QUALITY IMPROVEMENT CASE STUDY - USAID ASSIST · 2019-12-30 · QUALITY ASSURANCE PROJECT University Research Co., LLC • 7200 Wisconsin Ave., Suite 600 • Bethesda, MD 20814 •

Q U A L I T Y

A S S U R A N C E

P R O J E C T

University Research Co., LLC • 7200 Wisconsin Ave., Suite 600 • Bethesda, MD 20814 • www.qaproject.org

Q U A L I T Y I M P R O V E M E N T C A S E S T U D Y

Using Team Problem SolvingTo Improve Adherence with

Malaria TreatmentGuidelines in Malawi

August 2003

The Quality Assurance Project (QAP) is funded by the U.S.Agency for International Development (USAID) under ContractNumber GPH-C-00-02-00004-00. The project servesdeveloping countries eligible for USAID assistance, USAIDMissions and Bureaus, and other agencies andnongovernmental organizations that cooperate with USAID.QAP offers technical assistance in the management of qualityassurance and workforce development in healthcare, helpingdevelop feasible, affordable approaches to comprehensivechange in health service delivery. The project team includesprime contractor University Research Co., LLC (URC),Initiatives Inc., and Joint Commission Resources, Inc. Thework described in this report was carried out by the QualityAssurance Project under USAID Contract Number HRN-C-00-96-90013, managed by the Center for Human Services, URC’snonprofit affiliate, in partnership with Joint CommissionResources, Inc. and Johns Hopkins University.

QUALITYASSURANCE

PROJECT

TEL (301) 654-8338

FAX (301) 941-8427

www.qaproject.org

DedicationThis case study is dedicated to Mellina Mchombo, BSN, RN,a Quality Assurance Project staff member who died in 2002, not

long after the work in this case study was completed. As a QualityAssurance Specialist, Mellina helped ensure that the quality

improvement effort described in these pages bore fruit. A hard-working and dedicated professional, she faced very challengingcircumstances but never gave up trying. She was wonderful at

motivating and coaching health worker teams, helping them learnhow powerful they could be in improving the quality of healthcare.

We miss her, but her commitment and spirit still inspire us.

About this seriesThe Case Study Series presents real applications of qualityassurance (QA) methods in developing countries at varioushealth system levels, from national to community. The seriesfocuses on QA applications in child survival, maternal andreproductive health, and infectious diseases. Each case studyfocuses on one or more major QA activity areas: qualitydesign, quality improvement, the communication and develop-ment of standards, or quality assessment.

This case study focuses on quality improvement (QI), aneffective and systematic process of addressing the gapsbetween current practices and desired standards. Approachesto QI include individual problem solving, rapid team problemsolving, systematic team problem solving, and processimprovement. These methods vary in the time and resourcesrequired and the number of people who participate. Regard-less of the method’s intensity, QI approaches share four basicsteps: identification of opportunity for quality improvement,analysis of improvement area, development of possibleinterventions to provide improvement, and the testing ofpromising interventions and their implementation if successful.Sometimes, when the potential solutions to a problem arealready clearly defined, a shorter QI activity focused on field-testing the alternatives is used.

This case study illustrates systematic team problem solving.A five-member team at a rural health center in Malawi usedthis QI approach to reduce the number of patients returningwith malaria symptoms, reducing case load, drug costs, andthe risk of accelerating drug resistance.

Team Problem Solving Reduces Malaria Reattendance

AcknowledgementsThe Lifuwu Health Center Quality Improvement Team, assisted bythe Salima district quality assurance coaches, conducted the workdescribed here and provided the photographs. Jennifer Shabahangwrote the case study in close collaboration with Lynette Maliangaand Mellina Mchombo. Hany Abdallah conducted the cost analysis.Bruno Bouchet, Ya-Shin Lin, and Diana Silimperi provided technicalreview.

