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Use of Quality Improvement Tools to Improve Management, Scope, and Equity of Routine Immunization Services in Uganda

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The Stronger Systems for Routine Immunization in Uganda (SS4RI) project works closely with district health teams to add quality improvement concepts and tools to the standard RED management approach to create Reaching Every Community using Quality Improvement (REC-QI). REC-QI is a package of mutually reinforcing actions to improve the management, delivery and utilization of immunization services including: micro-planning, quality work improvement teams, better data use, supportive mentorship and quarterly review meetings. Uganda’s MOH has adopted the REC-QI approach for nationwide use and has requested that it be adapted to serve planning needs for other health interventions.

This poster was presented at the Institute for Healthcare Improvement Africa (IHI) Forum on Quality and Safety in Healthcare in Durban, South Africa February 19-21, 2018.

Published in: Health & Medicine
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Use of Quality Improvement Tools to Improve Management, Scope, and Equity of Routine Immunization Services in Uganda

  1. 1. Use of Quality ImprovementTools to Improve Management, Scope, and Equity of Routine Immunization Services in Uganda Background Globally, childhood immunization coverage, as estimated by a third dose of pentavalent vaccine (DTP3) has remained at approximately 85% since 2010 while in Uganda it has stayed at 78% since 2012 – below the global target of 90%. Novel approaches have been needed to strengthen local immunization management capacity to address obstacles to improved performance. Aim Strengthen the management and performance of routine immunization services in 800 health facilities across 26 districts in Uganda over the course of 24 months. Results Several measures are used to assess the effect of REC-QI on local immunization management, including: proportion of health facilities with current micro-plans, communities identified and reached with immunization services, number of vaccination sessions and number and percent of planned sessions actually conducted, vaccine stockouts, and immunization coverage. In three SS4RI districts where REC-QI has been fully introduced, the percent of facilities with micro-plans increased from 7% to 63%. The microplanning process is vital to both identifying communities and providing them with services. Data discrepancies have decreased and the completeness and accuracy of recording vaccine doses in child registers, a key tool used by health workers and community volunteers to trace vaccine-eligible children, has steadily improved. Lessons Learned • The introduction of REC-QI to strengthen immuni- zation management, particularly the addition of QI processes to micro-planning, has improved equity by identifying previously unreached communities and extending vaccination services to them. • PDSA cycles have been appreciated by health workers as a means of breaking large problems into smaller components and testing locally-generated solutions; however, health workers' limited docu- mentation of changes impedes the ability to quanti- fy their effectiveness. • It is difficult to gauge the direct effect of REC-QI on immunization coverage because: (a) its processes to improve data accuracy may result in a reduction in the reported numbers of vaccine doses adminis- tered; (b) immunization coverage is affected by other system inputs (e.g., vaccines, refrigerators) beyond REC-QI’s scope; and (c) the combination of quality improvement, capacity building, and immuni- zation system strengthening is intended to bring about lasting improvements rather than immediate, short-term gains in coverage. Uganda’s MOH has adopted the REC-QI approach to micro-planning for nationwide use and has requested that it be adapted to serve planning needs for other health interventions. Project Design: Reaching Every Community using Quality Improvement (REC-QI) With support from the Bill & Melinda Gates Foundation through the Stronger Systems for Routine Immunization (SS4RI) project and USAID’s Maternal and Child Survival Program (MCSP), John Snow Inc. (JSI) works closely with staff from the Ministry of Health (MOH)/Uganda National Expanded Programme on Immunisation (UNEPI) and district health teams to add quality im- provement concepts and tools to the standard Reaching Every District/Community management approach to create the Reaching Every Community using Quality Improvement (REC-QI) approach. SUPPORTIVE SUPERVISION AND ON-SITE MENTORSHIP to reinforce health worker practices. QUARTERLY REVIEW MEETINGS (QRMs). These are held with health personnel and local non-health stakeholders to review performance and “think outside the box” to problem-solve, mobilize local resources, and flag problems needing national level attention. REC-QI was developed within the context of Uganda’s health system and later refined to further support its scalability and sustainability. For example: • The supportive supervision checklist was condensed to fit within the health system’s available resources • QWITs, originally comprised of health workers, were expanded to engage communities in problem-solving, thereby promoting long-term sustainability • Annual data quality self-assessments were modified to become a daily exercise that regularly focuses atten- tion on data quality. The REC-QI approach has been introduced in approxi- mately 800 facilities with support from five district techni- cal officers and three national level technical staff who work closely with district MOH personnel. REC-QI DATAANALYSIS&USE SUPPORTIVESUPERVISION COMMUNITYQWITs QRM&MONTHLYMEETINGS MICRO - PLANS REC-QI is a package of mutually reinforcing actions to build health personnel capacity to improve the manage- ment, delivery, and utilization of immunization services. Its components include: MICRO-PLANNING. Although UNEPI has long required health facilities to prepare micro-plans, few facilities actually had them. REC-QI supported facilities to develop micro-plans, enhancing their utility by adding: • participatory community mapping to identify catchment populations • root cause and fishbone analyses to analyze problems • Pareto analysis to prioritize problems • Plan Do Study Act (PDSA) cycles to test solutions developed with community input. QUALITY WORK IMPROVEMENTTEAMS (QWITs) comprised of health workers and community members. They jointly conduct PDSA cycles, trace de- faulters, and seek community input on location and time of vaccination outreach sessions. DATA USE. This includes root cause and fishbone analysis, routine data self-assessment and improvement, and monitoring of coverage and drop-out. www.jsi.com/immunization Gerald Ssekitto, Rebecca Fields, Possy Mugyenyi, Milly Namaalwa | JSI 1,600 1,200 800 1,400 1,000 600 400 200 Villages Identified Villages Reached 0 Jun 16Baseline (Mar 16) Oct 16 May 17 Oct 17 FIGURE 1: INCREASE IN NUMBERS OFVILLAGES IDENTIFIED AND REACHED WITH IMMUNIZATION SERVICES INTHREE SS4RI DISTRICTS Jun 16Baseline (Mar 16) Oct 16 May 17 Oct 17 20% 60% 40% 0% 100% 80% FIGURE 2: INCREASE IN PROPORTION OF HEALTH FACILITIES WITH AVAILABLE MICRO-PLANS INTHREE SS4RI DISTRICTS 7% 23% 75% 57% 63% Jun 16Baseline (Oct 15) Oct 16 May 17 Oct 17 20% 60% 40% 0% 100% %Difference 80% FIGURE 3: DECREASE IN PROPORTION OF FACILITIES REPORTING DISCREPANCIES IN IMMUNIZATION DATA BETWEENTWO SOURCES 61% 57% 37% 37% 32%

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