REPUBLIC OF KENYA

MINISTRY OF HEALTH

PROGRAM QUALITY
AND EFFICIENCY
IMPLEMENTATION HANDBOOK

2022
PROGRAM QUALITY
AND EFFICIENCY
IMPLEMENTATION HANDBOOK

2022
 TABLE OF CONTENTS

Preface................................................................................................................................ iii
Executive Summary............................................................................................................. iv
Acknowledgement.............................................................................................................. vi
Abbreviations..................................................................................................................... vii

Introduction to this Handbook......................................................................................... viii

Who is this Handbook for?.............................................................................................viii
Establishing a Quality/Work Improvement Team............................................................ ix
What is the Purpose of this Handbook?.......................................................................... ix
The Structure of the PQE Handbook............................................................................... ix

Section 1: Problem Identification....................................................................................... 1

Overview.......................................................................................................................... 1

Section 2: QI Project Goal Setting...................................................................................... 5

Overview.......................................................................................................................... 5
Guiding Principles............................................................................................................ 5
Aim Statement................................................................................................................. 6

Section 3: Activity Implementation................................................................................... 11

Overview........................................................................................................................ 11
Operationalizing the Team............................................................................................. 11
Implementing a Small Test of Change........................................................................... 12
Improvement Methodology........................................................................................... 13

Section 4: Performance Measurement.............................................................................. 19

Overview........................................................................................................................ 19
Data Review Guide........................................................................................................ 19

Section 5: Selected QI Tools Sample................................................................................ 23

Annexes: Sample Operational & QI Tools......................................................................... 25

List of Contributors............................................................................................................ 33

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PREFACE

T he Division of National Tuberculosis, Leprosy and Lung Disease Program (DNTLD-Program)

is mandated to develop policies and guidelines for managing Tuberculosis (TB), Leprosy
and Lung Health in the country. Tuberculosis is a major driver of morbidity and mortality in
Kenya affecting all age groups. There are still significant gaps in the diagnosis and treatment of
tuberculosis, leprosy, and other respiratory disorders. This handbook, when used in conjunction
with the TB QI Framework, provides step-by-step assistance in the implementation of a program
quality and efficiency approach to resolving current gaps in the TB care and treatment continuum.
This will also improve the quality of care given to people seeking services in health facilities across
the country.

The success of a quality improvement initiative has so much to do with the implementation
approach it follows, is, therefore, necessary to provide implementing teams with guidance on
how to walk through the activity’s implementation process. The TB QIF highlights the various
implementation structures for program quality and efficiency program, it is for these structures
that this handbook comes in handy by describing the course of action during the implementation
of a QI initiative from problem identification to monitoring and evaluating a QI intervention being
implemented.

The handbook describes a step-wise approach to the application of quality improvement initiatives
for integrated work and quality improvement teams. The handbook describes key steps and
activities to be carried out in an improvement team set up both at the facility and community
levels. This handbook is based on the TB Quality and Improvement Framework which provides
the overarching principles and approaches for quality improvement interventions for the program.

This handbook provides teams with a planned approach to quality improvement interventions
that encompass team formation, problem identification, resource planning and utilization while
applying standard quality improvement methodologies. While great care has been taken to
ensure its usefulness in supporting improvement teams, it is not sufficient on its own, and teams
are encouraged to make use of any quality improvement resource materials, shared experiences
from best practice QI learning forums within their reach for additional learning and to strengthen
their grasp of quality improvement practices in service delivery.

Dr. Patrick Amoth, EBS

Ag. Director General for Health

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 EXECUTIVE SUMMARY

T his guide has been developed as a primer to meet the initial practical needs of Quality
Improvement (QI) teams. A better learning experience just like in any other practice will be
gained through sustained implementation of QI initiatives. Prior training on the art and science
of quality improvement (QI) practice is key in enabling users to better grasp the instructions in
the handbook.