Lifuwu Health Center TeamK. M. Machangwa, Medical Assistant – Team LeaderT. S. Phiri, Assistant Environmental Health Officer – Team RecorderL. M. Mulusa, Health Surveillance Assistant – Time KeeperC. Kachule, Health Surveillance Assistant – MemberF. K. Sapangwa, Health Surveillance Assistant – Member

Salima District QA CoachesMr. Gabriel Banda, Microscopist, Save the Children Fund (UK)Mr. Steve Mfune, Clinical Officer, Salima District HospitalMrs. Dorothy Kamanga, Registered Nurse, Salima District HospitalMrs. Twambilire Phiri, Registered Nurse, Salima District Hospital

Recommended citationShabahang, J. 2003. Using Team Problem Solving to ImproveAdherence with Malaria Treatment Guidelines in Malawi. QualityAssurance Project Case Study. Published for the U.S. Agency forInternational Development (USAID) by the Quality Assurance Project(QAP): Bethesda, Maryland, U.S.A.

AbbreviationsCHAPS Community Health Partnerships

DOT Directly observed treatment

QA Quality assurance

QAP Quality Assurance Project

QI Quality improvement

QIT Quality improvement team

SP Sulfadoxine-pyrimethamine

STI Sexually transmitted infection


Background

Malaria is one of the mostserious public health issuesworldwide, particularly in sub-Saharan Africa. It kills at least amillion people each year: about 3,000 aday. Almost 300 million people sufferfrom acute malaria each year, resulting notonly in death and morbidity but also severe economic loses.1

Moreover, incomplete treatment of malaria is a seriousproblem that can lead to anemia, cerebral malaria, and evendeath. Perhaps worst of all, misuse of anti-malarials cancontribute to the malaria parasite’s drug resistance. Malawi, asmall country in southeastern Africa, averaged 372 cases ofmalaria per 1,000 people per year from 1996 to 2000, about3.7 million cases.2 Government health centers there providefree consultations and medicine for malaria.

Funded by the US Agency for International Development(USAID), the Quality Assurance Project (QAP) providestechnical expertise, particularly in the area of quality improve-ment, to healthcare personnel in developing countries to helpthem improve healthcare services. QAP has teamed with theCommunity Health Partnerships (CHAPS) Project in Malawisince 1998 to develop better management systems andultimately improve the quality of healthcare.

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Using Team Problem Solving ToImprove Adherence with MalariaTreatment Guidelines in Malawi

QUALITY IMPROVEMENT CASE STUDY


This case study describes theexperience of a qualityimprovement team in Malawi’sSalima district. The teamworks at Lifuwu HealthCenter, a small outpatientcenter serving a largely ruralpopulation. Significant healthproblems presenting at theclinic include diarrhea, upperrespiratory tract infections,STIs, HIV/AIDS, and malaria.The last transmits year rounddue to the warm climate andproximity to Lake Malawi. Asthis case study reports, theteam recognized the severeimpact that malaria had onthe community and decidedto investigate and change thesystem of treating malariapatients as a step towardimproving overall quality ofcare at the health center.

Quality Improvement Methodology

Quality improvement, using the team problem-solving ap-proach, was initiated in six CHAPS districts in 1999 and aseventh in 2000. The approach used in Malawi is a six-stepmethodology (or “cycle”) that guides teams to identify andanalyze problems (“opportunities for improvement”) and thendevelop and implement solutions (see Figure 1). This approachpreceded the current four-step process described in the Aboutthis series section above and advocated by the QA Project atthis writing. Different analysis tools and activities are used ineach step, and the process also incorporates the principles ofteamwork, using data for decision making, focusing on thecustomer, and taking a systems view (inputs, processes, andoutcomes) of healthcare.

