SHORTENING TIME A CLIENT WHO HAS COME FOR DRUG REFILLS (ARVS AND/OR COTRIMOXAZOLE) TAKES TO EXIT MUTOLERE ART CLINIC. BY: JEROME ROY MUGISHA AND PASCHAL NSEKUYE (ST.FRANCIS MUTOLERE HOSPITAL). SUPEVISOR: DR. ELIZEUS RUTEBEMBERWA MUSPH/CDC DISSEMINATION WORKSHOP Hotel Africana 14th August 2009. Introduction and background • General hospital + specialization; in Kisoro district • PNFP, belongs to Kabale 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 .