The guide provides a follow through on how to handle key technical steps for a well laid out QI
project. It also highlights basic coordination and relational principles that support improvement
activities. It aims to enable a team to plan, execute, monitor and evaluate their quality improvement
implementation cycles effortlessly. The guide seeks to equip QI teams with a reference point that
is rich in the application for everyday use.

This implementation handbook is intended for use by the health care workers and quality
improvement teams whether engaged in collaborative or stand-alone QI activities, to provide
them with guidance in implementing QI activities in the TB program across all the service delivery
points. It is also aimed at QI coaches and mentors supporting the work and quality improvement
teams. To ensure sustainability and integration of QI initiatives, the handbook highlights key
considerations to guide in the establishment of Quality and Work Improvement teams to drive
implementation.

To aid QI teams implement qi interventions across the processes and outcomes in the TB care
cascade, the handbook has been structured around four key elements of a standard Quality
improvement initiative with successive steps filling into the next course of action. The set of
inter-related steps in the implementation of a QI approach are batched in five sections as follows;
i. Problem Identification – details the guide on how a QI team narrows down to a
particular practice area for intervention
ii. QI Project Goal Setting – provides a guide on setting appropriate and actionable
goals for intervention,
iii. Activity Planning - provides common tasks a team undertakes to set practice settings
when implementing interventions, such as implementation models for use, task
schedules and team management,
iv. Performance Measurement – a guide for developing and tracking performance
measures during the implementation cycle
v. Annexe – provides a sample of introductory tools to aid a team during a QI
implementation cycle.

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While the handbook is intended to guide PQE implementing teams across the program, it does
not replace technical QI guidance and support provided by Ministry of Health quality of care
standards and available guidelines. Where necessary, the implementing teams should undertake
appropriate consultations.

Dr. Andrew Mulwa

Ag. Director of Medical Services, Head Directorate
Preventive and Promotive

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 ACKNOWLEDGEMENT

T he Division of National Tuberculosis, Leprosy and Lung Disease Program (DNTLD-P) is

grateful to all stakeholders for their support and contribution to the development of this
PQE handbook. This was possible through collaboration with different institutions including the
Ministry of Health led by the Division of National Tuberculosis and Leprosy Program (DNTLD-P),
The Directorate of Health Standards Quality Assurance and Regulations (DHSQAR), NASCOP,
County representatives, and partners including CHS TB ARC II, Amref Health Africa, KCCB, Red
Cross, LVCT and SYSTEMS Evaluation limited.

Lastly, I acknowledge with gratitude the financial support to undertake this activity from The
Global Fund and USAID. Finally, special appreciation to the communication team in the program
for finalizing the document.

We also appreciate all those who have contributed in one way but have not been specifically
mentioned. Your efforts are recognized and appreciated.

Special gratitude also goes to the peer reviewers who participated in the review of the document.

Dr. Caroline Asin

Ag. Head, National TB Program

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ABBREVIATIONS

ACF Active Case Finding

CHEW Community Health Extension Worker
CHMT County Health Management Team
CHV Community Health Volunteer
CQI Continuous Quality Improvement
CTLC County TB and Leprosy Disease Coordinator
DOT Directly Observed Therapy
DR-TB Drug-Resistant TB Disease
DS-TB Drug Susceptible TB Disease
DST Drug Susceptibility Test
eKQMH Electronic Kenya Quality Model for Health
HCW Health Care Worker
KQMH Kenya Quality Model for Health
M&E Monitoring and Evaluation
MDR-TB Multi-Drug Resistant TB Disease
MoH Ministry of Health
DNTLDP Division of National Tuberculosis and Leprosy Disease Program
QI Quality Improvement
QIT Quality Improvement Team
SCTLC Sub County TB and Leprosy Disease Co-ordinator
SDP Service Delivery Point
TB Tuberculosis Disease
TB QIF TB Quality Improvement Framework
WIT Work Improvement Team

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 INTRODUCTION TO
THIS HANDBOOK

T his guide has been developed as a primer to meet the initial practical needs of QI
teams, on its own, it is not a comprehensive resource for learning all the QI skills,
techniques and knowledge. Other excellent improvement practice resources are available,1,2
users are therefore encouraged to make references where necessary with the already established
resources and the TB QI Framework. A better learning experience just like in any other practice will
be gained through sustained implementation of QI initiatives. Prior training on the art and science
of quality improvement (QI) practice is key in enabling users to better grasp the instructions in
the handbook.

