S2S eMTCT Change Package_cgoosen_9Dec2015 (003)

SOUTH TO SOUTH
eMTCT QUALITY IMPROVEMENT
COLLABORATIVE
CHANGE PACKAGE
2015

SOUTH TO SOUTH EMTCT QUALITY IMPROVEMENT COLLABORATIVE CHANGE PACKAGE, 2015 3
Table of Contents
ACKNOWLEDGEMENTS ................................................................................................................................................................................................................. 5
SOUTH TO SOUTH TEAM............................................................................................................................................................................................................... 6
ACRONYMS............................................................................................................................................................................................................................... 7
LIST OF TABLES........................................................................................................................................................................................................................... 8
LIST OF FIGURES.......................................................................................................................................................................................................................... 9
SECTION 1: INTRODUCTION.......................................................................................................................................................................................................11
1.1. PURPOSE......................................................................................................................................................................................................................11
1.2. HOW TO USE THE DOCUMENT ............................................................................................................................................................................................11
1.3. BACKGROUND................................................................................................................................................................................................................12
1.4. HOW CHANGEIDEAS WERE CREATED....................................................................................................................................................................................14
SECTION 2: CHANGE IDEAS........................................................................................................................................................................................................20
2.1 EARLY ANTENATAL BOOKING BEFORE 20 WEEKS GESTATION........................................................................................................................................................20
2.2 HIV RE-TESTING DURING ANTENATAL CARE............................................................................................................................................................................25
2.3 ARTINITIATION IN PREGNANCY..........................................................................................................................................................................................31
2.4 MOTHER POSTNATAL VISIT WITHIN SIX DAYS ..........................................................................................................................................................................33
2.5 EXCLUSIVE BREASTFEEDING RATES AT THIRD DOSE HEP B...........................................................................................................................................................38
2.6 INFANT 18-MONTH RAPID HIV TESTING COVERAGE .................................................................................................................................................................45
2.7 COUPLE YEAR PROTECTION RATE.........................................................................................................................................................................................49
2.8 HEALTH PROMOTION.......................................................................................................................................................................................................51

SECTION 3: RECOMMENDATIONS..............................................................................................................................................................................................54
3.1 LEADERSHIP INVOLVEMENT................................................................................................................................................................................................55
3.2 FORMING A TEAM...........................................................................................................................................................................................................55
3.3 IDENTIFYING QICHAMPIONS..............................................................................................................................................................................................56
3.4 REGULAR MEETINGS........................................................................................................................................................................................................56
3.5 DATA...........................................................................................................................................................................................................................57
3.6 QI COACHING ................................................................................................................................................................................................................58
3.7 TRAINING .....................................................................................................................................................................................................................58
3.8 USE OF QI TOOLS............................................................................................................................................................................................................59
3.8.1 Processmapping……………………………………………………………………………………………………………………………………………………………………………………………………….55
3.8.2 Cause and effectdiagrams…………………………………………………………………………………………………………………………………………………………………………………………57
3.8.3 Askwhyfive times - The 'five whys'……………………………………………………………………………………………………………………………………………………………………………59
3.9 COMMUNITY INVOLVEMENT..............................................................................................................................................................................................64
3.10 PRIORITIZATION..............................................................................................................................................................................................................64
3.11 FAILURE IS PART OF THE PROCESS ........................................................................................................................................................................................64
3.12 SUSTAINABILITY..............................................................................................................................................................................................................65
CONCLUSION............................................................................................................................................................................................................................67
REFERENCES.............................................................................................................................................................................................................................68
ANNEXURES .............................................................................................................................................................................................................................69

Acknowledgements
South to South gratefully acknowledges the Department of Health; Amathole district, Cape Winelands district, Pixley ka Seme, and sub-district management that
facilitated our entry into the Mnquma, Breedevalley, Langeberg, Witzenberg, Emthanjeni, Renosterberg, Thembelihle and Siyancuma sub-districts. We would also
like to thankthem for theiron-goingsupportandgenerosityinsharingtheirtime,effective practices,aswell astheirexperienceswithus.We dulyappreciate their
willingness and acceptance to participate in the Quality Improvement eMTCT Collaborative.
Sincere appreciationisofferedtothe facilityoperational managersandQIteammembersof the followingfacilities:Bergsig PHC,Annie BrownClinic,Prince Alfred’s
HamletClinic,Nduli Clinic,WolseleyClinic,Opdie bergClinic,TulbaghClinic,BellaVistaClinic,Breede RiverClinic,CeresHospital,NkqubelaClinic,McGregorClinic,
Cogmanskloof Clinic, Zolani Clinic, Montagu CHC, Happy Valley Clinic, Robertson Hospital, Montagu Hospital, De Doorns CHC, Empilisweni CHC, Orchard Clinic,
Rawsonville Clinic,SandhillsClinic,TouwsRiverClinic,WorcesterCHC,WorcesterDistrictHospital,De AarTownclinic,De Aarclinic,K.E.Twani Clinic,MontanaClinic,
Masibambane Clinic,PetrusvilleClinic,Keurtjieskloof Clinic,HopetownClinic,HopetownCHC,DouglasCHC,GriekwastadCHC,L.AdamsClinic,BreipaalClinic,Campbell
Clinic,ButterworthGatewayClinic,CLBikitshaClinic, Hebe Hebe Clinic,HighviewClinic,IbikaClinic,KotanaClinic,Macibe Clinic,MnyibasheClinic,Ndabakazi Clinic,
Nqamakwe CHC, Nozuko Clinic, Ntseshe Clinic, Tutura Clinic, management and maternity staff at Butterworth Hospital; and non-supported clinics.
We would also like to speciallyacknowledge Maureen Tshabalala, Sarah Olver and Cathy Green from Institute for Healthcare Improvement (IHI) for the strong
partnership.
We acknowledge our partners; ANOVA, Beyond Zero, Aurum Institute and Health Systems Trust.
Last but not least, a big thank to all South to South technical advisors and managers who were involved in the past eMTCT Quality Improvement Collaborative;
Katherine Brittin, Puni Mamdoo, Samantha Hanslo, Maxime Molisho and Bola Oyebanji.
Thisprojectwasmade possible throughfundingprovidedbythe UnitedStatesAgencyfor International Development(USAID),underthe President’sEmergencyPlan
for AIDS Relief (PEPFAR).

South to South Team
eMTCT qualityimprovementadvisors CarolinDiergaardt
DorothyWilliams
Gina Bernhardt
ChristalienHüsselmann
Olatunji Adetokunboh
IMCI advisors Madoda Sitshange
NombuleloMatshikwe
Doranne McDonald
JustinEngelbrecht
Strategic Information NajuwaArendse
CarmenLouw
AshleyNiekerk
Lee AnnHuman
RoshinEssop
MbuleloMshudulu
Learning Support Charlene Goosen
Justine Geiger
Michael Jackson
Operations YumnahWickstrom
BerniaDrake
Jeannie Saffier
AshtrolithaRudolph
Ellende Wet
Management Ilesanmi OOluwatimilehin
Carindu Toit
Beryl Green
Admire Chirowodza
NtiyisoShingwenyana

Acronyms
AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal Care
AP Action Period
ART Antiretroviral Therapy
BANC Basic Antenatal Care
BF Breastfeeding
CARMMA Campaign on Accelerated Reduction of Maternal
and Child Mortality in Africa
CD4 T-lymphocyte cell bearing CD4 receptor
CHWs Community Health Workers
CPT Cotrimoxazole Preventative Therapy
DHIS District Health Information System
DTAP-IPV/Hib Diphtheria, Tetanus, acellular Pertussis,
Inactivated Polio Vaccine, Hib (Haemophilus
influenza type b)
EBF Exclusive Breastfeeding
EC Eastern Cape
EDD Expected Dateof Delivery
eMTCT Elimination of Mother-to-Child Transmission of
HIV
HCT HIVCounselling and Testing
HCWs HealthcareWorkers
Hep B Hepatitis B
HIV Human Immunodeficiency Virus
IEC Information, education and communication
IHI Institute for HealthcareImprovement
IM Information Management
IYCF Infant and Young Child Feeding
LS Learning Session
MDG Millennium Development Goals
MNCWH Maternal, Neonatal, Child and Women’s Health
MSM Men who have Sex with Men
MTCT Mother-to-child Transmission of HIV
NC Northern Cape
NDoH National Department of Health
NIDS National Indicator Dataset
NVP Nevirapine
PHC Primary HealthCare
PMTCT Prevention of Mother-to-Child Transmission of
HIV
PN Professional Nurse
PNC Postnatal Care
QI Quality Improvement
QIC Quality Improvement Collaborative
S2S South to South
SAG South African Government
SD Sub-district
STIs Sexually Transmitted Infections
TB Tuberculosis
WBOTs Ward-based Outreach Teams
WC Western Cape
WHO World Health Organisation
sd-NVP Single dose Nevirapine
sd-Truvada Single dose Truvada

