Implementing Continuous Quality Improvement of TB Prevention Activities

This toolkit describes discrete action steps needed to fully implement TB prevention measures at a health care facility. While some of these action steps may prove easy to implement, others will be difficult or even impossible due to the physical and financial constraints of the institution. Given the very serious threat TB poses for patients, staff, and the community, every facility should continuously strive to optimize the effectiveness of its TB prevention activities. This is best accomplished by formally incorporating a continuous quality improvement (CQI) process into each facility’s TB prevention workplan. CQI is a process that is intended to address inefficiencies at a systems level. By identifying and improving on system-based issues, the CQI process should enable staff to do their work more easily and efficiently. Much of the following text draws upon guidance documents from the Institute for Healthcare Improvement and their Model for Improvement; I-TECH has found these methods valuable in a wide range of contexts.

Successful implementation of CQI requires active support from leadership and commitment of staff to the process. The same commitment that led to implementation of TB prevention activities should also extend to continuously working to improve performance in these areas. However, without active advocacy of facility level leadership to promote CQI in TB prevention, it is not likely to happen.

Institutions that already formally conduct CQI activities may have little difficulty expanding their scope to include TB prevention among the activities they address. However, for institutions that are less familiar with this process, we offer the following stepwise approach to incorporating CQI into a facility’s TB prevention workplan, followed by examples of how this approach has been successfully implemented in resource-limited settings.

Step 1: Establish a team or committee responsible for CQI

To formalize CQI for TB prevention, it is important to have a dedicated CQI team. Either an existing facility committee can include this responsibility in its scope of work, or a new team can be created (often called the Quality Improvement Team). In many settings, it will make sense for the CQI/TB prevention team to include members of the same committee charged with planning and implementing TB prevention activities. Initially, the committee’s primary responsibility would be to make sure that specific planned activities are being implemented; thereafter its primary responsibility could switch to monitoring their success and initiating and leading improvement efforts.

Step 2: Review performance indicators to identify areas for improvement

Performance indicators allow teams to identify areas for improvement in TB prevention. Prior sections of the toolkit identify monitoring indicators for infection control, intensified case finding, and IPT. For intensified case finding, we suggest using the indicators cited in A Guide to Monitoring & Evaluation for Collaborative TB/HIV Activities (WHO 2009). For IPT, it is a good idea to review the discussion on the IPT M&E page and consider using the suggested indicators. For TB infection control, we suggest using the CDC’s TB IC M&E Tool for Clinical Sites to identify which components of TBIC to focus on.

Step 3: Prioritize CQI activities by drawing upon the experience and wisdom of staff

Following the implementation of TB prevention activities, we recommend that the QI team initiate quarterly meetings with key staff. Meetings allow staff to review the performance indicators and identify possible ways to improve performance. The goal of these meetings is to reach consensus on areas where improvements are either very much needed or could easily be made. Meetings also capitalize on the staff’s cumulative experience in identifying strategies for making these improvements.

When an improvement activity is underway, team members may need to meet more frequently. These meetings may be daily 10-minute “huddles” or weekly short check-ins to debrief and revise the small-scale changes that are being tested.

Often there are many competing problem areas to address; it is important to prioritize these areas so that work can be accomplished successfully. The following considerations may be helpful in prioritizing where to start:

  • The urgency of the problem and the conse­quences of not improving it. In a clinical set­ting, for example, the safety of patients and health care providers would be high priority.
  • The feasibility of improving the situation—is it within the team’s control, or is it outside of its sphere of influence?
  • The resource implications of not addressing the problem, as well as the availability of estimated resources needed to address the problem.
  • The availability of quantitative or qualitative data to help understand the problem area(s). Viewing data over time facilitates understanding of the problem and its probable causes. If the team lacks sufficient data, it may decide to start collect­ing data about that problem while simultane­ously working to improve another area.

Step 4: Develop an aim statement and measurement strategy

Based on the discussion at the initial staff meeting, the CQI/TB Prevention Committee or point person should draft an “aim statement,” that identifies what improvement in the quality of TB services the staff intends to accomplish and how this will be measured. This “aim statement” is intended to be a living document that should be referred to at subsequent meetings. (More information on aim statements can be found in the I-TECH technical implementation guide, Applying the Model for Improvement at I-TECH).

Step 5: Develop change strategies geared towards achieving the aim

Once the team has identified its specific aim, members should meet and creatively think of ideas that can be tested for achieving that aim. There may be a number of effective strategies that have been published or demonstrated in other settings—the team may wish to adapt those and test to see whether they work in the current setting.

Step 6: Test strategies using Plan-Do-Study-Act cycles

After identifying several strategies that may lead to improvement, teams will begin small-scale testing of each strategy. This allows the team to evaluate the effectiveness of the strategies and revise them based on test outcomes. The approach allows ideas to be tailored to specific settings, and gives the team the ability to test each strategy’s effectiveness before expending resources on large-scale implementation. Plan-Do-Study-Act (PDSA) cycles adopt this model by outlining four steps: (1) planning the intervention, (2) doing the intervention, (3) studying the outcome, and then (4) acting or adjusting the intervention based on the outcomes achieved. The team can then refine their work further by repeating this cycle. (See Applying the Model for Improvement at I-TECH for more information on PDSA cycles).

Sites should maintain ongoing documentation of the CQI activities, which should be regularly reviewed to identify both facility accomplishments and the areas of TB prevention that have yet to be examined. This documentation should routinely be compared to the CQI/TB Prevention Committee’s aims, to ensure that CQI activities remain in line with previously identified aims. The Improvement Project Tracking Tool is one example of a format for ongoing documentation of improvement activities.

Included here are two examples of improvement projects aimed at enhancing TB prevention activities:

CQI Example 1: Improving TB screening of HIV-infected patients

CQI Example 2: Improving Follow-Up of TB Suspects

Selected Resources

Additional Examples of TB Prevention CQI Projects:

"IPT Namibia and Case Detection QI Haiti." HealthQual International/New York State Department of Health AIDS Institute. TB: Improving Care and Treatment through Quality Improvement [brief]. HIVQual International. 2009; 1(Issue II [2]).

Additional Resources for Online Training in CQI, and Additional Tools:

Institute for Healthcare Improvement website

The Institute for Healthcare Improvement website maintains a wealth of information on health quality improvement methods. According to the site: “An independent not-for-profit organization based in Cambridge, Massachusetts, IHI focuses on motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals; and ensuring the broadest possible adoption of best practices and effective innovations.”

The institute also distributes a brochure describing the institute and its mission.

MEASURE Evaluation Group

This site, provided through the Measure Evaluation Group, features a compendium of indicators for monitoring and evaluating national tuberculosis programs. It was developed in 2004. The indicators may be useful for tracking as part of a quality improvement project; they are summarized in a short publication distributed by the group. [link to]

I-TECH/UW. I-TECH Technical Implementation Guide: The Model for Improvement. Seattle: I-TECH/UW;2010.

This technical implementation guide from I-TECH describes the Model for Improvement and its application in I-TECH programs. It is a good basic introduction to the steps involved in an improvement project, and contains additional resources for further reading.

Massoud R, Askov K, Reinke J, Franco LM, Bornstein T, Knebel E, et al. The Quality Assurance Project: QA Monograph.

This monograph from the Quality Assurance Project contains practical information about conducting improvement activities, as well as guidance on flow charts, cause and effect analysis, and tools for analyzing and documenting improvements.