FHI - Improving the Quality of TB Services in Senegal

MARCH 2009—"Small changes lead to big results, if you use the right improvement model," says Family Health International's advisor on quality improvement and health systems strengthening, Bruno Bouchet, MD. His words were proved true recently by staff of the USAID-funded TB/HIV care demonstration project in Senegal's Mbao District.

The right model
In this case, the collaborative quality improvement model was the right one. It was used by quality improvement (QI) teams made up of healthcare providers implementing the demonstration project, personnel from the National TB Program, and FHI/Senegal technical specialists.

Each of the Mbao District's 16 health facilities had a QI team, and their work was supported by a district-based quality management team. The teams used the collaborative QI model to identify recurrent problems affecting the quality of TB care in the district, examine possible causes, and suggest system changes that could bring about improvements.

The collaborative QI model encouraged all TB care stakeholders to analyze the TB system, create flowcharts of the care processes, and develop performance indicators that can be plotted on graphs to allow before-and-after comparisons of performance trends when changes are introduced.

Problems identified and small changes made
The QI teams identified a number of areas they thought could be improved by instituting small changes. The country's TB cure rate was stagnating at about 70 percent; about 9 percent of TB patients were lost to follow-up annually; only 47 percent of TB suspects received within 48 hours the three sputum-smear exams required by Senegal for TB diagnosis; and less than 1 percent of new TB patients were tested for HIV annually.

In July 2008, the QI team implemented some relatively small changes that they thought might bring about needed improvements. These included extension of lab hours for sputum-smear exams, and the addition of a lab technician to both examine sputum smears and accompany patients who receive their third positive sputum-smear result to the treatment center across the compound. Healthcare providers now insist that TB patients return the day after their first sputum-smear exam to complete their second and third exams.

The rate of loss to follow-up for patients is now measured monthly instead of quarterly to speed up the district response, and telephone calls are made from TB treatment centers to follow up on patients.

To increase testing for HIV among new TB patients, healthcare providers have integrated HIV counseling into their services for these patients, and decentralized posts (or rural health clinics) are now using rapid HIV tests.

Reviewing results
Only five months after the changes were made, the TB cure rate in the district went up from 70 to 87 percent. The number of patients lost to follow-up went down to zero; the percentage of TB suspects who received three sputum-smear exams within 48 hours increased from 47 percent to 80 percent; 89 percent of TB patients were put on treatment immediately after timely lab exams and diagnosis; and 85 percent of newly diagnosed TB patients were tested for HIV.

These results were reported in a study of the impact of the changes by FHI/Senegal Country Director Barbara Sow and Senior Technical Officer for TB Abdoulaye Ly, MD.

The study also noted some changes that did not produce improvements: community health workers did not improve their detection of chronic coughers and patients' adherence to treatment did not increase significantly.

The report noted that lessons learned in Mbao are consistent with those of similar QI projects:

The performance of health workers is positively affected by self-assessments of quality against explicit processes of care.
The use of an explicit QI model boosts the performance of traditional public health programs.
Small changes can have a significant impact on service quality and health systems.

The results of this pilot quality improvement activity are very encouraging. The National TB Control Program asked FHI to replicate the changes and the collaborative QI model in other districts, with Mbao playing a leading role. FHI is working to scale up its TB improvement project to two other districts and has hired an additional staff person to work on quality improvement. Senegal's National AIDS Program also took note of the study, and requested that the QI model be used to improve voluntary counseling and HIV testing in two districts.

PHOTO: A nurse in the Mbao health center lab prepares for sputum smear exams. (FHI/Senegal)