List of tables
Table 2.1. Experiences from early booking quality improvement projects .....................................................................................................................................22
Table 2.2. Experiences from antenatal re-testing qualityimprovement projects............................................................................................................................26
Table 2.3. Experiences from antenatal ART initiation quality improvement projects ......................................................................................................................32
Table 2.4. Experiences from mother postnatal visit within six days quality improvement projects..................................................................................................34
Table 2.5. Experiences from exclusive breastfeeding quality improvement projects.......................................................................................................................39
Table 2.6. Experiences from infant 18-month rapid HIV testing improvement projects ..................................................................................................................46
Table 2.7. Experiences from couple year protection rate improvement projects............................................................................................................................50
Table 2.8. Health promotion interventions to support change ideas .............................................................................................................................................53

List of figures
Figure 1.1. South Africanevolution of the PMTCT guidelines........................................................................................................................................................13
Figure 1.2. Five foundation stones of qualityimprovement..........................................................................................................................................................14
Figure 1.3. Diagram of the South to South eMTCT learning collaborative cascade..........................................................................................................................15
Figure 1.4. Model for improvement and PDSA cycle.....................................................................................................................................................................16
Figure 1.5. Map of supported districts.........................................................................................................................................................................................17
Figure 1.6. PMTCT care pathway.................................................................................................................................................................................................19
Figure 2.1. Mnquma sub-district antenatal first visit before 20 weeks rate....................................................................................................................................24
Figure 2.2. Example of process redesign toimprove clientflow forfollow-up antenatal clients ......................................................................................................28
Figure 2.3. SOP designed for re-testing at a community health.....................................................................................................................................................28
Figure 2.4. Pregnancy wheel.......................................................................................................................................................................................................29
Figure 2.5. A sticker with the re-test date was placed on the outside of the Maternity Case Record ...............................................................................................29
Figure 2.6. Mnquma sub-district antenatal client re-test rate (supported sites).............................................................................................................................30
Figure 2.7. South to South PMTCT Desk Reference ......................................................................................................................................................................32
Figure 2.8. Envelope with discharge form and postnatal appointment date...................................................................................................................................36
Figure 2.9. Professional nurse calling health care facility for appointment.....................................................................................................................................36
Figure 2.10. Cape Winelands sub-districts postnatal visit rate (supported sites).............................................................................................................................37
Figure 2.11. Breastfeeding videos shown at clinic level as part of QI coaching meetings.................................................................................................................42
Figure 2.12. On-the-spot latching assistance ...............................................................................................................................................................................42
Figure 2.13. Mnquma sub-district exclusive breastfeeding rate ....................................................................................................................................................43
Figure 2.14. Infant exclusively breastfed at Hep B third dose rate, Breedevalley, Langeberg and Witzenberg..................................................................................44

Figure 2.15. PCR register with the date for 18-month testingindicated in the comments block......................................................................................................48
Figure 2.16. Adapting the PCR/NVP register................................................................................................................................................................................48
Figure 2.17. A professional nurses checking the PCR/NVP register for HIV-exposed infants who are due for 18-months HIV testing.................................................48
Figure 2.18. The monthly tracking on CYPRform designed by one clinic in Mnquma sub-district adopted by a few clinics................................................................52
Figure 2.19. Professional nurses at Macibe clinic explaining to the youth different family planning methods at a consultation.........................................................52
Figure 2.20. Breastfeeding open days at clinics where “on the spot“ latchingwas demonstrated and importance of exclusive breastfeeding promoted ...................54
Figure 2.21. Postersin local languages to raise awareness of the early postnatal visit....................................................................................................................54
Figure 3.1. Example of a run chart ..............................................................................................................................................................................................57
Figure 3.2. Example of a process map .........................................................................................................................................................................................59
Figure 3.3: Example of a cause andeffect diagram.......................................................................................................................................................................61
Figure 3.4. Example of five why’s................................................................................................................................................................................................63

SECTION 1: INTRODUCTION
1.1. Purpose
The change package representsasummary of change ideasand change conceptsfor Eliminationof Mother-to-ChildTransmissionof HIV (eMTCT) during antenatal,
perinatal and postnatal periods. The ideas were developed and tested by QI teams in health facilities, in three districts in three provinces in South Africa; Eastern
Cape (Amathole district),NorthernCape (PixleyKaSeme district) andWesternCape (Cape Winelandsdistrict) fromMarch 2012 toMarch 2015. Thisisa resource for
frontline health workers, managers, and supervisors wishing to improve the quality of Prevention of Mother-to-ChildTransmission of HIV (PMTCT) health care
provision in an effective and standardised way, and to spread all the successful change ideas to other provinces, districts, sub-districts and other organisations.
The ideas and changes tested in this package are backed up by data of the PMTCT indicators extracted from the district health information system (DHIS).
1.2. How to use the document
This guide isa practical tool for frontline healthworkers,managers andsupervisorswhowouldlike toimprove andsustainthe healthoutcomesof the PMTCT care
path way. Facility-level QI teams can adapt and test change ideas and change concepts. These successful changes can be shared with managers for scale-up.

1.3. Background
Despite extensive scale up of HIV and tuberculosis (TB) services,many women and children are not receiving the complete packages of prevention and treatment
servicestheyneed. There isa needtoaddressvarioussectorsof the healthsystemtoensure continuedandsustainedimprovementsinhealthcare.The promotion
of human resources, performance and skills represents a key intervention area to ensure health systems strengthening achieve health policy goals.1,2
The National ActionFrameworkfor‘NoChildBorn withHIV by 2015 and Improvingthe Healthand Wellbeingof Mothers,Partnersand BabiesinSouth Africa’3
was
developedbythe National Departmentof Health(NDoH) Technical WorkingGroupin2012. It providesadirect linkbetweencurrentpolicyandthe implementation
of PMTCT servicesintegratedwithMaternal,Newborn,Child, Women’sHealth(MNCWH) and Nutritionservicesandcreatinglinkages fora multi-sectoral response
in the country with clear targets for the next five years.
The abovementionedActionFrameworkprovidedthe policycontextforthedevelopmentof the SouthtoSouth(S2S)capacitybuildingprogram,whichaimstosupport
implementationof the SouthAfricanGovernment(SAG) policiesandguidelinestoimprovematernalandchildHIV healthoutcomes.Overthe years,theSAGNational
ConsolidatedGuidelineshave beenevolvingtokeeptrackwiththe newscience andemergingevidences(Figure1.1).The integrationof eMTCTservicesintogeneral
MNCWH and nutrition servicesisoutlinedinthe National eMTCTActionFramework,SouthAfrica’sNational StrategicPlanforaCampaignon AcceleratedReduction
of Maternal and Child Mortality in Africa (CARMMA), and the National Strategy for MNCWH and nutrition.
The S2S change package aims to describe changes that facility QI teams tested and which proved successful in improving key PMTCT indicators towards eMTCT.
Change ideascanspreadverticallyfromdistrictstoprovincesandNDoH,andhorizontallyacrossfacilities,sub-districtsanddistricts.The change package isaresource
for staff and managers wishing to improve the quality of PMTCT health care provision.

Figure 1.1. South African evolution of the PMTCT guidelines
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
2001 (pilot) - 2002
Labour
sd NVP (mother & infant)
Modified obstetric
practices
Post-natal
Free infant formula
2008
ANC
VCT
AZT from 28 weeks
HAART if CD4<200
Labour
sd NVP & 3 hourly AZT
(mother)
Post-natal
sd NVP & 7 day AZT
2013
ANC
Option B - FDC
Start HAART at 1st booking
Post-natal
Exclusive breastfeeding
with HAART cover (Sept
2012: no free formula)
Infant NVP for 6 weeks
2010
ANC
PICT
AZT from 14 weeks
HAART if CD4 <350
Labour
sd NVP, TDF + FTC
3-hourly AZT
Post-natal
Infant NVP for 6
weeks/duration
breastfeeding
Early ART - all HIV + infants
2014
ANC
Lifelong ART for all HIV+
pregnant, breastfeeding, 1
year postpartum women
Repeat HIV 3 monthly
during pregnancy and
breastfeeding period
Post-natal
Birth PCR for all high risk
neonates
Extended NVP for 12
weeks, or dual NVP + AZT
for infants of mothers with
inadequate viral
suppression
2015
Post-natal
Birth PCR for all HIV-
exposed neonates
Repeat PCR at 10 weeks
(at 18 weeks for those on
extended 12 weeks NVP)
Rapid HIV test at 18
months

1.4. How change ideas were created
The NDoH definesQuality Improvement(QI)asachievingthe bestpossible resultswithinavailableresources.QIincludesanyactivitiesorprocessesthatare designed
to improve the acceptability,efficiencyandeffectivenessof servicedeliverytoimprove healthoutcomesonan ongoingandcontinuous.5
Itisa methodthat aimsto
improve processes of care and bridge the gap between the written and implemented policy. This method is based on five foundation stones (Figure 1.2).
Figure 1.2. Five foundation stones of quality improvement4

The S2S programme hasadoptedthe InstituteforHealthcare Improvement’s(IHI)QualityImprovementCollaborative (QIC)approachinordertoachieve systemlevel
changes,and bring change withinthe complex SouthAfricanhealthsystem (Figure 1.3).The QIC isa methodfor testingandimplementingevidence-basedchanges
quickly across organisations.5
Figure 1.3. Diagram of the South to South eMTCT learning collaborative cascade

