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