A Continuous Quality Improvement Intervention to Improve Antenatal HIV Care Testing in Rural South Africa: Evaluation of Implementation in a Real-World Setting

Background: We evaluated continuous quality improvement (CQI) targeting antenatal HIV care quality in rural South Africa using a stepped-wedge cluster-randomised controlled trial (Management and Optimisation of Nutrition, Antenatal, Reproductive, Child health, MONARCH) and an embedded process evaluation. Here, we present results of the process evaluation examining determinants of CQI practice and ‘normalisation.’ Methods: A team of CQI mentors supported public-sector health workers in seven primary care clinics to (1) identify root causes of poor HIV viral load (VL) monitoring among pregnant women living with HIV and repeat HIV testing among pregnant women not living with HIV, and (2) design and iteratively test their own solutions. We used a mixed methods evaluation with field notes from CQI mentors (‘dose’ and ‘reach’ of CQI, causes of poor HIV care testing rates, implemented change ideas); patient medical records (HIV care testing by clinic and time step); and semi-structured interviews with available health workers. We analysed field notes and semi-structured interviews for determinants of CQI implementation and ‘normalisation’ using Normalisation Process Theory (NPT) and Tailored Implementation of Chronic Diseases (TICD) frameworks. Results: All interviewed health workers found the CQI mentors and methodology helpful for quality improvement. Total administered ‘dose’ was higher than planned but ‘reach’ was limited by resource constraints, particularly staffing shortages. Simple workable improvements to identified root causes were implemented, such as a patient tracking notebook and results filing system. VL monitoring improved over time, but not repeat HIV testing. Besides resource constraints, gaps in knowledge of guidelines, lack of leadership, poor clinical documentation, and data quality gaps reduced CQI implementation fidelity and normalisation. Conclusion: While CQI holds promise, we identified several health system challenges. Priorities for policy makers include improving staffing and strategies to improve clinical documentation. Additional support with implementing clinical guidelines and improving routine data quality are needed. Normalising CQI may be challenging without concurrent health system improvements.

"A continuous quality improvement intervention to improve antenatal HIV care testing in rural South Africa: evaluation of implementation in a real-world setting"

This file includes:
• Additional methods • Semi-structured interview topic guide • Tables S1-S4

Data sources for CQI intervention at clinics
To estimate clinic-level performance on our primary endpoints in real-time, clinic registers containing routine Department of Health (DoH) monitoring and evaluation (M&E) indicators were sourced. Antenatal registers containing information on HIV testing, HIV results and treatment were accessed by the CRH team (CQI mentors) working with health workers at each clinic during improvement activities. Average monthly estimates of women eligible for each endpoint were made and set as targets for achievement. Monthly trends in actual testing were then plotted on run charts against the desired target for each endpoint. Additional data documents were created to implement patient follow-up and document resultsthese included an informal logbook (exercise book) per clinic with one staff member allocated as the main custodian. Data quality was poor with incompleteness and discrepancies between source registers and monthly summaries (summary statistics submitted to the district Facility Information Officer for collation at district, provincial and national level M&E). Poor clinical documentation in patient medical records was also noted. Improvement activities were conducted to resolve routine data quality issues in M&E documents residing at clinics. However, as patient antenatal medical records (MCRs) were not available at clinics until after delivery, real-time improvement activities targeting clinical documentation were difficult to implement. Constraints of the stepped-wedge study design precluded comprehensive efforts at improving data quality as repeated training and supervision were needed.

VL indicator no longer required in DHIS register (March 2016)
Patients leave clinic before VL test can be performed due to queues

Small clinic building
No printer cartridge or toner #

No eMTCT monitoring forms
Computer not working * Clinics are listed in order of randomisation # Lack of printer cartridge or toner at clinics resulted in shortage of monthly tally sheets (for DoH monitoring and evaluation) -tally sheets were therefore supplied by Hlabisa Hospital § Information not available * Clinics are listed in order of randomisation # Lack of printer cartridge or toner at clinics resulted in shortage of monthly tally sheets (for DoH monitoring and evaluation) -tally sheets were therefore supplied by Hlabisa Hospital § Information not available "√": identified as a barrier at that clinic; "-": not a barrier as clinic already had appropriate procedures or staff in place. Barriers listed were those identified during situational analysis of each clinic (during two-week lead-in to Intervention step). ANC, antenatal care; DHIS, District Health Information System; eMTCT, elimination of mother-to-child transmission of HIV; MCR, maternity case record. * "Gross" staffing shortages at clinic 3a; delays implementing PDSA likely due to unavailability of operational manager +/-professional nurse to kickstart activities ** "Extreme" staffing shortages were noted at this clinic which was frequently full. The operational manager was on annual leave at the start of the intervention, and the Acting operational manager was often providing clinical services and unable to attend CQI meetings. PDSA dates refer to activities relevant to HIV VL monitoring and/or repeat HIV testing ( Figure 1, Change Ideas). General data quality improvement activities including PDSAs (e.g. checks for consistency between source documents) are not included in this table. PDSA, Plan-Do-Study-Act cycle. • Unreliable estimates of progress towards monthly targets * "Guidelines" referred to here are CQI tools and activities CRH CQI team could only identify eligible patients for both VL and HIV re-testing based on clinic-based documentation (clinic registers) of HIV testing and positive diagnoses, ART initiation and VL monitoring as MCRs are retained by patients until delivery. Discrepancies between data sources were noted in all clinics at the start of CQI: registers vs tally sheets vs monthly summaries. This may have influenced targeted testing rates per month as well as interpretation of progress over time.
Observations described here were documented after the Intensive intervention phase had commenced (after the situational analysis) -some factors persisted after the situational analysis (eg, knowledge gaps in guidelines).