The QIC implementedquarterly learning sessions (LS) as platforms for sharing change ideasfor improvement which have beentested by facility-basedQI teams in
participating facilities over a period of four to five months. In between learning sessions, action periods (APs) took place during which S2S QI advisors provided
monthlyfacilitylevel coachingandQIteamswere encouragedtotestout change ideasusing the Model forImprovement(Figure 1.4).Thissupportincludedtraining
in QI methodology and clinical topics related to PMTCT.
Figure 1.4. Model for improvement and PDSA cycle5
Three questions
Action plan

The eMTCTQIC wasimplementedfromMarch2012 toMarch 2015 across54 facilities:all26facilitiesacross three sub-districtsinCape Winelandsdistrictparticipated;
14 out of 28 facilities in Mnquma sub-district in Amathole district, and 14 out of 19 facilities across four sub-districts in Pixley ka Seme district (Figure 1.5).
Figure 1.5. Map of supported districts
Amathole
Eastern Cape
14 Facilities
Cape Winelands
Western Cape
26 Facilities
Pixley ka Sema
Northern Cape
14 Facilities

The QICwasidentifiedasanideal methodtodevelop,test,anddisseminatethe qualityimprovementinterventionstoachieve integrationof services.The QICfocused
on improving:
1 Early antenatal booking before 20 weeks gestation
2 HIV re-testing during antenatal care
3 ART initiation in pregnancy
4 Mother postnatal visit within six days
5 Exclusive breastfeeding rates at third dose Hep B
6 Infant 18 months rapid HIV testing coverage
7 Couple year protection rate

Keyindicatorsinthe PMTCTCare pathwaywere selectedandchange ideas were testedsystematicallyonasmall scale byusingDHISdata(Figure 1.6) before the idea
was adoptedona large scale.Thiswas to check if the ideaachievedthe intendedoutcome andtotrouble-shootunintendedconsequencesorspecial circumstances.
Change ideasweredevelopedusinganumberof qualityimprovementtools,e.g. fishboneanalysis,fivewhy’sandprocessmapping.Facilitiesmonitoredtheirprogress
by plottingruncharts(line graphsplottedovertime).The change package wascompiledbyharvestingof change ideasduringlearning sessions and coaching visits.
* Infant PCR testing dependson the duration ofNVP prophylaxis
Figure 1.6. PMTCT care pathway

SECTION 2: CHANGE IDEAS
2.1 Early antenatal booking before 20 weeks gestation
2.1.1 Background
The firstvisit(alsoknownas’booking’) forantenatal care isthe entrypointintothe PMTCT cascade of care. Early bookingisessential toimprove maternalandchild
healthoutcomes as it allowsforpropermonitoringof pregnancy,earlydetectionof HIV and providesopportunitiesforHIV re-testinglaterinpregnancyfor women
who previously tested HIV-negative.
Nationally, early booking is defined as the first antenatal visit before 20 weeks gestation. However, there is recognition of the importance of booking for antenatal
care as soon as the pregnancy is discovered.
2.1.2 Problem statement and aim
Late bookingfor antenatal care was identifiedatNDoH-facilitatedworkshopsin2011 as an importantbarrier towards reachingeMTCT goalsand was prioritisedas
one of six implementation focus areas in the eMTCT Action Framework.3
We aimedtoachieve the national targetof 60% (2012 to 2015) froma baseline of:
 34% forMnquma Sub-district

2.1.3 Indicator monitored: Antenatal first visit before 20 weeks rate
Reference: DistrictHealth Information System Database.National Department of Health
•The proportionof womenwhohave a bookingvisit(firstvisit) beforetheyare 20 weeksintotheirpregnancy.Definition
•Antenatal firstvisitbefore 20weeksNumerator
•Antenatal firstvisittotalDenominator

2.1.4 Change ideas
Table 2.1 summarises the experiences from the early booking quality improvement projects.
Table 2.1. Experiences from early booking quality improvement projects
Change concepts Change ideas How the change was implemented
1. Improvedquality of ANC
servicesat the facility
Early detectionof pregnancy
Pregnancyscreeningat
facilitywithimmediate
booking
A urine testwasofferedtothose withsymptomsof pregnancy.
Pregnancyscreeningwasdone inthe triage room.
Positive urinepregnancytestclient,wasescortedbylaycounselloror professional nurse forHCT
and Antenatal booking.
2. Reduce waiting time for
antenatal bookingvisits
Fast-lane forantenatal
clients
Administrative clerkidentifyall womenattendingthe clinicforpregnancytesting.
3. Integrating ANCinto
community outreaches
Pregnancyscreeningdone by
CHW’s usinga screeningtool
designedbyDOH.
CHW’s use a pregnancyscreeningchecklisttoidentifywomenthatmightbe pregnant.
Urine testingforpregnancyperformedbyCHW’s,if clientispositiveforpregnancy,theyare
referredforearlybookingatthe nearestPHC.
4. Increase awareness of
the importance ANC
early bookingat clinic
and community level
Use of standardisedscripted
healthtalks.
The standardisedscriptedhealthtalk byCHWsduringhome visits included:symptomsof
pregnancy,benefitsof earlybooking,disadvantagesof notbookingearly,andwhere toaccess
servicesif pregnancyissuspected (Annexure 1).
Healthserviceswere promotedatschools toput the focuson teens whichincludedfamily
planningandantenatal services due tothe increase inteenage pregnancyrate.
A healthtalkregisterwasstartedwhichcouldbe updatedona dailyandweeklybasisforhealth
topicscovered.
Usingthe local radiostationto talkaboutimportance of earlybooking.

5. Empower the
community to demand
and own safe
motherhoodservicesin
the healthfacilitiesto
improve their health
Regularcommunitydialogue
meetingswithcommunity
forumsand other
communitygroups
Clinicstaff representedthe healthservicesatlocal meetingsona quarterlybasis,presentingthe
importance of earlybooking andotherhealthrelatedtopics.

The aim at Mnquma sub-district was to improve the Antenatal first visit before 20 weeks rate from baseline median of 34% (Jul 2012 to Jun 2013) to achieve the
national target of 60% in supported facilities by March 2014. Early booking rates increased over time in this sub-district and the target of 60% was successively
achieved from November 2014 (Figure 2.1).
Figure 2.1. Mnquma sub-district antenatal first visit before 20 weeks rate

2.2 HIV re-testing during antenatal care
2.2.1 Background
In2008, the PMTCTpolicyrecognisedtheimportance ofkeepingHIV-negativewomennegative,especiallypregnantwomen.Inadditiontoriskreduction,HIV-negative
womenwere offeredarepeatHIV testat or around34 weekstodetectlate sero-conversion.Thiswasredefinedasa 32-weekHIV re-testinthe 2010 PMTCT policy,
as this coincided with the 32-week basic antenatal care (BANC) visit. From April 2013, the policy was amended to include three-monthly HIV re-testing during
breastfeeding.
There were lowratesof antenatal retesting.We aimedtoachieve the nationaltargetof 70% for ANC re-testrate froma baseline of:
 52% forsub-district(EC)
 54% forsub-district(NC)
 50% forsub-district(WC)
2.2.3 Indicator monitored: Antenatal client HIV retest rate
•Antenatal clientsretestedforHIV asa proportionof antenatal clientstestednegativeforfirstHIV testdone duringcurrentpregnancy.Definition
•Antenatal clientHIV retestNumerator
•Antenatal clientHIV firsttestnegative (Antenatal clientsHIV firsttestMINUSAntenatal clientHIV firsttestpositive)Proxy Denominator

2.2.4 Change ideas
Table 2.2 summarisesthe experiencesfromHIV re-testingQIprojects.
Table 2.2. Experiences from antenatal re-testing quality improvement projects
Change concept Change ideas How the change was implemented
1. Increasingdemand for
antenatal HIV re-testing
Renewedfocusbyclinicstaff on
informingandcounsellingclients
regardingantenatal HIV re-testing
At the firstantenatal visit,the professional nurse orlaycounsellorinformedan
HIV-negativeclientof the HIV re-testdate,counselledthe clientonriskreduction
and the importance of remainingHIV-negativeduringpregnancy.
2. Improvedprocess flowfor
followingupantenatal clients
Redesigningthe processflow for
the clientssothat the antenatal re-
testwas done before the antenatal
consultation(Figure2.2)
Workingwithstandardoperating
procedures (SOP)
The nurse measuringthe clients’vital signsalsoscreenedclientstosee whena
re-testisdue andreferredthe clientdirectlytothe counsellorforHIV testing,
before antenatal consultation.
SOP was put inplace for antenatal HIV re-testingproceduresinordertoavoid
confusionwhenstaff rotate throughdifferentdepartments anddue totask
shifting(Figure2.3).
3. Minimise lossofclients
betweendifferentservice
points
Presence of alay counselloratthe
antenatal clinictoensure re-testing
isdone at the antenatal clinic
Lay counsellorsatthe antenatal clinicensuredre-testingwasdone atantenatal
clinicsandtherebyreducedthe lossof clientsbetweenservice points.
4. Task shiftingamong healthcare
providers
Professionalnursesworkingin
antenatal care assumed
responsibilityfordoingHIV testing
at the antenatal service pointto
bringtestingclosertoclients.
Tasks were dividedbetweentwoprofessional nurseswithone involvedwith the
antenatal consultationandanotherone performedthe investigationsandHIV
testing.

