 minutes and 1

hour 30 minutes, with majority of the patients (80%) now spending 30

minutes to 1 hour

• Before: Time spent at lab ranged between 30 min & 4 hours with majority

of Clients(86%) spending 1hr to 4 hrs

120

100

80

B ef o r 60 e A ft er 40

20

0 30 ­ 60min 61 ­ 90m in Above 90

Figure 6: Waiting time: Clinician’s room & Pharmacy • The minimum time spent by clients at the clinicians’ room increased from

2 minutes to 10 minutes. While the average time for the clients at the

clinicians’ room became 22 minutes.

• The minimum time spent by clients at the pharmacy (doubled): It

increased from 15 minutes to 30 minutes. 30

25 Before 20

15 After 10

5

0 Clinician Pharmacy 10 Public Health Impact

• Increasing availability of staff at work during the day resulted in more

HIV/AIDS clients getting improved quality of ART services and hence

live a long productive life

Lessons Learnt from challenges

• Reviewing the progress of an intervention at regular intervals was

necessary as new problems arose and needed to be addressed as soon as

possible e.g:

• Whereas there was reduction in waiting time at Laboratory, there was an

increase in minimum waiting time at the pharmacy from 15 minutes to 30

minutes. This was solved by recruiting one more qualified staff for the

pharmacy.

• Data collection, analysis and interpretation of results needed involvement

of the staff themselves because that was when the project was perceived as

not spying on them but intended to improve service delivery. Secondly,

that was when they believed in the results got and accepted to make

changes with ease.

11 Conclusion and Recommendations

Conclusion

Increasing availability of staff in Rakai ART clinic reduced waiting time and

improved clients’ satisfaction with the services provided.

Recommendations

• Rakai Hospital Medical superitendant should through use of quality

improvement methods maintain adequate numbers of staff in ART

clinic all the time.

• The DHO should ensure that data tools to monitor quality of care are

integrated in the monthly data tools collecting information from

HIV/AIDS Clinics in HSDs.

Sustainability Plan / Future plans

• The activities started under this project will be sustained through

integrating them with the existing primary health care activities. For

instance after the DHT members were trained in quality of care concepts,

then quality of care supervision was carried out with the routine

supervision. In the same way, the data on quality of care will be collected

routinely with surveillance data that is gathered on weekly basis.

However, those activities that needed separate funding, a budget line was

created and approval sought through council. Training of health workers

from Health Centre IIIs in quality of care will take place in the financial

year 2009/2010. While Kalisizo Hospital & Kakuuto HC IV were helped

12 to start those same activities last financial year. In the extension period, the activities started in the HIV/AIDS clinic were spread to involve all

Rakai hospital staff in the different departments of the hospital so as to improve quality of all services provided in the whole hospital.

13 • References

1. Uganda Service Provision Assessment Survey 2007. Ministry of Health.

2. Yellow Star, 2001. Ministry of Health.

3. Continuous Quality Improvement in Hospitals, 2002. IHI

4. The Republic of Uganda Government Standing Orders, Volume 1.

Ministry of Public Service, Uganda.

5. Concept paper on Health Sub­district, 1999. Ministry of Health, Uganda.

6. Health Sector Strategic Plan II. Ministry of Health, Uganda

7. Study on magnitude and dimension of limited access to anti­retroviral

therapy services in 3 sub­counties of Rakai District, 2007. Community

Initiatives for Prevention of HIV/AIDS (CIPA)

14 Appendices

Appendix 1 Time Check Sheet for arrival time at Rakai HIV / AIDS Clinic Date:………………………………………………………….. < 8.00 am 8.00 – 8.30am 8.31­9.00am 9.01­9.30am >9.31am

Appendix 2

Check Sheet for tracking waiting time of patients at different ART Clinic­stations

Date:………………………………………………………………

Waiting room Counseling Clinicians’ Laboratory Pharmacy Room Room Start End Start End Start End Start End Start End time time time time time time time time time time

Appendix 2

Exit interview guide

Preamble: Dear Sir / Madam, We want to improve service delivery at our clinic. We do not need your name but information on what you find to be good or bad in our Clinic. Hence we shall ask you a few questions. 1. Is this your first time at Rakai ART Clinic or re­attendance? 2. How do you judge the way, the ART Services are offered? GOOD / BAD 3. IF BAD, what does the ART Clinic Staff need to improve? 4. If, GOOD, what is it that is making the services ‘Good’ ?

15 THANK YOU FOR ANSWERING OUR QUESTIONS

16