Over the course of project year three, LIFT is introducing the quality improvement (QI) process to referral sites. The purpose of QI is to ensure things that should happen actually do happen, and is reflected in the often used slogan “what gets measured gets done”. In LIFT’s referral work, the application of QI concepts is fairly easy to understand. We seek to link vulnerable clients and their households to non-health services in order to improve health outcomes, especially through linkage to and retention in HIV care and treatment. When you start to explore the mechanics of this referral work, you find that there are a large number of complex steps—and each must be in place for referrals to succeed.
Imagine a simple process that you undertake each day—for example, making a cup of tea.
You don’t need to think about it, but in order to accomplish the task you need materials (a cup, a teapot, tea, etc.), some special equipment (a kettle to boil water), and you need a reason to do it (you want tea). Most importantly, you need to understand the process required to make a good cup. This is a simple one-person job and can be done in a few minutes. It’s also easy because it is a culturally familiar process and we learn how to do it as children, but even this seemingly simple process had a number of considerations behind it.
Referral work is even more complex. The materials (referral forms, registers, and so on) are complex and require in-depth training. The special equipment, for LIFT, includes access to Microsoft Excel and mHealth apps to collect data. The people involved are numerous and diverse, including Ministry of Health staff, local and international NGOs and FBOs, community health workers, and others—and all must come together to understand why referrals matter before LIFT can support the launch of a referral system. LIFT’s multi-sectoral approach makes our QI work different from many QI initiatives which focus exclusively on health systems.
In order to make this process easier to implement, LIFT is using standard QI methods, including:
- Developing QI Aims. These are statements that specify a start time and an end time for the QI work and a specific, measureable change that will be tracked each month. For example, all LIFT sites include a QI aim to measure the percent of PLHIV who complete a referral. This QI aim ranges from 0% (i.e., nobody completes their referral) to 100% (i.e., all complete their referrals), and over the course of the QI initiative should move closer and closer to 100%. A good test of a QI aim’s utility is how easily it can be expressed as numerator and denominator, which clearly shows where data are coming from. This example QI aim has the numerator number of PLHIV completing their referral in a given month divided by the denominator number of PLHIV referred in a given month.
- Documenting Change Packages. These are the specific sticking points that, in the opinion of stakeholders involved in referral work, prevent a given QI aim from being realized. Staff engaged in referral work should take care to incorporate these ideas into their normal work process and record how well that works. In our example QI aim, change ideas include: 1) Follow up with incomplete referrals for PLHIV, 2) Create awareness amongst all health facility staff about the referral system, and 3) Maintain client confidentiality so clients feel comfortable and not stigmatized.
- Holding Quarterly Collaborative Meetings. Referral work occurs on a day-to-day basis, but it is important to bring all stakeholders together at regular intervals (in this case, every quarter) to share data and discuss progress towards QI aims. The data shared included detailed reports of the aims, especially time series charts that display progress towards a given QI aim. Stakeholders need to see data, but they also need an opportunity to discuss the QI aims, what successes they observed in their own work, and what challenges they faced. The collaborative meeting should help consensus emerge about the most important process improvements needed for success. This learning is essential to maintain quality at high levels and forms the foundation of spread or scale initiatives.
- Using the PDSA Cycle. PDSA stands for Plan, Do, Study, and Act. This cycle recognizes that QI work is cyclical and takes time. The first step is to plan, which involves creation of QI aims, QI teams, change packages, etc. at an initial stakeholder meeting. The second step is to do the work. In LIFT’s case, this means continuing with referral implementation and collecting data about how the process unfolds on the ground. The third step is to study the data at subsequent quarterly collaborative meetings. Stakeholders should look at data and discuss why they see improvements happening, and if they do not see improvements, what additional changes are needed to produce a change? Finally the fourth step is to act on the learning gleaned from the previous steps and adapt, adopt or abandon changes.