5. Remindersystem for re-test
date
The re-testdate iscalculatedwith
use of pregnancywheel (Figure
2.4) and recordedina specified
locationinthe maternitycase
record and/orpatientfolder
The professional nurse doingthe antenatal consultationrecordedthe re-testing
date witha colour-codedstickeronthe front/inside of the maternitycase
record/patientfolder/ANCregister(Figure 2.5).
6. Tracking and tracing clients
requiringantenatal HIV re-test
Trackingof clientswhoare due for
HIV re-testingusingeitherthe
antenatal registerora masterlist
The antenatal registerormasterlistwasreviewedweeklybythe professional
nursesresponsible forantenatal care andclientsthatdidnotreturnfor antenatal
HIV re-testingasscheduledweretracedand contactedeithertelephonicallyor
visitedby communityhealth workers.
7. Improveddata collectionand
reporting
Data capturer clarifiedthe data
elementdefinitionsandthe
appropriate methodof recording
re-testingdata
Ensuringthat the staff memberperformingthe HIV re-tests,oftenalay
counsellorenteredall datainthe HIV testingregister.
A codingsystemwasusedinsome facilities,e.g.“firstbooking”.
The professional nurse wasalso encouragedtomaintainre-testingdatacollected
inthe informationtick registerforre-testing,asisrequiredbythe Departmentof
Health.
Dailytallyingandweeklyvalidationcomparingdatafromdifferentdatasources
was done forantenatal HIV re-testingtoensure dataquality.

Figure 2.2. Example of process redesign to
improve client flow for follow-up antenatal
clients
Figure 2.3. SOP designed for re-testing at a community health
The "old" way
Registration of client
Vital signs (enrolled nurse)
ANC consultation (professional nurse)
HCT (lay counselor or professional
nurse)
Initiation of ART if required
Dischargefromclinic
The "new" way
Registration of client
Vital signs (enrolled nurse)
Clientfor HIV re-test identified
HCT (lay counselor)
ANC consultation (professional nurse)
Initiation of ART if required
Dischargefromclinic
Patient collects file at
reception
Enrolled nurse
•Identifies clients duefor HIV re-
testing
•Refers to PN1 for HCT
Professional nurse 1
•Does HCT
•Records resulton maternity case
record & HCT register as a “re-test”
Professional nurse 2
•Provides BANC
•Checks if re-test was done – if not
yet done, refers clientback to PN1

Figure 2.5. A sticker with the re-test date was placed
on the outside of the Maternity Case Record
Figure 2.4. Pregnancy wheel

Supportedclinicsinthe Mnquma sub-districttestedchange ideastoimprove antenatal clientHIV re-testrate duringthe actionperiodfromJulyto September 2013
(Figure 2.6). Supported facilities improved from a baseline of 41% to reach a median of 66% (October 2014 to March 2015). Improvement was demonstrated from
April 2013 and reached the target of 70% by March 2014.
Figure 2.6. Mnquma sub-district antenatal client re-test rate (supported sites)

2.3 ART initiation in pregnancy
2.3.1 Background
In response tothe global call toeliminatemother-to-childtransmission(May2011) and the call fromthe International AIDSSociety (IAS) tomove tomore efficacious
regimens(2012), SouthAfricatransitionedfromOption A toOptionBstartinginApril 2013, and subsequentlytoOptionB plusinJanuary2015. These policychanges
prioritisedpregnantandbreastfeedingwomenintheroll-outof thefixed-dosecombinationtabletusingasimplifiedtreatmentregimenproventoimproveadherence
and treatment outcomes. Option B plus aligns the PMTCT and ART programmes, thus simplifying management processesnecessary for service deliveryand allows
simplificationof healthmessagingforthe communityandclients.Bydesign,the numberof stepsalongthe PMTCTcascade isreduced,allowingforsame-dayinitiation
of ART.
2.3.2 Indicator monitored: Antenatal client initiated on ART rate
•The proportionof the total numberof ANCclientswhoare HIV positive andnotonART, whoare initiatedonARTwhile
pregnant
Definition
•Antenatal clientinitiatedonARTNumerator
•Antenatal clienteligible forARTDenominator

2.3.3 Change ideas
Table 2.3 summarisesexperiencesfromARTinitiationandretentioninHIV care QI projects.
Table 2.3. Experiences from antenatal ART initiation quality improvement projects
Figure 2.7. South to South PMTCT Desk Reference
Change concept Change idea How the change was implemented
1. Increasingthe number ofHIV
positive ANCclientsinitiatedon
ART
AssistingsupportedsitesinnewART
initiationpolicyroll-out
On-site clinicalmentoringtohealth care workersonthe newpolicy.
User-friendlyPMTCTtoolswere alsodevelopedanddistributed (Figure 2.7).

2.4 Mother postnatal visit within six days
2.4.1 Background
The daysand weeksfollowingchildbirth (thepostnatal period) isacritical phase inthe livesof mothersand newbornbabies.Majorchangesoccur duringthisperiod
which determines the well-being of mothers and newborns, yet this is the most neglected time for the provision of quality services.
Low uptake of postnatal services within six days after delivery. We aimed to achieve the national target of 70% (2012 to 2015) from a baseline of:
 36% for sub-district (WC)
 10% for sub-district (NC)
2.4.3 Indicator monitored: Mother postnatal visit within six days rate
•Numberof mothersthatreceive postnatal care within6daysof deliveryafterdischarge fromplace of deliveryasa proportionof all
deliveriesinfacility
Definition
•Mother postnatal visitwithinsix daysafterdeliveryNumerator
•DeliveryinfacilitytotalDenominator

2.4.4 Change ideas
Table 2.4 summarises the experiences from the postnatal visit within six days QI projects.
Table 2.4. Experiences from mother postnatal visit within six days quality improvement projects
1. Improvedcommunication
betweenbirthingunitand
clinic
Dailyfaxingof birthnotificationsto
clinics
Birthunitclerk/orhealthstaff fax all birthnotificationtothe specificclinics,where
motherwill goforPNC.
Post-natal appointmentdate,and
time bookedatspecificclinicsgiven
to mother(Figure 2.8)
Healthstaff phone clinicsfortomake an appointment(date andtime) forsix-day
follow-upvisitsforbothmotherandinfant before discharge (Figure 2.9).
Some clinicshave adedicated slotformotherstocome to the clinic.
Postnatal motivational leafletgiven
to motherof whyit is importantto
reportwithinsix daystothe clinic
(Annexure2).
On discharge inlabourward,the healthstaff explains,andgivesthe mothera
motivational leafletof whyitisimportanttoreportwithin six daystothe clinic.

2. Strengthenthe linkages
betweencommunityand health
facility
FollowupvisitsbyCHWson a daily
basiswithnamesfromfaxedbirth
notifications
CHW’s receivesall the namesof motherswhodeliveredfromadministration
clerk/lay counsellororanystaff memberwhoare coordinatingthe followupvisits.
CHWs to trace clientsaroundthe
time of expecteddate of delivery
(EDD) and informof six days
postnatal visit
Pregnantmotherswere followedupbycommunitycare workersbefore the date of
delivery.The antenatal registerwasusedto make a colourcodedmonthlylist of the
motherswhowill deliver(fromthe monthlylistthe nameswere putinorderper
weekof whowill deliverfirst).EachCHW wasassignedtovisitthe mothers
accordingto visitarea.Theyvisitedthe motherwhowill deliverfirstwithinthe first
twoweekstodiscussthe importance of six dayspostnatal visit.Afterthe visitthey
will ticktheirnamesfromthe list.Afterwardsthe clinicwouldrequestalistfrom
the deliverysite tolookwhodeliveredandthencompare the listtohowmanyof
those namesonthe listwere visitedandhowmanycame back within6 days.
3. Use support health servicesto
improve postnatal visits
The namesof womenwhowere
takento hospital fordeliverywere
giventothe clinicsforpostnatal
visitschecks.
The EmergencyMedical Services(EMS) personnel made alistof womeninlabour
whowere takento the hospital fordeliveryduringthe course of the week.Thislist
was transferredtothe notice boardinthe clinicand wasusedto checkwhich
womencame back withinsix daysforpostnatal care.
4. Improving the quality of PNC
services
The use of a postnatal checklistto
encourage thorough examination
of motherandinfant(Annexure 3).
S2S technical advisorsadaptedachecklistfromexistingresourcestoprompt
professionalnursestoprovide comprehensive mother-infantconsultationandstaff
was trainedonthisformof the importance of postnatal managementof mother
and child.