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Lilongwe

Blantyre

LakeChilwa

LakeMalombe

LakeMalawi(Nyasa)

Zambezi

Mzuzu

Chambeshi

Luan

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Z A M B I A

Bua

MALAWI

NkhataBay

Nkhota Kota

MonkeyBay

Zomba

Shire

Karonga

M O Z A M B I Q U E

Luw

egu

Luge

nda

TA N Z A N I A

M O Z A M B I Q U E

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Team Problem Solving Reduces Malaria Reattendance ■ 3

Malawi qualityimprovement

team members

Figure 1. Problem-Solving Steps for QualityImprovement Used in Malawi

Step 2:Define the problem

operationally

Step 1: Identifyproblems (opportunities

for improvement)

Step 3: Identifywho should work on

the problem

Step 4: Analyzeand study the problem to

identify major causes

Step 5: Developsolutions and actions for

quality improvement

Step 6:Implement and evaluate

the improvement

▼

▼

▼

▼

▼

▼

District staff learned to be QA coaches in a three-week QAPtraining of trainers, studying quality improvement (QI) in bothclassroom and practical settings. These coaches then trainedhealth facility staff and mentored them as they worked through

Team Problem Solving Reduces Malaria Reattendance4 ■

their first problem-solving cycle. The Lifuwu Health Center QIteam formed in October 1999 and included all health centertechnical staff: the medical assistant, the assistant environ-mental health officer, and three health surveillance assistants.Two coaches visited the team monthly or whenever a teammeeting was planned, listening to and observing the team(not facilitating meetings) and stepping in to help when theteam was stuck or did not fully understand a conceptcovered in the training.

Step 1. Identify the Opportunity forImprovementBrainstorming opportunities for improvement. TheLifuwu team’s first problem-solving cycle began with theassistance of the QA coaches during the team’s training. Theteam “brainstormed” (developed a list in a way that encour-aged all to participate) 21 problems that adversely affectedthe quality of care at the health center. The coaches helpedthe team members think about and discuss the problemsand how to select the problem they could most likely solve.With this guidance, the team decided that 14 of the 21problems were beyond their scope of influence: that is, theseproblems would require more resources or authority thanthey had (e.g., hiring more staff or arranging transportationfor clients). Two problems were considered simple enough tobe resolved by a single person, and two were too compli-cated for a team’s first problem solving. This process ofelimination led to three problems the team might address:1) lack of patient adherence to malaria treatment; 2) familyplanning and antenatal clients’ refusal to be seen by a malehealth provider; and 3) maternity clients’ refusal of referral tothe district hospital. Table 1 displays all of the opportunitiesfor improvement the team considered.

Prioritizing the opportunity for improvement. Theteam used a decision (or criteria) matrix (Table 2) to choosefrom these three opportunities for improvement. This matrix isa tool to evaluate several options based on explicit criteriathat the team had deemed important. The criteria were:


Lack of spare parts for bicycles

Table 1. Opportunities for Improvement Considered by the Lifuwu Team

Beyond the Team’s Scope of Influence

Shortage of drugsLong distance to travel to health centerShortage of syringes for immunizationShortage of staff housesShortage of staffDelays in receiving medical suppliesIntegrated services done in one roomLack of maternity services

Refrigerator not workingDelays in paying electricity billsresulting in vaccine wastageLack of chairs in the laboratoryFacility too small for the activities doneLack of uniforms for staffLack of supplies for traditional birthattendants

Simple Problems That Do Not Require Team Problem Solving

Lack of privacy

Patients with anemic children refusereferral because of HIV test

Too Complicated to Pursue as First Problem Solving

Cultural barriers to utilization of healthcenter and its activities (e.g., cam-paigns, surveys)

Lack of patient adherence to malariatreatmentClients for family planning andantenatal care refuse to be seen bymale health provider

Short List

Maternity clients refuse referral todistrict hospital

1) Risk: there are risks to patients if the problem is notaddressed.

2) Importance or magnitude: The problem has existed forsome time and is widespread.

3) Problem prone: Other problems will probably be caused ifthis issue is not eliminated.

Each team member assigned a score from one to three toeach criterion for each problem. The points were totaled, asshown in the right-hand column of Table 2, to reveal that“Lack of patient adherence to malaria treatment” scored thehighest. Satisfied with this outcome, the team agreed toaddress lack of patient adherence to malaria treatment as theiropportunity for improvement.


