Quality Improvement (QI) through Small Tests of Change (STOC) to Improve Health Systems in Resource-Limited Settings

Background: QI procedures have been proven to be highly effective in the poorest health systems, but often applied inappropriately. Objective: Demonstrate correct application of QI measures at ART programs in resource limited settings.  

Methodology: A descriptive before-and-after study with no control group is used to evaluate outcomes. October 2011-June 2012 and April–December 2013 were defined as pre and post -intervention stages respectively.  Time-series analysis was used to compare trends. Interventions involved training of Health Care Workers (HCWs) on CQI, establishment of CQI teams. Outcome measures included proportion of women screened for cervical cancer, lost to follow-up (LTFU) rates and linkage to care trends. The outcomes were achieved by employing several STOCs through Plan Do Study Act model.

Results: The program has 2,551 patients on ART. The median baseline CD4 count at start of ART was 349 cells/µl (IQR 201-497). Seventeen HCWs from 4 facilities were trained on CQI. Proportion of women screened for cervical cancer increased from 32% (95% CI, 16-48) to 77% (95% CI, 68-86); LTFUs rates reduced from 56% (95% CI, 43-69) to 24% (95% CI, 7-41); linkage to care improved from 58% (95% CI, 45-71) to 84% (95% CI, 76-92) and patient retention improved from 89% (95% CI, 83-96) to 94% (95% CI, 89-99) at pre and post-intervention periods respectively.

Conclusions: There is need to focus on building the capacity of HCWs to deliver quality services at primary health care facilities through promotion of data use for decision making, building QI teams, and carrying out STOCs