Figure 2.9. Professional nurse calling health
care facility for appointment
Figure 2.8. Envelope with discharge form
and postnatal appointment date

20%
30%
40%
50%
60%
70%
80%
90%
Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15
Supported Baseline
Learning SessionMarch2014
From a baseline performance of 43%,supportedfacilitiesstartedshowingimprovements fromApril 2014 to above the national targetof 60% and fluctuatedbelow
target afterwards (Figure 2.10).
Figure 2.10. Cape Winelands sub-districts postnatal visit rate (supported sites)
National Target
Baseline

2.5 Exclusive breastfeeding rates at third dose Hep B
2.5.1 Background
Breastfeedingisanunequalledwayof providingideal foodforthe healthygrowthanddevelopmentof infants;itis alsoanintegral partof the reproductive process
withimportantimplicationsforthe healthof mothers.Reviewof evidence hasshownthat,ona populationbasis,exclusive breastfeeding(EBF) forsix monthsisthe
optimal wayof feedinginfants.Thereafterinfantsshouldreceive complementaryfoodswith continuedbreastfeedinguptotwo yearsof age or beyond.7
In SouthAfrica,infantfeedingpracticesare sub-optimal,withratesof exclusive breastfeedingremaininglow.Althoughearlyinitiationof breastfeedingpost-delivery
is a common practice, mixed feeding rather than exclusive breastfeeding is the norm.
We aimedtoachieve the national target of 40% (2012 to 2015) froma baseline of:
 34% forsub-district(WC)
 18% forsub-district(EC)
 0% for sub-district(NC)
2.5.3 Indicator monitored: Infant exclusively breastfed at Hep B third dose rate
•Baby reported to be exclusively breastfed at Hepatitis B third dose immunisation (preferably 14 weeks after birth)Definition
•InfantexclusivelybreastfedatHepB thirddoseNumerator
•HepB thirddoseDenominator

2.5.4 Change ideas
Table 2.5 summarises the experiences from exclusive breastfeeding QI projects.
Table 2.5. Experiences from exclusive breastfeeding quality improvement projects
1. Supporting exclusive
breastfeedingathealth care
facilities
Use exclusive breastfeedingcheck
lists
Reinforcementwasdone atfacilitiesof existingexclusive breastfeedingchecklists.
Designatedprivate areasfor
breastfeedinginthe labourwards
and clinics
At one of the clinics, adivider(screen) wasusedtocreate a private space for
breastfeedingmothersinthe waitingroomwhere educationalbooklets/pamphlets
were available toreadwhile breastfeeding.
Otherclinicshave a private roomforbreastfeedingsupportgroups.
The consultationtookplace ina private space priorto discharge sothat women,
whoare HIV positive,couldreceive sensitiveinformationandmedicationinprivate
at a deliberate time withanopportunityfordiscussion.
Exclusive breastfeedingbuddy.The motherwouldidentifysomeone influential in
herlife asa ‘buddy’whocouldsupportherwithpracticing exclusivebreastfeeding.
The professional nurse wouldprovide the invitation (Annexure 4),the mother
wouldbringthe buddytothe appointment,andthe professional nurse and
counsellorwouldensure thatEBFcounsellingisprovided.

2. Ensure adequate training of
healthcare staff
Breastfeedingskills development Duringthe action periodforexclusive breastfeedingrate atthirddose Hep3, South
to SouthImprovementadvisorsofferedmodulartrainingsincludingavideoon
breastfeedingtosupportstaff atcliniclevel (Figure 2.11).
Peer-to-Peercoachingandmentorship.Inconsultationwiththe clinicstaff the QI
teamallocatedanexperiencedprofessionalnurse toprovide in-service trainingfor
nurses,whohadnot receivedanytraininginbreastfeeding.
Task shifting.The S2Steamgave trainingto CHW’s,and theywere giventhe
responsibilitytosupportexclusivebreastfeedingforclientsattendingantenatal and
postnatal care.
3. Communicate Breastfeeding
Policywith staff at hospital
level
Helpingmotherstoinitiate
breastfeedingwithinone hour
afterbirth
The districthospital hadno processin place to enable skintoskincare immediately
following an infant’s birth and thus Step 4 of the Ten steps to successful
breastfeeding,“Helpmothersto initiate breastfeedingwithinone hourafterbirth”,
was identified as a suitable point to start.
A sisterwouldgo to the theatre to assistmotherswho had caesareansectionswith
early skin-to-skin contact and breastfeeding initiation.

4. Show mothers how to
breastfeed
On the spotlatching(Figure 2.12) All womenwere providedwithasessiononhandexpressingandEBF ondischarge
fromthe maternal obstetricunits.
On the spotlatchingtechniquesweretaughtwhilemotherswere breastfeedingin
the waitingroomor in the breastfeedingcornerbyhealthstaff.
Supportand assist mothersaboutspecificbreastfeedingskillandensure thatthey
are able todo the following:
 Positionthe infantcorrectlysothatinfantcan latchon the breastwithno
painduringfeeding
 State whenthe infantisswallowingmilk
 Manuallyexpressmilkfrombreasts
The followinginformationisalsogiven:
 The infantshouldreceive eightormore feedingsof breastmilkin24 hours,
and breastfeeduntil satisfied
 Infantmusthave at leastsix wetnappiesin24hours fromday 3 or 4 of life
and runnyor softyellowstools
5. Communitysupport
interventions
Communityhealthworkers
demonstrate handexpressing
technique tomothersathome
Train the trainer- communityhealthworkerswere trainedonhandexpressionof
breastmilkandduringtheirhome visitstosupport exclusive breastfeeding;they
trainedmothersonhandexpressionof breastmilk.
Birthunitsenda listof namesof mothersthat exclusive breastfeed,toCHW’s
coordinatorforfollowupvisits.
6. Improve data collectionfor EBF
at third dose Hep
Extra columnusedforEBF only
Use of tracer cards to record infant
feedingoptions
Weeklyverificationof dataaroundEBF at thirddose Hep,inimmunizationregister.
Clinicsalsousedcurrenttracercards to write inthe commentsblockat six,10 and
14 weekstorecordinfantfeedingoptions.

Figure 2.11. Breastfeeding videos shown at clinic level as part of QI
coaching meetings
Figure 2.12. On-the-spot latching assistance

The aim at Mnquma sub-districtwastoimprove the exclusivebreastfeedingrate fromabaseline medianof 18% toachieve the national targetof 40% (Figure 2.13).
Figure 2.13. Mnquma sub-district exclusive breastfeeding rate

The aim inCape Winelands sub-districtwastoimprove the exclusive breastfeedingrate fromabaseline medianof 34%to achieve the national targetof 40% (Figure
2.14).
Figure 2.14. Infant exclusively breastfed at Hep B third dose rate, Breedevalley, Langeberg and Witzenberg

2.6 Infant 18-month rapid HIV testing coverage
2.6.1 Background
The National ConsolidatedGuidelines (April 2015)8
still recommendsthatall HIV-exposedchildrenwithanegative HIV PCRtest shouldhave a HIV (antibody) testat
18 months of age. It is convenient to do this test at 18 months since it is the same time as the DPT-Hib-IPV4 immunisation visit. Final infection status should be
documented in the Road-to-Health Booklet. Children still breastfeeding at the 18-month visit require a further HIV antibody test six weeks after cessation of
breastfeeding has occurred.
Low infant HIV rapid (antibody) testing uptake around 18 months. We aimed to achieve the national target of 100% from a baseline of:
 87% for sub-district (EC)
 62% for sub-district (NC)
2.6.3 Indicator monitored: Infant rapid HIV test around 18 months uptake rate
•BabiestestedforHIV antibodiesaround18monthsafterbirthas the proportionof babiesbornto HIV-infectedwomen18
monthsago
Definition
•InfantrapidHIV testaround18 monthsNumerator
•Live birthto HIV-positive women(18monthsago)Proxy denominator

2.6.4 Change ideas
Table 2.6 summarisesthe experiences frominfant18-monthrapidHIV testinguptake rate qualityimprovementprojects.
Table 2.6. Experiences from infant 18-month rapid HIV testing improvement projects
1. Use of registersfor clinical care
and follow-up
Flaggingthe date for18-month HIV
testin PCRregister
Whenan infantwasfirstenteredintothe PCRregister,the date fortestingat18
monthswasflaggedbydocumentingthe date in the commentsblock.(Figure 2.15).
Birthcohort use of PCRregister
(Figure 2.16)
QI teamsintroducedthe entryof babiesintothe registeraccordingtobirthcohort
to enable betterfollow-upof babiesandeasytracingof babiesfor18-month HIV
testing.Thiswasdone since all the babiesborninthe same monthwouldreach18
monthsduringthe same period.The registerwasreviewedonamonthlybasis,and
babiesthatdidnot returnfor the 18-monthvisitwere tracedusingthe CHWs from
the ward-basedoutreachteams.
Mother-infantpairregister Priorto the implementationof the PCRregister, S2Sdesignedaregisterforfollow-
up of HIV-exposedmother-infantpairsaccordingtobirthcohort. Thiswas usedin
parallel toroutine reportingtoolsasapilotbyfive clinicswhichworkedatthe child
healthservice point. The tool enabledthe sisterstokeeptrackof the HIV-exposed
babies,toreviewattendanceona monthlybasisandtoinitiate clienttracingusing
(WBOTs) CHWs for those thatdefaultedcare.The registerswere alsousedto
retrospectivelytrace andrecall babieswhowere 18monthsor older.

2. Integrationof services Appointingastaff memberto
checkdifferentservice registers
and complylistof HIV-exposed
infants(Figure 2.17)
The labourward staff checkthe postnatal andantenatal registerof those mothers
whowere HIV positive 18 monthsagoso that the HIV-exposedinfantcanbe traced
more easilydue toall the differentregistersthatare usedforrecording.
A listwasmade of all deliveriesthatoccurredduringa givenweekandsenttothe
childhealthservicessothatthe namesof the HIV-exposedinfantswere written
immediatelyinthe PCR/NVPregister.
Attendingtomother-infantpairas
one
A particularComprehensiveHealthCentre(CHC) wastomove the postnatal service
fromthe labourwardto the childhealthdepartmentsothatthe motherand infant
can be seenasa pair and alsofor betteridentificationof the HIV-exposedinfants.