Step 2. Define the Problem OperationallyAn operational definition of a problem or opportunity forimprovement expresses the difference between the currentand desired state of affairs. The team suspected that patientadherence to malaria treatment was a problem because theywere seeing clients who had received malaria treatment returnwith the same symptoms soon after treatment. Such clientsare referred to as “reattendants,” officially defined as clientswho return with malaria symptoms within a week of receivingmalaria treatment. Returning within a week signals the samebout of malaria, not a new infection, since the chances of anew case of malaria manifesting itself within a week are low.An initial survey of the health center’s records indicated thatsince October 1996, when the clinic opened, about 29percent of malaria clients were reattendants. The team agreedto target an improvement resulting in having less than5 percent of malaria patients per month return with the samesymptoms.

In Malawi, sulfadoxine-pyrimethamine (SP) is the recom-mended drug for treatment of malaria. It is usually given withan antipyretic medicine (such as Acetaminophen) to reducefever because, unlike chloroquine, SP itself does not reducefever. The adult dose of SP is three tablets (equivalent of1500mg sulfa/75mg pyrimethamine) taken once; the pediatricdose is determined by weight or age.

Table 2. Decision Matrix to Choose Opportunity for Improvement

Risk Importance Problem Prone

Lack of patient adherence to malaria 8 7 8 23treatment

Clients for family planning and 5 6 6 17maternity cases refuse to be seen bymale providers

Maternity clients refuse referral to 6 4 5 15hospital

Problem Criteria Total


Step 3. Identify Who Should Work on theProblemQI efforts work best when those who are involved in theprocess participate in the analysis and development ofsolutions. The staff created a high-level flowchart to illustratethe process that malaria patients encountered at the healthcenter. This exercise helped the team identify which healthworkers come into contact with a malaria client or affect thequality of services related to the reattendants problem. Whilethe composition of the team is typically revised at this point toinclude health workers involved in the process, the Lifuwuteam already comprised all the technical staff, so its member-ship was not changed.

Step 4. Analyze the Problem to IdentifyMajor CausesConstructing a fishbone diagram. Thorough problemanalysis is important to help the team avoid jumping tosolutions that may not address the true source of the problem.To begin their analysis, the team brainstormed on the question“What are general categories of issues that could affectpatient adherence to malaria treatment?” The result was usedto construct a fishbone (or cause-and-effect) diagram. Thisdiagram presents a fish-like image, with a problem statementfor the fish’s head, which is attached to a main bone that

Tablets fortreatingmalaria.


branches into ribs that present the problem’s proposedcauses. The ribs are arranged in categories.

As Figure 2 shows, the categories of causes generated by theteam—the “ribs”—were: environment, treatment, patient/family, and staff/provider. Using these categories, the teamthen asked questions to explain how and why each categorycould affect patient adherence to malaria treatment. Forinstance the team asked, “How or why could treatment typeinfluence adherence?” The answers to the question formedthe fish’s bones:

1. Patient or caretaker unable to differentiate Acetaminophenand SP

2. Patient or caretaker did not follow instructions given

3. Tablets are too big to swallow

4. Patient not satisfied with prescribed treatment

Figure 2. Fishbone Diagram of Reasons for Lack of Adherence toMalaria Treatment

STAFF PROVIDER

Not satisfiedwith prescribedtreatment

Did not followinstructionsgiven

High prices ofsome medication

Prefersinjections/capsules

Doesn’t understandinstructions

Afraid of side effects

Doesn’t feel thathe/she has malaria

Unable todifferentiate SP and

Acetaminophen

Tablets too bigto swallow

Hot climate

Language

Cultural beliefs

Poorinterpersonal

relationship

TREATMENT ENVIRONMENT

PATIENT/FAMILY

Lack ofCompliance by

Clients toMalaria

Treatment

Illiteracy

Does notgive properinstructions

Doesn’t havetime due topressure work

Rumors that SP kills


The fishbone diagram helped the team identify the majorfactors that could affect adherence to treatment.

Verifying hypothesized causes. The team then discussedwhat information they needed to find out which causes theyhad hypothesized during the fishbone exercise actuallyreflected reality. To do this, they decided to quantify thenumber of reattendants; to ask reattendants if they followedthe health worker’s instructions on taking the drug; and if theydid not follow instructions, to ask why. During February 1999,the team collected these data by reviewing patient recordsand interviewing patients.