The guide provides a follow through on how to handle key technical steps for a well laid out QI
project, it also highlights basic coordination and relational principles that support improvement
activities. When applied, therefore, it will enable a team to plan, execute, monitor and evaluate
their quality improvement implementation cycles effortlessly. In developing this guide, we seek
to equip QI teams with a reference point during implementation.

Who is this Handbook for?

This implementation handbook is designed for use by health care workers to provide guidance
in implementing QI activities in the TB program across all the service delivery points namely;
TB and CCC clinic, laboratory, outpatient services, In-patient services, special clinics/units and
community-based care. It is especially aimed at guiding the following key teams and personnel
in QI implementation;
i. TB Program Managers/Officers (CTLC/SCTLC)
ii. QI Focal Persons/Coaches/Mentors
iii. QI Teams
iv. Work Improvement Teams
v. County implementing partners
vi. Health facility management teams.

It is also designed to guide quality improvement teams not necessarily engaged in PQE
collaborative activities. Finally, it is aimed at QI coaches and mentors supporting the work and
quality improvement teams.

1
Kenya Quality Model for Health. MoH
2
Kenya HIV Quality Improvement Framework. NASCOP

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 NOTE: Quality / Work improvement teams shall be established in-line with the
TB QI framework guide. The membership and roles shall also be aligned to
the existing ToR as per KQMH and the TB QI Framework.

What is the Purpose of this Handbook?

While the handbook is intended to guide PQE implementing teams across the program, it does
not replace technical QI guidance and support provided by MoH quality of care standards and
available guidelines. Where necessary, the implementing teams should undertake appropriate
consultations.

The Structure of the PQE Handbook

This handbook is designed to act as a guide to teams implementing Program Quality and Efficiency
initiatives to improve TB case identification, management and health outcomes. This handbook
contains a set of inter-related steps in the implementation of a QI approach for processes and
outcomes across the TB care cascade;
i. Section I: Problem Identification – details the guide on how a QI team narrows down to
a particular performance gap for intervention.
ii. Section II: QI Project Goal Setting – provides a guide on setting appropriate and
actionable goals for an intervention.
iii. Section III: Activity Planning - provides common tasks a team undertakes to address the
identified root causes of the identified problem of the performance gap.
iv. Section IV: Performance measurement – a guide developing and tracking performance
measures during the implementation cycle.
v. Section V: Annex – provides a sample of introductory tools to aid a team during a QI
implementation cycle.

Establishing a Quality/Work Improvement Team

Quality improvement is a work approach in solving existing gaps within a health system to
improve the quality of care and performance. Its success is pegged on the involvement of the
team that is implementeing the improvement ideas3. QI projects work best when priorities are
set locally unless external benchmarking data show otherwise, to sustain implementation of the
program quality and efficiency activities, every facility should establish work improvement teams
or integrate existing improvement teams to drive the implementation. Some key considerations
on individual skills mix to guide team membership composition;
i. Subject matter expert – a clinician versed in TB clinical care.
ii. Improvement champion – a member conversant with QI methodologies.
iii. Data handler – member conversant with basic data abstraction and management
techniques.

3
Kenya Quality Model for Health. MoH

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 iv. Care advocate – a patient representative from the local TB community group.
v. Community health representative – member conversant with TB care pathway within
the community health unit.
vi. Process owner – member with overall administrative/management responsibility of the
program at the respective level.