Figure 2.15. PCR register with the date for 18-month testing
indicated in the comments block
Figure 2.16. Adapting the PCR/NVP register
Figure 2.17. A professional nurses checking the PCR/NVP register
for HIV-exposed infants who are due for 18-months HIV testing

2.7 Couple year protection rate
2.7.1 Background
The provisionof familyplanningservicesthatenableswomenandmenin reproductiveage groupstoachieve theirreproductive healthisessentialtotheirwell-being
ingeneral.Adequateprovision,unhinderedaccessanduse of contraceptive servicesare crucial elementsinachievingHIV preventiongoalsascontraceptionservices
contribute extensively to elimination of mother-to-child transmission of HIV and HIV prevention.
Contraceptive YearProtection(CYP)canbe describedasameasure of likelyprotectionprovidedbycontraceptivemethodsduringagivenyear.CYPallowshealthcare
programme to compare the contraceptive coverage provided by different family planning methods.
There islowadministrationanddistributionof differenttypesof contraceptivemethodsamongwomenof reproductiveage group, leadingtolowcouple year
protectionrate.
We aimedtoachieve the national targetof 62% (2012 to 2015) froma baseline of 28%for Mnqumasub-district.
2.7.3 Indicator measured: Couple year protection rate
•The estimatedprotectionprovidedbyfamilyplanning(FP) servicesduringaone-yearperiod, baseduponthe volume of all
contraceptivessoldordistributedfree of charge toclientsduringthatperiod.
•The rate at whichcouples(specificallywomen)are protectedagainstpregnancyusingmoderncontraceptive methods,
includingsterilisations,asaproportionof the female population15-49years.
Definition
•Contraceptive yeasdispensedNumerator
•Population15-49 yearsfemalesDenominator

2.7.4 Change ideas
Table 2.7 summarisesexperiencesfromcouple yearprotectionrate QIprojectsconductedone of the provincesparticipatinginthe QICollaborative.
Table 2.7. Experiences from couple yearprotection rate improvement projects
1. Integratedof familyplanning
services
Integrationof familyplanning
servicesintootherhealthservices
While inthe consultingroom,male orfemale clientswere askedabouttheirfamily
planningchoice andwhattheywere currentlyusing.
Dual familyplanningmethodse.g.male orfemale condomswere alsoinitiatedand
distributedtoclientswhowere usingoral orinjectable methods.
2. Couple Year ProtectionRate
(CYPR) tracking form
Adoptionof CYPRtrackingform
(Figure 2.18)
CYPR trackingformwas designedtotrackthe CYPRrate per monthsothat theycan
act on lowperformance.
3. Strengtheningofyouth friendly
service
Settingaside specificafternoon in
the weekformale andfemale
youthcan attendthe clinic
In the consultationroomwiththe youth,the professionalnurse explaineddifferent
typesof methods,the side-effectsandimportance of adherence tofamilyplanning.
The nursesalsodemonstratedhowtouse a male and female condomtothe youth
(Figure 2.19).
Healthpromotionthrough
electronicmedia
A professional nurse regularlytookpartonlocal radioprogramme and speakabout
familyplanningandprovidedhercell phone numberoverthe airsothat the
teenagerscancontact herif theywantedtoaccesscontraceptive orotherhealth
services.

4. Dispellingmythsand
misconceptions
Involvementof community
memberstodispel misconceptions
Professionalnursesspoketotraditional healersandhealthcommittee’smembers
aboutdispellingmisconceptionsandmythssurroundingfamilyplanningandon
howthe communitymemberscanbe protectedagainstHIV/AIDS.The traditional
healersandhealthcommittee’smembersthenspreadthe wordaboutthe
abovementionedtopicsattheirmeetingstoraise communityawareness.
5. Availabilityofall contraceptive
methodsin clinic
Promotionof all available
contraceptive methods inthe
clinics
Up-skill professional nursestoprovide client-tailoredcounsellingforvarious
contraceptive methods.
6. Updatingdata statistics Updatingdata to include
Implanon® statisticsintocouple
yearprotectionrate indicator
Withthe roll-outof Implanon®andthe delayinupdating reportingtoolsandDHIS,
facilitieswere instructedtokeepaseparate registerof all contraceptiveimplants
inserted.Usingthese numbers,QIteamstogetherwiththe S2SAdvisorwere able
to manuallyinclude this dataintothe calculationof CYPRforroutine monitoring.

Figure 2.18. The monthly tracking on CYPR form designed by one clinic in Mnquma
sub-district adopted by a few clinics
Figure 2.19. Professional nurses at Macibe clinic explaining to the youth different
family planning methods at a consultation.

2.8 Health promotion
Table 2.8 indicateshealthpromotioninterventionsusedtosupportchange ideas.
Table 2.8. Health promotion interventions to support change ideas
Health promotionawareness Increasedfocus onexclusive
breastfeedingduringthe action
period
Designof Information,EducationandCommunication(IEC) materialstosupportBF
(designof materialsinlocal languages).
Songswrittenandsungin the clinicto supportexclusive breastfeeding.
Each clinicpresentedavideoclipof three minutes,whichtheymade duringtheir
actionperiodof change ideasandtested.
Healtheducationinthe waitingroom/labourwardwithscriptednotes/posters
(Figure 2.20).
A postnatal posterwasdesignedto
informmothersandthe
communityaboutthe importance
of six dayspostnatal followupvisit
Posterswere designedinlocal languagestoraise awarenessof the importance of
the earlypostnatal visitwithinsixdays(Figure 2.21).
Infantpacks forearlypostnatal
clients
Everymotherwhovisitedthe clinicwithinsix dayspostnatal receivedaninfantpack
whichcontainedinfantproducts,e.g.nappies,lotion,babypowder,face cloth.This
servedasmotivationforothers(still togive birth) toalsocome within six days
postnatal.

Figure 2.20. Breastfeeding open days at clinics where “on the spot“ latching was demonstrated and importance of exclusive
breastfeeding promoted
Figure 2.21. Posters in local languages to raise awareness of the early postnatal visit

SECTION 3: RECOMMENDATIONS
Thissectionsharesrecommendations forpromotingqualityimprovementinterventions.
3.1 Leadership Involvement
 Create visionandbuildwill
 Share all possible informationaswidelyaspossible
 Involve those affectedbythe change inplanningandimplementing
 Encourage people toairtheirfeelings/askforadvice
 Explainthe impactof change on individuals,notthe organisation
 Be honestaboutthe benefitsandchallengeschange willbring
 Celebrate milestoneslarge andsmall
3.2 Forming a team
It is important to form an improvement team in the facility or department where you are hoping to bring about improvement.
Once youhave establishedateam,discussthe logistics, includingmutuallyavailablemeetingtimes.Inselectingthe membersforthe QIteamfocusonhealthworkers
that are most key to the process of care.
The team meetingsshouldbe aplace of sharedlearningandunderstanding,where eachparticipantfeelscomfortable contributingtheirthoughtsandfeelingsabout
the best ways to improve. The leader will need to facilitate this atmosphere of openness.

3.3 Identifying QI champions
A facility champion improvement leader should be identified by the QI team to be the main contact person. The facility champion should be able to keep the
momentum, scheduling regular meetings with the team and following up on improvement tasks.
The QI champion organizesanddrivesthe ongoingwork,measurement,andteam.Thispersonneedstoworkeffectivelywiththe executive leadershipandmembers
of the improvementteam.The day-to-dayleaderalsoservesasthe "keycontact"responsible forcoordinatingcommunicationonthe progressona QI projectto the
overall organization, staff, and board of director.
3.4 Regular Meetings
 RegularQI meetings(atleastonce afortnight) withasetagenda
 Focussedonaims
 Identifyingbarrierstoreachingaims
 Creatingor sourcingchange ideas
 PlanningPDSAs
 ReviewingPDSAsand change ideas
 Sharinglearningfromlearningsessionandreviewingdecisionsandplans. Makingchangesasnecessary.
 Testingchange ideasduringactivityperiods
 Workingwithsupportof S2S and sub-districtmanagers
 Continuousmonitoringof data;improve accuracy
 Attendance atlearningsessions
 A moansessionwithoutthe generationof change ideas
 Disconnectedfrompreviousmeetings

3.5 Data
Run charts are graphs of data overtime andare one of the mostimportanttoolsforassessingthe effectivenessof change (Figure 3.1).Ithelpsto, studythe
performance of a process,identifytrendsovertime,andmeasure the change inperformance followingachange inprocess.
Run charts have a varietyof benefits:
 Theyhelpimprovementteamsformulate aimsbydepictinghowwell(or poorly) aprocessisperforming
 Theyhelpindeterminingwhenchangesare trulyimprovementsbydisplayingapatternof data that you can observe asyoumake changes
 Theygive directionasyouworkon improvementandinformationaboutthe value of particularchanges
Figure 3.1. Example of a run chart

3.6 QI coaching
QI coaching is provided to health facilities by an external facilitator or coach with the goal of building internal capacity for QI activities.The QI coach supports the
healthfacilityinidentifying andachievingitsimprovementgoals,bytraininginhowtouse data,helpingdevelopQIskillsamongstaff,andsharingtools andresources.
3.7 Training
Continuous traininginQImethodologyatdistrict,sub-districtandfacilitylevelwillensurethatall healthworkerslearnanddevelopskillsinQI,andwill be abletoput
it into practice to deliver effective patient care. The improvement skills developed through training will teach healthworkers the tools and techniques to improve
processes and lay a foundation for sustaining quality improvement projects.