During the 20-day data collection, 761 malaria clients wereseen. Of these, 77 percent (588) were new cases, and 23percent (173) were reattendants. Interviews were conductedwith 160 reattendants: 73 percent (117) of them said they hadfollowed the treatment instructions, and 27 percent (43) saidthey did not. These 43 were asked why they did not follow theinstructions: 36 said they forgot; 4 said they did not under-stand; and 3 said they confused the treatment with otherdrugs (Table 3). The team was aware that although 73 percentof reattendants said they followed the instructions, this couldbe an overestimate, as respondents may not have wanted toadmit noncompliance.

Table 3. Data Collected on Malaria Reattendants, February 2000

Number Percent

Total number of malaria patients 761 100%

Number of new cases 588/761 77%

Malaria reattendants 173/761 23%

Reattendants interviewed who said they did notfollow instructions 43/160 27%

Reasons why reattendants did not follow instructions 43 100%

Forgot 36/43 84%

Did not understand 4/43 9%

Confused treatment with other drugs 3/43 7%


Additionally, the team noticed that malaria pills had beenthrown on the health center grounds. During the data collec-tion, discarded pills were seen on five days. Although staffcould not quantify how many clients were discarding theirmedications, it was another indication of noncompliance.

Step 5. Develop Solutions for QualityImprovementThe data collection exercise helped the team quantify thenumber of reattendants. In addition, it confirmed the problemcauses the team had discovered in the fishbone exercise andsuggested additional issues: not understanding instructions,forgetting the instructions, confusing the malaria treatmentwith other drugs, and possible distrust of the treatment.

Equipped with this information, the team brainstormedpotential solutions to the problem:

■ Provide health education to the community on the impor-tance of taking SP as recommended by the treatmentguideline,

■ Assign two dispensers to give the SP dose at the healthcenter as directly observed treatment (DOT),

■ Check all reattendants with a malaria blood slide to confirmthat they really have malaria,

■ Assign a health worker to look for discarded drugs alongthe paths to the villages,

■ Assign a health worker to follow up door-to-door withpatients who receive SP to make sure they take themedicine.

Prioritizing solutions. A decision matrix was used todecide which solution(s) to implement. The criteria werefeasibility in terms of resources, acceptability to the commu-nity, and efficiency in terms of time needed for implementation.Looking for discarded drugs and door-to-door follow up wereeliminated due to insufficient staff to perform these tasks; theteam also agreed that these ideas were not really solutions butrather ways to monitor whether clients were adhering to thetreatment. The highest score went to health education,

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followed by DOT at the health center, and then using a bloodslide to confirm malaria. The team felt that for their interventionto have the most impact, all three solutions should beimplemented at once; DOT would be the main component, asthe team believed it would have the most effect on theproblem while the other two solutions would help.

Step 6. Implement and Evaluate theImprovementThe solution. A system was devised for patients to taketheir malaria pills under supervision. The grounds laborer andhospital attendant were assigned to administer the medicationas directed by the clinician, providing a clean cup and water.In addition, health education on malaria was intensified both atthe health center and in the community. All health workers,including support staff, participated in giving daily healtheducation talks at the health center. These talks covered theimportance of taking SP on time and fully, and the signs,symptoms, and prevention of malaria. Health surveillanceassistants discussed the importance of proper SP dosing withthe village health committee and at outreach clinics. Malariablood slides were routinely examined for all reattendants toconfirm that they indeed had malaria.

A clinic staffmember

examines ablood smearto determinethe presence

of malaria.

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The DOT system for administering malaria treatment wasinstituted in March 2000. The health education on SP andmalaria lasted several months, until clients had becomefamiliar with the new procedure for SP administration at theclinic.

Evaluation and results. After the interventions wereimplemented, the team continued monitoring the percentageof malaria patients who were reattendants. There was animmediate and sustained decrease in the percentage ofreattendants (Figure 3): prior to SP’s being given underobservation, the 12-month average percentage ofreattendants was 31 percent. In the first month the interven-tion was implemented, the percentage of reattendants fell to7 percent; the next month it dropped below 5 percent whereit stayed for the 12-month monitoring period.

