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