3.8 Use of QI tools
3.8.1 Process mapping
A useful wayof understandinghowaprocessworks,isto use “processmapping”.A processmap can alsobe calledaflowdiagram(Figure 3.2).
Figure 3.2. Example of a process map

Steps in process mapping
 Consideraprocessinyour systemyouwishtoanalyse basedon an auditor assessmentprocess
 Gather togetherrepresentativesof all stakeholdersinvolvedinthe process
 Make sure to look at the current processand not the ideal process
 On individual post-itnotes(orpiecesof paper),write downeachmajorstepinthe processfromstart to end(one note perstep)
 Identifywhodoeswhattaskineachstepand listitbelowthe majorsteps
 Arrange stepsinorder
 Focuson the way thingsworkmostof the time i.e.the currentsituation
 Analyse the stepsinthe process
 Askthe followingquestions:
o Can any stepsbe eliminated?
o Can the processbe done insome otherway?
o Can itbe done ina differentorder?
o Can itbe done somewhereelse?
o Can itbe done inconjunctionwithanotherprocess?
o Can any bottlenecks(placeswhere peoplewait) be removed?

3.8.2 Cause and effect diagrams
Thisdiagramisalsocalleda“fishbone”oraroot cause analysis.Itisavisual displaythathelpstoexplorepossible causesof acertaineffect (Figure 3.3).Itcanbe used
to identify potential changes that can be tested during the quality improvement project.
Figure 3.3: Example of a cause and effect diagram

Steps in creating a fishbone
 Write the effect(the problem)inthe box onthe right handside of the page (headof the fish)
 In the otherblocks,write downthe majorcausesof the problemyouwantto address(calledthe fishbones)
 Generate a listof eachcause foreach category(branchbones)
 Developthe causesbyasking“why”until youhave reachedauseful levelof detail
 Use your“fishbone”tochoose the topthree root causesthat youhave an opportunitytoinfluence andthathave a bigimpacton the problem
 Brainstormideastoaddressthese top3 causes
 Whichof these ideascanyoutest?
 Selectone topideato developaplan

3.8.3 Ask why five times – The ‘five whys’
In contrast to the fishbone,whichisusedto gather all possible causesfora problem,‘ask-why-five-times’(orthe ‘five whys’) isatechnique forprobingdeeperinto
the causal chain. The technique triestoidentifythe rootcause more rigorously,whichissometimesdifferenttothe initial,assumedcause. Figure 3.4 illustratesan
example of the five whys.
Figure 3.4. Example of five why’s3

3.9 Community Involvement
Community healthcare workers can play a crucial role in identification of ill health, as well as spreading messages throughexisting formal and informal structures,
such as community organizations, religious groups and social gatherings. They can also strengthen the linkages between health facilities and the community.
3.10 Prioritization
Areasfor improvementcanbe identifiedbyroutinelyandsystematicallyassessingqualityof care in the care path way of the patient.QIprojectsmay be identified
from baseline assessments, customer satisfaction surveys,or formal organizational reviewthat identifies gaps in services. The QI projects that are selected and
prioritized should show alignment with the organization’s mission.
Selectingthesitesisimportantandthere needstobe clearcriteriaforexample,baselineassessments,highvolumeandhighriskareas,andthe buy-inandcommitment
of managers of the organization.
3.11 Failure is part of the process
QualityimprovementprojectsteamsandOrganizationalManagementneedtoknowthateveryprojectexperiencessomesuccessesandsome failures.Yet,regardless
of the level of success or failure, every project should contribute to organizational learning and continuous improvement.
"I have not failed 1,000 times. I have successfully discovered 1,000 ways to NOT make
a light bulb."-
Thomas Edison

3.12 Sustainability
Sustainabilitycanbe describedas‘whennewwaysof workingand improvedoutcomesbecomethe norm’.A more detaileddescription,whichincludesthe notionof
‘steady state’, is as follows:
‘Not only have the process and outcome changed, but the thinking and attitudes behind them are fundamentally altered and the systems surrounding them are
transformed aswell…asa result,whenyoulookattheprocessoroutcomeoneyearfromnow…ithasbeenableto withstandchallengeandvariation ...sustainability
means holding the gains and evolving as required. (NHS Institute for Innovation and Improvement 2005).
3.12.1 Tips for improving sustainability
a) Ask yourself what exactly it is that you want to sustain
What isit that the teamwant to sustain?
 The specificchange?
 The measuredoutcome of a change?
 The change concept?

b) Engage leaders
Thinkaboutwho needstobe involvedforchangestohappenorwhoultimatelyinfluenceswhetherornot somethinghappens?
c) Involve and support front-line staff
Front-line staff membersplayanimportantrole throughouteveryquality improvementinitiative.
d) Ensure the change is ready to be implementedandsustained
It istoo earlyto considerfull implementationandsustainabilityif yourimprovementteamhasnotyetfinishedtestingtheirchange ideasthroughPDSA cycles.
e) Embed the improvedprocess
Buildthe change principleintothe structureof the organisationandmake itanewstandard.Itisimportanttolinkthe goal of theimprovementprojecttothe strategy
or vision of the organisation.
f) Buildongoing measurement
Establishmentof anongoingmeasurementsystemandastandardisedwayof communicatingresultscanbe veryan excitingandmotivatingfactorforteams.

Conclusion
PMTCT transmission rates decreased over the January 2012 to March 2015 period in one province. The 18-month rapid HIV test positivity rate is particularly
encouragingasit indicatesearlydetectionof HIV-positive infants. Keystakeholderbuy-inatboththe districtand sub-districtlevel iscritical forqualityimprovement
success. Managementsupervisionandoversight isimportanttoensure sustainedQIactivities.Teachingqualityimprovementatfacilitylevel greatlyimpactedfacility
performance since staff became motivatedandunderstoodthe qualityimprovementprocess.Non-supportedfacilities thatparticipatedinQI learningsessionsalso
showed improvements in their eMTCT process measures outcomes.

References
1. SteynK, DamascenoA. Lifestyleandrelatedriskfactorsforchronicdiseases. Disease andmortalityinsub-SaharanAfrica.2006;2:247-65.
2. Wyss,K. Anapproach to classifyinghumanresourcesconstraintstoattaininghealth-relatedMillenniumDevelopmentGoals.HumanResourcesforHealth.
2004;2(11):8.
3. National Departmentof Health. QualityImprovementGuide:QualityImprovement –the keyto providingimprovedqualityof care.National Departmentof
Health,Office of StandardCompliance.2012.
4. VosL, DuckersML, WagnerC, van Merode GG. Applyingthe qualityimprovementcollaborativemethodtoprocessredesign:amultiple case study.Implement
Sci.2010;5:19.
5. LangleyG, NolanK,NolanT, NormanC, ProvostL. The ImprovementGuide:A Practical ApproachtoEnhancingOrganisational Performance.2009.
6. National Departmentof Health, National ActionFrameworkforPMTCT- Nochildborn withHIV by 2015 and improvingthe healthandwellbeingof mothers,
babiesandpartnersinSouthAfrica,2012-2016.
7. WorldHealthOrganization.Global targets2025. To improve maternal,infantandyoung childnutrition.Available [Online] http://www.who.int/nutrition/global-
target-2025/en/ (assessed13November2015).
8. National Departmentof Health.National consolidatedguidelinesforthe preventionof mother-to-childtransmissionof HIV (PMTCT) andthe managementof
HIV in children,adolescentsandadults.April 2015.

Annexures
Annexure 1: Standardised scripted health talk for CHW
Early Booking for Antenatal Care
Today we want to talk about booking early during pregnancy:
1) What do we meanby early booking inpregnancy?
 Withinthe firstthree monthsof fallingpregnantor
 As soonas youhave missedyourperiodyoucan have a pregnancytest.
2) Whyis it important to book early?
 To ensure thatyou will have aHEALTHY babybecause you are as healthyaspossible
 We can do thisby:
o Checkingforanypregnancyprobleminyouor yourunbornbaby
o Treatingany problemthatmayhappenduringpregnancye.g.highblood
pressure,diabetes(highsugar),vaginal bleeding
o Testingforany infections e.g.HIV orotherSTI’s
o Givingmedicationstoimprove yourhealthandhelpandhelpbabytogrow
well
o Helpingyouprepare forlabourandparenthood
3) REMEMBER:
 If you have stoppedusingcontraception(e.g.three monthsinjection) andyouhave
not hadyour periodbutyouare planningtofall pregnant,please come tothe clinic
for a pregnancytest
 Avoidsmoking,drinkingalcoholandusingdrugsbecause thiswill harmyourbaby’s
health,growthanddevelopment,aswell asyourownhealth
 Make sure youcome back to the clinicforat leastfourantenatal check-upsduring
each of your pregnancies
 You mustget advice abouthealthyeatingduringyourpregnancy
 Learn aboutthe bestway to breastfeedyourbabysuccessfully
 It isveryimportantfor youto come to every appointmentthatthe sisterhasmade
for you
 Please involve yourpartnerinthe pregnancy
 Continue topractice safe sex
Becoming a MOTHER is a special time in your life – enjoy the journey!