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SECTION 1:
PROBLEM
IDENTIFICATION
Overview
At the onset of every improvement initiative, teams will need to identify/scope for new projects/
programmes of work and identify gaps in clinical practice.
This section is to enable the team to handle three key steps in the QI cycle;
i. Gap Analysis:– An overview of care dimensions against results achieved.
ii. Situation Analysis:– A deeper dive into the potential listed problems analysing existing
data to gain a deeper understanding of the gap identified.
iii. Root Cause Analysis:– a look into a wider variety of potential causes of the identified
problem.

This section guides the teams on how to approach this key step by reviewing existing evidence
on the given topic to identify key issues for consideration.

Phases:
• Initiation meeting – enable the team members to identify a QI topic and objectify it
• Relevant evidence retrieval as per the QI topic identified
• Critical analysis of evidence, and
• Development of project mandate.

Table 1: Problem Identification Steps

Stepwise approach to Problem Identification – Example based on TB ACF Cascade

Key steps/ ACF Quality of Care dimensions based on standards, guidelines, client needs and
Questions expectations; QI Tools and Data Sources

Key steps Description QI Tools Data sources for ACF

Step 1: The first step in problem 1. Bar Graph 1. Facility ACF Summary
Identification diagnosis is gathering 2. Pie Chart 2. Departmental ACF
of gaps/ information to establish the Summary
diagnosing current status. The work 3. Histogram
the problem improvement team (WIT) will 4. 5 S’s Tool 3. Data abstraction tool
lead the collection, analysis, 4. Presumptive register
synthesis and comparison of 5. TB4 Register
data with defined standards.
This includes an assessment of 6. CMR
the work environment. 7. Laboratory reports.

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 Key steps Description QI Tools Data sources for ACF
Step 2: After the WIT has identified 1. Brainstorming 1. Facility ACF Summary
Situation gaps, they should delve 2. Time Series/Run 2. Departmental ACF
Analysis deeper into the listed Chart Summary
problems to get a better
understanding of the various 3. Flow chart/Process 3. Data abstraction tool
dimensions of the problems Map 4. Presumptive register
to inform the process of 4. Pareto Chart 5. TB4 Register
prioritization. 5. Client focus groups. 6. CMR
7. Laboratory reports.
Step 3: From the list of identified 1. Pareto chart 1. Brainstorming Sessions
Problem problems, the WIT should 2. Decision matrix 2. Facility reports.
prioritization then proceed to prioritize the
problems to focus on the most 3. Multi-voting.
important problems which
when addressed are likely to
have the highest impact.
Step 4: Root The WIT should then conduct 1. Cause and effect 1. Brainstorming Sessions
cause analysis a process of identifying diagram (fishbone) 2. Facility reports.
the underlying sources 2. 5 whys
of problems to identify
appropriate solutions. 3. Flow charts.

Table 2: Problem Identification Guide - ACF Care Cascade Sample

ACF Specific Considerations during problem diagnosis4

While applying the above process to problem identification, there are some key considerations to
take into account in the context of TB ACF. These considerations are however not exhaustive.

Step in the Considerations Standards

cascade/
Domain
Workload 1. Include all service delivery points/departments All service delivery points
that contribute to the facility ambulatory workload should be conducting TB
while establishing the facility workload such as ACF.
OPD, MCH, pediatric OPD, nutrition clinic.
All service delivery points
2. Use process maps or flow charts to analyze should have the prerequisite
patient flow through various service delivery tools for TB screening.
points including the laboratory and identify
where, why, and how patients are missed by
active case finding.
3. Check availability and quality of documentation
of the workload and screening across all
departments.

4
ACF Toolkit. Field guide on systematic screening of active TB in Kenya. 2016

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Step in the Considerations Standards
cascade/
Domain
Screening 1. Review both quantitative and qualitative ACF 100% of the workload
data from both primary and secondary data should be screened for TB.
sources, previous supervision reports, routine All persons in the health
data abstraction, Patient feedback/Patient facility need to be screened
engagements forums/support groups/ Patient exit routinely for TB as per the
interviews. symptomatic screening
checklist & ACF toolkit.
2. Compare the actual situation with the standards.
3. Check how many service delivery points in the Screening should be
facility should be conducting ACF documented in the 705A
4. Check how many of these have ACF service in and B.
place.

