SHORTENING TIME A CLIENT WHO HAS COME FOR DRUG REFILLS (ARVS AND/OR COTRIMOXAZOLE) TAKES TO EXIT ART CLINIC.

BY: JEROME ROY MUGISHA AND PASCHAL NSEKUYE (ST.FRANCIS ).

SUPEVISOR: DR. ELIZEUS RUTEBEMBERWA

MUSPH/CDC DISSEMINATION WORKSHOP

Hotel Africana

14th August 2009. Introduction and background

• General hospital + specialization; in district

• PNFP, belongs to diocese

• HIV care (HE, OVC care, VCT) from 90’s; ART in 2005.

• ART clinic Mondays +Thursdays (market days) in OPD

• Many non HIV patients due to available transport

• Turnover of 120 patients against 2 clinicians and 4 dispensers on each clinic day; 20-30 patients are for refills

• Congestion leading to delay in getting refills for HIV(+) clients

Back ground ct’d Flow of patients for refills

Enter Reception Cashier

Drugs in Clinician Exit pharmacy Problem identification

Used systematic steps

1.Brainstorming—Listed 12 problems

2.Multivoting—Reduced the problems to 4

3.Theme selection matrix—problem with greatest impact on customer Theme selection matrix

Theme Customers Impact on Need to Overall customer improve rating

Low utilization of HIV + Clients 4 2 8 family planning by HIV + clients

Clients’ delay in Clients on ARVs 5 4 20 exiting Mutolere and or Septrin ART clinic Low male Partners to HIV + 4 1 5 involvement in HIV/AIDS care females Few babies born Children born to 5 3 15 to HIV + mothers in PMTCT HIV + mothers program are followed up Average time for refills (from baseline study)

AV. TIME FOR REFILLS

120

100

80

60 AV. TIME

40 Av. Av. time(Mins) spent

20

0 REC-CASH CASH-CLIN CLIN-PHARM TOTAL TIME Stations visited Problem statement

• At Mutolere ART clinic that runs on Mondays and Thursdays, HIV (+) clients take on average 105 minutes just to have drug refills (ARVS and/or Cotrimoxazole). This is a long period and it interferes with their other activities, can cause defaulting and creates or worsens stigma owing to prolonged mixing with curious non HIV (+) patients. Project objectives

• Reduction of time for refills by 30% through:- Decreasing number of service points Pre-packing ARVs before clinic days Eliminating need to go to pharmacy • Thus reducing on the distance travelled within the hospital but more importantly eliminating chance of some clients finding dispensing window already congested by other patients Methodology • Sensitization of top hospital management • Sensitization of all staff; then concentrated on QIT • Analysis (Fish-bone method), countermeasures identification plus barrier + aids analysis leading to:-  Assigning triage to a nurse on clinic days  Pre-packing ARVs before the clinic days  Eliminated need to go to pharmacy (created dispensing area for ARVs in clinician’s consultation room)  Altering HIV client flow o Pharmacy in charge reconciles the transactions after a clinic day for accountability

Methodology…. New client flow

.

Enter Reception Cashier

Exit Clinician +Drugs Results

• A 43% reduction in total time required to get refills (from 105 minutes to 59.9 minutes) • A 52% reduction in time from clinician to drugs (from 52.2 minutes to 25.5 minutes) • Triage reduced time from reception to cashier • No moving forth and backward in the hospital • Clients get drugs before fatigue • Staff offer more explanation about the drugs Results ct’d

Graph showing average time between stations before and after intervention

120

100

80 Before 60 After

40 Time (Minutes)

20

0 REC-CAS CAS-CLIN CLIN-DR TOTAL Stations Lessons learnt

• Systematic steps in CQI very beneficial • Countermeasures needed no substantial additional resources • Team work led to success • Involving hospital management enabled change of some policies • Triaging negated need for waiting after registration • Staff sensitisation partly obliterated resistance to change

Challenges experienced

• Some resistance to change (some staff and patients wonder why ‘VIP’ treatment !) • Regular movements to MUSPH for modules • Late receipt of the facilitation from MUSPH • Some QIT staff left us during implementation • Competing priorities due to nature of our jobs • Not yet able to carry out client satisfaction survey Future plans

• Share these results to units in the district offering ART • To share these findings with fellowship office • Continuous monitoring • Management to monitor the impact of new client flow half yearly • Documentation of these achievements-abstracts, manuscripts • Hospital to apply CQI principles in other areas affected by patient delays

Acknowledgements

• Our supervisor for untiring support • MUSPH for considering us to participate • The staff at fellowship office for their co-operation • Management Mutolere hospital for allowing the change project and accepting our regular absence • Staff Mutolere hospital for their co-operation • QA team members Mutolere hospital