Cost Analysis

Drug savings. A cost analysis was conducted to demon-strate the savings, in terms of financial and human resources,brought about by the DOT intervention. As displayed in Figure4, in the 12-month period after the intervention, 2,227

40

35

30

25

20

15

10

5

0M

Per

cent

age

of m

alar

ia p

atie

nts

who

are

“re

atte

nden

ts” DOT implemented

March 2000

A M J J A S MO N D J F M A M J J A S O N D J F M A

1999 2000 2001

Figure 3. Decrease in Malaria Reattendants after Implementationof DOT

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reattendants would have been expected, based on theaverage percentage of reattendants before the intervention,31 percent. However, the actual number of reattendants was214, a reduction of 2,013 cases or 90 percent. Assuming thatthe 9-cent cost of a dose of SP is saved for every reattendantthat is prevented by the DOT, the DOT intervention resulted insavings up to $181 in SP doses (or $2,255 at the retail valueof SP).3 The $181 could be used to treat 2,013 new malariapatients or to purchase other supplies or equipment.

Staff time savings. The DOT intervention also led tosavings in health worker time and other benefits related tofewer complications from malaria. With regard to healthworker time, staff estimate that the average consultation witha malaria patient (either new or reattendant) is about sevenminutes. Seeing 2,013 fewer reattendants in the 12-monthperiod following the introduction of DOT saved 235 hours or29 person-days. This time was used to attend to otherpatients and perform other tasks.

Figure 4. Decrease in Reattendants Most Likely Attributable toDOT Program

Before*

Number of new†

malaria patients

After

Number of malariareattendents

7, 388

2,284

7, 203

2,227

214

Expected numberof reattendents

Actual numberof reattendents

31% 31%

Decrease in reattendantslikely due to DOT:2013 cases

* To control for seasonality, equivalent 12-month periods before and after theimplementation of DOT were compared.

† Patients who were not treated for malaria within the past week

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Table 4 summarizes the financial and human resource savingsto the health center that might be attributed to the DOTintervention.

Benefit to the patient and the community. With regardto other benefits, it is expected that the DOT interventionwould have a positive effect on patient outcome. A patientwho takes his/her SP dose according to the DOT procedure ismore likely to recover from malaria and not suffer complica-tions that can result from failing to take the drug or taking itincompletely. Fewer complications from malaria mean reducedpatient suffering and increased productivity.

In addition, ensuring completion of the prescribed SP regimenretards drug resistance. Drug resistance carries a high cost tothe community in the form of extra visits to the doctor,hospitalization or extended hospital stays, a need for moreexpensive antibiotics to replace the ineffective ones, lostworkdays and, sometimes, death.

Table 4. Savings Due to DOT over a 12-Month Period

Change Savings

Number of fewer reattendants due to DOT $2013

Total savings due to SP doses saved(health center wholesale price) $181

Total savings due to SP doses saved(retail price) $2255

Savings in health worker time 235 hours or29 person-days

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Quality Improvement InsightsThe Lifuwu team significantly decreased the number of malariareattendants seen at the health center. The following are insightsabout using team problem solving:

The first problem a team tackles should be chosen withextra care. Since the team is learning the methodology when ittackles its first problem, coaches should guide teams in selectingproblems that are within their scope of influence and that do notrequire resources that the team may not be able to obtain. Successwith the first problem will inspire the team to move on to others.Since problem solving works only to the extent that the team ismotivated, it is imperative to use the selection of the problem as partof the motivational strategy.

On the other hand, some of the problems listed in Table 1 that weredeemed to be beyond the scope of the team’s influence may nothave been. For instance, the problem “facility too small for theactivities done” might have been a problem that could have beenaddressed with creative solutions for improved patient flow or betteruse of existing space. In choosing the problem, teams should think“outside the box.”

Community education stressed the importanceof taking SP regularly.