Presumptive 1. Check the understanding among HCW of how 10 -20% of people screened
presumptive TB cases are defined across different are presumptive for TB.
service delivery points. All presumptive for TB
must be documented in the
presumptive register.

Investigated 1. Check availability of sample collection SOP/Job 100% of presumptive TB

Aid and that it is in use. should be investigated
(laboratory and/or imaging).
2. Check on the frequency of sample transportation.
3. Measure and monitor Turn-Around Time for
sample delivery to the laboratory and result
feedback.
4. Compare the yield of the outcome/test with the
standard.

Diagnosed This includes those bacteriologically confirmed 5-10% of the presumptive

with TB from sputum, stool, aspirates as well as the clinically patients are expected to
diagnosed (X-ray, history, etc.). have TB.
Bacteriologically confirmed are expected to be 70%
and clinically diagnosed 30%.

Linked to 1. Pay attention to the linkage process, use process Linkage to treatments -
treatment and flow charts to find potential gaps that would 100% of all those diagnosed
result in loss of patients. with TB should be started on
treatment and notified.
2. Check that all diagnosed in the laboratory are
initiated on treatment.
3. Check for the presence of an active linkage
process such as escorted linkage.

Completed Treatment outcomes for all patients put on TB 90% and above should be
treatment medication. successfully treated.

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 Step in the Considerations Standards
cascade/
Domain
Leadership 1. Check for presence and activity of a facility quality Established QI/Work
and improvement team including representation of Improvement Teams.
governance ACF focal person, and community representative.
Terms of Reference for QI/
2. Check for availability of an ACF focal person in Work Improvement team
the facility, an ACF champion in departments. members elaborated.
3. Check regularity of facility management and
departmental meetings and inclusion of TB/ACF
in the agenda.
4. Check for inclusion of TB/ACF in the facility and
departmental work plans.

Community- 1. Check that the facility has an established Community-level activities

facility connection to the community health structures linked to the facility-based
linkage through the community health and public health quality improvement
departments. activities.
2. Check that TB/ACF tasks for the officers from
these departments include mobilization, referral
and linkage, and follow-up in the community are
included in the roles of the CHVs.

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SECTION 2:
QI PROJECT
GOAL SETTING
Overview
For each project mandate that the work improvement team develops, an accompanying goal
shall be developed. This enables the team to determine its desired progress path during the
improvement process.

The steps below are provided as a guide to aid teams in goal setting:
1. The county profile will provide the baseline for every program indicator under review for
PQE initiative, this will be disaggregated by county, -sub-county and health facilities for
ease of context by the PQE team
2. The team shall apply an incremental approach in setting improvement goals to enable it
meet the sub-county and county targets
3. The work and quality improvement teams will set goals based on the principles outlined
below.

Guiding Principles
The goals are similar to SMART objectives--remember you want to have ‘stretch’ goals. The team
should set ambitious goals broken down into manageable bits for quick wins through small tests
of change. This enables the team to build momentum from the small bits of success and not to
lose focus from disappointments from the tests that don’t meet expectations.
1. What are we trying to accomplish?
a. Identify the problem and identify the overall goal (i.e. your long term outcome).
b. Use words like improve, reduce, and increase.
2. Why is it important?
a. This should answer the questions “so what?” or “why bother doing this project?”
3. Who is the specific target population?
a. Who or what area is the project focused on?
4. When will this be completed?
a. Include a specific time for completing the improvements (month/day/year).
5. How will this be carried out?
a. It is NOT a specific list of tasks/strategies you will do, instead what methods you

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 will use at a high level (i.e. QI methods and principles).
6. What are your measurable goals?
a. What are some processes and short term outcome goals that will help you know
that you have achieved your overall project aim? (e.g. - ACF cascade standards).
b. Include 4-6 goals.
c. Break down the ACF cascade standards into achievable targets spread over a
period of time to eventually achieve the standard.