70
Annexure 2: Postnatal leaflet on the importance of the six-day postnatal visit

Annexure 3: Postnatal review checklist
MOTHER WITHIN 6 DAYS MOTHER AROUND 6 WEEKS
Mother name:
Date:
Exam by:
Clinic: Clinic no:
Mother name:
Date:
Exam by:
Clinic:
RECORD OBSERVATIONS RECORD OBSERVATIONS
Temp: Pulse: BP: MUAC: Temp: Pulse: BP: MUAC:
Urine dipstix: Hb <10g/dL? YES NO Urine dipstix: Hb <10g/dL? YES NO
REVIEW CASE HISTORY REVIEW CASE HISTORY
Patient history:anyrisk factors?
 labour dischargesummary
 HIV status/ tested last 3mifpreviously negative
 TB history
YES NO Patient history:anyrisk factors?
 labour dischargesummary
 HIV status/ tested last 3mifpreviously negative
 TB history
YES NO
ASK THE MOTHER ASK THE MOTHER
Feeling unhappy?
How are you feeling? How are you coping with being a
mother?
YES NO Feeling unhappy?
How are you feeling? How are you coping with being a
mother?
YES NO
Dizzyness/fainting?
Have you been feeling light-headed or fainted?
YES NO Dizzyness/fainting?
Have you been feeling light-headed or fainted?
YES NO
Poor appetite?
How is your appetite/ eating?
YES NO Poor appetite?
How is your appetite/ eating?
YES NO
Infant feedingproblems?
What has thebaby been fedin the last24 hours?
(EBF/EFF/MF) $$
How is feeding going?
Do you have any breast problems?
How many times does baby feedin 24hours?
Do you give your babyanyother foodor drink?
YES NO Infant feedingproblems?
(EBF/EFF/MF) $$
Do you have any breast problems?
How many times does baby feedin 24hours?
YES NO
TB or breathing difficulties?
Do you have chest pain?
Are you coughing?
Do you get shortof breath?
Are you sweating at night?
Are you losing weight?
Do you have a fever?
YES NO TB or breathing difficulties?
Do you have chest pain?
Are you coughing?
Do you get shortofbreath?
Are you sweating at night?
Are you losing weight?
Do you have a fever?
YES NO
Problems withC/S woundor episiotomy? YES NO Problems withC/S woundor episiotomy? YES NO
Lochia offensive?
Does your vaginal bloodsmell bad?
Are you passing clots larger than a R5coin?
YES NO Vaginal discharge offensive? YES NO
Heavyvaginal bleeding?
Are you bleeding heavilyvaginally?
YES NO Urinaryincontinence?
Do you accidentally wet yourselfwith urine?
YES NO
Urinaryincontinence?
Do you accidentally wet yourselfwith urine?
YES NO Able to resume normal activities of dailyliving? YES NO
CONDUCT TOP TO TOE EXAMINATION CONDUCT TOP TO TOE EXAMINATION
Pale? YES NO Pale? YES NO
Short of breath? YES NO Short of breath? YES NO
Breast inflamedor nipples cracked? YES NO Breast inflamedor nipples cracked? YES NO
Uterus appropriatelyinvoluted? YES NO Uterus appropriatelyinvoluted? YES NO
Uterus tender? C/S wound infected? YES NO Uterus tender? YES NO
C/S wound sutures removed? YES NO C/S wound healed? YES NO
Episiotomyor perineal tear infected? YES NO Episiotomyor perineal tear healed? YES NO
Leg(s) swollen withtender calf muscle?Suspect DVT? YES NO
TREATMENT REQUIRED TREATMENT REQUIRED
On Iron/folate? YES NO On Iron/folate? YES NO
Type of contraceptionaccepted
Discuss options withmother
Type of contraceptionaccepted
Discuss options withmother
HIV+: ART adherence problem? YES NO HIV+: ART adherence problem? YES NO
HIV-:re-tested in last 3m? YES NO HIV-: re-tested in last 3m? YES NO

BABY WITHIN 6 DAYS BABY AROUND 6 WEEKS
Babyname
Today’s date: Date ofbirth:
Age of baby:
Exam by:: Clinic:
Babyname
Today’s date: Date ofbirth:
Age of baby:
Exam by:: Clinic:
OBSERVATIONS OBSERVATIONS
Weight
Babyshouldnot have lost more than10% of
birth weight;by2 weeks babyshouldbe back to
birth weight.
Temp Plot on RTHB:
Weight
Length
Head circumference
Temp
REVIEW REVIEW
Anyproblems documentedon RTHB or labour
record?
YES NO Anyproblems documentedon RTHB or labour
record?
YES NO
HIV-exposed? YES NO HIV-exposed? YES NO
ASK THE MOTHER ABOUT THE BABY ASK THE MOTHER ABOUT THE BABY
General:anyproblems?
How is baby doing? Any problems?
YES NO General:anyproblems?
How is baby doing? Any problems?
YES NO
Infant feedingproblems?
(EBF/EFF/MF) $$
How many times does baby feedin 24hours? (normal
is 8 -12 times in 24hours)
YES NO Infant feedingproblems?
(EBF/EFF/MF) $$
How many times does baby feedin 24hours? (normal
is 8 -12 times in 24hours)
YES NO
Infant feeding EBF EFF Mixed Infant feeding EBF EFF Mixed
8 or more wet nappiesin24 hours? YES NO 8 or more wet nappiesin24 hours? YES NO
Passing normal babystool?
Has baby’s stoolchangedfrom black sticky tar to
yellow or greenstool?
YES NO Passing normal babystool? YES NO
TB contacts? YES NO TB contacts? YES NO
EXAMINE EXAMINE
Colour:jaundice?Cyanosedblue? Pale?
Cyanosis may indicate an underlying heart condition
and requires immediatereferral
YES NO Colour:jaundice?Cyanosedblue?
Cyanosis may indicate an underlying heart condition
and requires immediatereferral
YES NO
CNS: moro reflex absent? Rootingreflex absent?
Babyfloppy?
YES NO Excessive sleeping/not alert? YES NO
Eyes:conjunctivitis?Red reflex absent?
A white pupilor loss of theredreflexis abnormaland
requires referral
YES NO Respondto sounds?
Looks at mother whenfeeding?
YES NO
Mouth problem?
Oral thrush? Cleft palate?
YES NO Mouth problem?
Oral thrush? Cleft palate?
YES NO
Breathingproblem?
>60 breaths in1 minute?
Chest indrawing?
Nasal flare?
Grunting?
YES NO Breathingproblem?
>60 breaths in1 minute?
Chest indrawing?
Nasal flare?
Grunting?
YES NO
Abdomen:distended? YES NO Nappyarea:rash?Genitalia problems? YES NO
Umbilicalcord smelly? YES NO
Nappyarea:rash?Genitalia problems? YES NO
TREAT TREAT
Vaccinate YES NO
NVP administration? If on
PMTCT, ask momto explainhow
she is givingNVPto baby
YES NO N/A NVPadministration? If onPMTCT,
continue NVPif mom less than12
weeks onFDC, or suspect poor
adherence, or mother VL not
undetectable
YES NO N/A
Notes:
PCR test done? YES NO N/A
Cotrimoxazole prophylaxis given? YES NO N/A

Annexure 4: Breastfeeding buddy invitation
The support a new mother receives is very important to assist her in making the best
decisions for her health and her baby’s health
Dear ..............................
You area valued supporter of this new mother and baby and have an important roleto play.
We would liketo inviteyou to attend the antenatal appointments at the clinic with ..............................
Her next appointment is on ..............................
We would love for you to come with.
Here are a few reasons why we want you to come with:
 You may be at home supportingthe new mother and baby
 You will havethe rightadviceto support the mother to exclusivebreastfeed
 You will beableto providethe best information and support
 You may be the future caregiver of the new baby if the mom starts workingagain
 You will beableto supporther duringchallengingtimes
 You have an important roleto play in the good health of this mother and baby
 You will startbuildingan importantsupportiverelationship
 You could become a positiverolemodel to the mother you support
 You will get an opportunity to ask questions about the supportyou can give
 You can become a health promoter in your community
 You can be a good birth companion which reduces the risk of a difficultdelivery for the mother and baby
 You can supportthe mother to attend her appointments before and after birth
 You can keep her company at her appointments
 You can become a mentor throughout her pregnancy
 You can ask the questions that the mother is too shy or scared to ask
We look forward to seeingyou atthe clinic.
Kind regards
..............................

Disclaimer
This material was made possible by the support of the American people through the United
States Agency for International Development (USAID). The contents are the sole responsibility
of South to South and do not necessarily reflect the views of USAID or the United States
government

S2S eMTCT Change Package_cgoosen_9Dec2015 (003)

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