586 posters, 8 topics, 23 sessions, 1,077 authors, 622 institutions
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ISQua's 40th International Conference 2024
24th - 27th September 2024 | Istanbul, Türkiye
P426b
4A Framework: A Systemic Approach to Quality Improvement to Address System Challenges in South African HIV Programme
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Patient Safety & Quality Improvement
1. Background
The HIV/AIDS epidemic and weaknesses in the health system in South Africa, paired with the global focus on ending AIDS as a public health threat by 2030, drove the National Department of Health to move away from vertical programming to a systems level improvement strategy. This strategy was developed by the Aurum Institute in partnership with the National Department of Health HIV/AIDS and STI cluster. The strategy was based on Aurum’s Improvement Framework called the 4A Framework and developed into a system wide Improvement approach called the Nerve Centre Approach (NCA). The NCA is a data driven strategy that guides health care workers at all levels of the health system to improve service delivery through the adoption of standardised, problem-focused and improvement-driven platforms and tools. Many QI projects have been developed in facilities across the country, however most were not sustained or linked to the next level of operation or support and systems change.
2. 4A Quality Improvement Framework
In developing the NCA, we used a Quality Improvement project management framework (4A Model). This framework gives an overall, big picture view needed when wanting to make any improvement. This framework/model can be used every day when addressing any problem. If applied correctly, it will stop the same mistakes happening over and over again and ensue that your efforts are effective and sustainable. The framework suggests that all improvement work should follow the following 4 phases:
Assess: Before any intervention is ventured into, an assessment should be done. Together assess the current situation, determine what the cause of the problem is, decide what the current priority is and where you want to start.
Act: Now that you know what the real problem is, you know what is causing it, and you have developed a plan of action; it is time to ACT. To get a different more sustainable result we must do something differently. Some interventions include:
Whenever something different is done in a health system, it is important to determine the impact of the change. Was this change a success or not? How do you know? This part of the framework must be data driven i.e. outcome and process measures.
Anchor: Once we find what works, anchor it into the system so we don’t keep reinventing the wheel. Remember, if we don’t know what we have done, or how we have done it, how will we ever be able to do it again! This model is a simple way of looking at all work to make sure it is sustainable and effective.
3. What is a Nerve Centre
Our health system constantly faces challenges and problems that are experienced at facility level. Some challenges are because of problems occurring at a facility that can be addressed by facility staff; other problems on the other hand, are out of the control of facility staff and they rely on managers to make the changes. The role of management therefore must be to CHANGE THE SYSTEM rather than focusing on individuals as the source and solution of the problem. To do that, the NCA has introduced 3 levels of change for all levels of management: (1) Providing supportive supervsion (2) Addressing Drivers of Programme Excellence (3) Nerve Centre Meeting Process
5. Facility Level Interventions
The NCA has provided a standardised 8-step approach to QI for the countries HIV programme at facility level. The step-by-step assessment is a tool that assists teams to identify specific gaps in their own system, process or workflows, and/or resources. Users need to follow each step to identify the gaps. Indicator summary charts provide a quick overview of all the data elements that are contributing to an indicators’ performance. They enable data-driven decisions when identifying problem areas and planning for improvement activities.
6. Impact and National and Provincial Level on Total Remaining on ART
South Africa percentage growth improved by 0,4% from 2,27% in 2023 to 2,66% in 2024. The total TROA growth in numbers for 2024 (Reporting yr.) in numbers is 148 487, which is a gain of 28 722. In 2023 the growth in numbers was 119 765. Gauteng from 32 197 to 43 289, contributing 32% (43 289/133 543) to the National TROA growth. KZN growth in raw numbers is 14 643, compared to the 4 055 achieved in 2023. Eastern Cape indicates a 0,8% (5 277) gain in 2024 from the 3,80% (21 784) achieved in 2023 to 4,63% (27 554). EC is expected to contribute 11% to the country so it overachieved by 9%. Free State gained 0,9%, growing from 2,3% 2023, to 3,2% in 2024.
7. Conclusion
The Nerve Centre Approach based on Aurums’ 4A Improvement Framework, is a national quality improvement approach that is showing incredible improvement at all levels of the health system. The approach has been catalytic in ensuring alignment to national strategies, a standardised culture of joint problem solving, and centring all changes on data for all levels of government. The approach has revived an atmosphere of commitment that change in a very complex health system is possible!