Aim Statement
Consistent with the program performance reviews and the problem identified in Section I i.e. after
the root cause analysis process, the QI team should identify change ideas or countermeasures
that can be implemented to address the root causes contributing to the identified problem. The
basic QI tools for use during this process include;
1. Prioritization/Decision.
2. Aim Statement Matrix.
3. Driver Diagram.

Table 3: Four Column Aim Statement Matrix (Examples in bold)

QI Project Aims Performance Link project to the Organizational QoC

Measures Organizational Aims Aims
What does the QI How do you know How you know How the project
project address: your project is your project is contributes to
progressing towards progressing towards improving the ACF
To increase the rate your aims: your aims: cascade indicator:
of presumptive case
identification from Presumptive cases % Increase from the How do we measure
the current 6% of all identified from all identification rate of the impact this
RTI patients seen at RTI patients seen at 6% of all RTI patients the project will have
the OPD to 15% in the OPD seen at the OPD on ACF? – Increase
the next 12 weeks (Ratio or Rate) in overall Case
Identification

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Figure 1: Driver Diagram Template
Improvement focus: Active Case Finding

Aim Primary Drivers Secondary Drivers Change Concepts

Primary • System components • Elements of the associated • Small Tests of Change

which will contribute primary driver – used to (PDSA Cycles)
Outcome
to moving the aim create projects/tests of • Tasks/Action Plans
• Outcome Measure(s) change that will affect the
• Measures
primary driver
• Process Measure(s)

To strengthen Structured Availability of PQE Develop PQE implementation tool kit

& improve the approach to implementation tools
implementation PQE and ACF Develop ACF fliers out of the toolkit
of ACF by implementation Availability of ACF
mainstreaming across the country implementation toolkit Disseminate tools to the health facilities
Program Quality
and Efficiency
Establishment of PQE Train teams on PQE
approach for TB
case finding. PQE teams in Health Facilities
implementation Pair PQE teams with coaches/mentors
teams Reactivate & strengthen
dormant existing PQE Provide routine Technical Assistance
teams
Task schedules and responsibility allocation
ACF activity PQE Activity work plan
implementation Monitor implementation progress
based on PQE Implementation
approach resources/inputs Rationalize and optimize available resources

The driver diagram should be used to list possible change ideas for each aim statement. The
change ideas are then scored using a prioritization/decision matrix to pick on which change idea
to be implemented first.

The matrix ranks change ideas from 1 to 3 based on:

• Time required to implement the change (least time to implement the change idea
ranks high),
• Resources needed to implement the change (fewer resources ranks high)
• Importance of the change in improvement (more important ranks high)
• The Urgency to implement the change (more urgent gets a higher rank)
• Difficulty in implementing the change (easy to implement ranks high while a change that
is difficult to implement is ranked low).

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 Table 4: Sample TRIUD Decision/Prioritization Matrix Template

Proposed change ideas for implementation Score the change ideas using the matrix
consideration below, the highest-ranked idea is prioritised
for implementation

T R I U D TOTAL

1.
2.
3.
4.
5.
Notes:
T – Time required to implement the change (least time to implement the change idea ranks high),
R – Resources needed to implement the change (fewer resources ranks high).
I – Importance of the change in improvement (more important ranks high).
U – Urgency to implement the change (more urgent gets a higher rank).
D – Difficulty in implementing the change (easy to implement ranks high while a change that is
difficult to implement is ranked low).

Figure 2: Tree Diagram with Decision Matrix

NB: Where two or more change ideas get an equal score, the QI team member should rank and
score the change ideas individually, the change idea that is scored highest by most members, is
prioritized for testing.