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Teams should adapt and use existing approaches, whenpossible. The Lifuwu team thought creatively and adapted theconcept of directly observed treatment (DOT), which had been usedsuccessfully in treating tuberculosis. It is important for teams toknow that they can use interventions that have been successfulelsewhere, instead of having to invent new ones. Other healthcenters could replicate this intervention to prevent malariareattendants.

Use education to prevent resistance to change. When theDOT administration of anti-malarials was initiated, it was combinedwith an education campaign on the importance of taking SPcorrectly and the new DOT procedure. The information eased clientsconcerns about the new system and reduced resistance to thechange.

At the health center level, successful interventions arethose that health workers control. This intervention wassuccessful partly because the team changed something that wasunder its control: how anti-malarials are administered at the healthcenter. Changing human behavior (in this case, the behavior ofclients) would have been much more difficult. If the team had onlyinstituted health education on taking SP properly, they probablywould not have been as successful, since they have no control overclient behavior outside the health center. However, the team couldcontrol how anti-malarials were administered at the health center,and the DOT procedure ensured that the drugs were taken correctly.

Quality improvement can lead to the better use of existingresources. By significantly decreasing the number of reattendants,the health center realized a savings, enabling its scarce resources tobe used for other services. With far fewer reattendants, SP was notwasted and health workers had more time for other patients or othertasks. The cost analysis demonstrated that QI can improve the useof resources in addition to improving the quality of health services.

The cost savings of QA described in this case study should beconsidered along with the cost of doing QA. The latter would includesuch costs as staff time to meet and complete the problem-solvingsteps and coaching travel and time. However, now that the team is

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familiar with the methodology of systematic team problem solving,the cost of doing QA decreases for future problem-solving cycles.

The team problem-solving process empowers healthworkers. Before understanding the QA approach, the health centerstaff would not have tackled the problem of malaria reattendants.Although they knew the problem existed, they did not have the skillsto analyze it and implement and monitor solutions. Several teammembers indicated that before using QA, they would just passproblems along to their district supervisors. Now they have theability and experience to solve problems within their scope ofinfluence. They are more likely to initiate change and call for district-level assistance only when necessary. The team members are proudto have implemented one of the definitions of QA in their own healthcenter: “Doing the right thing, right, the first time.”

Children and adults were observed taking theirmedications.

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Endnotes1 Roll Back Malaria website: www.mosquito.who.int. May 2001. “Malaria: a

global crisis.”

2 Community Health Sciences Unit, Malaria Control Programme, MalawiMinistry of Health and Population, June 2001.

3 The health center pays $.09 per dose of SP from Central Medical Stores andgives it to patients free. The retail price for a dose of SP is $1.12.

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Using Team Problem Solving toImprove Adherence with MalariaTreatment Guidelines in Malawi:Summary

In October 1999, as part of the Malawi Community HealthPartnerships Project, the Lifuwu Health Center initiatedteam problem solving to improve the quality of healthcare.A five-member team, with assistance from district-levelcoaches, followed a six-step methodology to improvepatient adherence to malaria treatment. The team hadnoted that many patients were returning with malariasymptoms within a week of being treated. Simple toolswere used to analyze the problem, collect data, and makedecisions. In March 2000, a new system for administer-ing drugs to patients was implemented: instead of sim-ply going home with their malaria drugs as before,patients took their drugs at the health center in the pres-ence of a health worker. Health education, at the healthcenter and in the community, fostered the change byexplaining the new system and its rationale. Comparingthe 12 months before and after the intervention, the av-erage percentage of malaria reattendants fell from 31 to3 percent. This decrease resulted in health center sav-ings of up to $181 for the wholesale price of drugs ($2255retail price) and human resource savings of 235 hours or29 person-days. The solution the team used to resolvethe problem of treatment adherence—the use of directlyobserved treatment (DOT)—is a best practice that couldbe applied at other health centers.

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QUALITY IMPROVEMENT CASE STUDY - USAID ASSIST · 2019-12-30 · QUALITY ASSURANCE PROJECT University Research Co., LLC • 7200 Wisconsin Ave., Suite 600 • Bethesda, MD 20814 •