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The QI team will set process and short terms outcome goals based on gaps identified along the
TB ACF cascade of care, in line with the standards outlined in the table below:

Table 5: ACF Care Cascade Standards

Component Standards Assumptions Source documents

Workload All service delivery points All SDPs across the facility MOH 717,
should be conducting TB document workload output.
MOH 731 and MOH 366
ACF
(HIV Care and treatment
All service delivery - Daily Activity Register).
points should have the
prerequisite tools for TB
screening.
Screening 100% workload should be All clients/patients visiting TB symptoms
symptomatically screened the health facilities will be questionnaire.
for TB. symptomatically screened for
ACF Rubber stamp.
TB.
100% of bacteriologically
confirmed TB patients All contacts of bacteriologically
and children under 5 confirmed TB patients and
years with TB should have children under 5 years with TB
their contacts screened. will be screened.
Presumptive 10 - 20% of people 15 - 30% of people screened MOH 705 A & B at OPD
screened are presumptive will have respiratory
for TB. symptoms.
Other departments
At least 60% of those with
will use daily activity
respiratory symptoms who
registers and/or
are clinically evaluated are
summaries to get the
presumptive.
proportion of clients with
respiratory illnessamong
the total caseload.
Investigated 100% of presumptive TB Presumptive persons should Presumptive TB register
should be investigated be investigated either through
Lab register
(laboratory and/or laboratory tests and or
imaging). imaging. Imaging registers.
Diagnosed 5-15% of the presumptive This includes those Presumptive register.
with TB will be diagnosed with bacteriologically confirmed
TB. from sputum, stool, aspirates
as well as the clinically
diagnosed (X-ray, history, etc.).
Bacteriologically confirmed
are expected to be 70% and
clinically diagnosed 30%.
Linked to 100% of people All diagnosed TB cases (Cases TB Patients Record card
treatment diagnosed with TB should Identified) should be notified (TB-5)
be put on treatment. from the facility to the national
TB treatment registers
level.
(TB-4).

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 Component Standards Assumptions Source documents

Completed 90% and above should Treatment outcomes for all TB4 facility treatment
treatment be successfully treated. patients put on TB treatment. register.

Box 1: Sample Goal Statement

To increase linkage to treatment of persons diagnosed with TB from the
current 76% to 90% in the next 6 months.

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SECTION 3:
ACTIVITY
IMPLEMENTATION
Overview
This section provides a team with guidance on how to approach the implementation of a QI
initiative, from planning to execution. It highlights the conduct of team engagements, proposed
key tools to aid the process and the proposed QI methodology for deploying the small tests of
change.

Operationalizing the team

Key elements that drive a quality or work improvement team’s success at the facility
i. Having the right mix of people for the local improvement team in each workplace; include
patients, clinicians, middle managers, and others who do the work.
ii. Identifying a team leader who is not necessarily the most senior clinician, but someone
able to champion the cause, is committed and can encourage and facilitate teamwork
within the workplace.
iii. Senior program/facility staff’s ability to acknowledge the importance of the work, and
provide support and resources (allowing meeting time), but not impeding the operations
of the team.

Roles and Responsibilities of Team Members

Each member of a QI/Work Improvement Team is responsible for any aspect of the team’s
objectives and is relied upon for his/her active participation through; information and experience
sharing, perspectives and ideas generation, decision making and activities planning. Some of
these responsibilities include and are not limited to;
i. Attending and participating in all team meetings.
ii. Helping ensure that the team stays on track and focused on its goals.
iii. Sharing responsibility for tasks outside of team meetings e.g. communicating team
decisions, clients/staff education and data collection.
iv. Reviewing and defining the roles of team members.
v. Reviewing and defining team goals and objectives.
vi. Establishing team ground rules and meeting schedules.

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 Meeting Guide for Implementation Teams
Every team should at the onset establish the meeting ground rules, along with these areas and
much more as per context:
i. Attendance: Accepted reasons for non-attendance and the procedure to follow for
expected absence
ii. Quorum: Minimum number of team members present for meeting to proceed
iii. Meetings: Agreed venue, time, frequency, breaks, and acceptable interruptions
iv. Participation: Active participation guide, speaking freely, listening to each other, basic
conversation courtesy and conduct
v. Tasks/action points: Responsibility allocation and completion timelines

Meeting productivity guide - suggested key considerations;

Consider 30 minutes to 45 minutes meeting duration every week or every two weeks depending
on the task.
i. Every meeting should have an agenda brief with a:
a. Defined meeting agenda.
b. Defined meeting objective/and purpose.
c. Summary of key action points after every meeting.
ii. Appropriately document meetings using:
a. Meeting template annexed
b. Implementation progress tracker may also be tracked using:
• QI Project Checklist.
• PDSA Summary sheet.
• QI Project Plan.

Implementing a small test of change

Having prioritized a change idea and an aim statement developed for it, the QI team should plan
on how to put the idea to test, allocate and spread out the tasks to enable ease of implementation.
The basic QI tools to support the team in this process are;
1. Work Environment Improvement (5S) Tools.
2. Activity plan template.
3. PDSA Cycle Template.
4. PDSA test recording template.

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Improvement Methodology
1. Work Environment Assessment and Improvement
Work environment assessment and improvement is a critical process in the quality improvement
cycle. The 6S Process provides a structured approach to enable a team to organize and achieve
cleanliness around the workspaces. It’s an organization approach guided by 6 words that start
with the letter S;

Figure 4: 6S Template

Establishing Eliminating
improvements unnecessary care
aspects/processes
gained as part of
SUSTAIN SORT
common practice
(SHIKILIA) (SASAMBUA)

Ordered tasks/
commodities for
SAFETY efficiency
(USALAMA)

STANDARDIZE Assuring safety of SET

(SANIFISHA)
staff & patients (SETI)
with every task
Establishing
implemented
standard care
protocols
Cleaning and
SHINE establishing order
(SAFISHA) in the workplace

Once the workplace has been organised, the team is in a better position for the introduction of
continuous quality improvement using the Model for Improvement methodology described here.

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 Table 7: 6S Description

6S Phase Sort Set Shine Standardize Sustain Safety

Actions Eliminate Organize Keep spaces Make the 1 st
Train staff Assure safety
clutter, and store clean and 3S (Sorting, on the 6S for staff and
unnecessary everything tidy at all Setting & discipline patients
processes in its rightful times and Shining) the when
or things place with it is better norm in all
Consistently carrying out
that add no clear labels to clean as workspaces
apply the 6S the work
value to care work is done approach environment
delivery Organize Document the to all improvement
Maintain equipment Tidy up process for workspaces tasks
only /items in workspaces each service to enable e.g.
essential a way that at the end & develop the culture appropriate
tools and supports of the day standard to take root PPE for staff
equipment ease of ready for the operating while sorting
usage next day or procedures a storage
person room

2. The Model for Improvement (PDSA)5

PDSA model is a framework for developing, testing and implementing changes in the improvement
practice. PDSA is used for action-oriented learning and incorporates testing a change in the real
work setting by planning, implementing, observing results, and then acting on what is learned,
Once the QI team makes a decision on which change idea will be implemented first, activity
planning and resource allocation should be done to support the implementation of the change
idea. This can be done using the PDSA improvement model (Plan, Do, Study and Act). Detailed
planning should be done by the team before commencing implementation and testing of each
proposed change idea.

Figure 5: PDSA Explainer

PDSA Primer Questions that every test cycle should answer:

1. What are we trying to accomplish?
2. How will we know that change is an improvement?
3. What change can we make that will result in an improvement?

5
Institute for Healthcare Improvement. Model for Improvement: ihi.org/PDSA

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 • What will happen if we try something different?
• State Objectives, Questions/Predictions.
PLAN • Develop plan to test the change - Who, When, Where, How?
• Identify the data to collect.

• Let’s try it! - Carry out the plan on a small scale.

DO • Document observations - processes, outcomes, problems/challenges.
• Start making sense of the data being collected.

• Did it work? - Complete data analysis.

STUDY • Compare results with predictions at the palnning stage.
• Summarize and reflect on lessons learnt.

• What’s NEXT? - Adapt, Adopt, Abandon?

• Ready to implement?
ACT
• Give it anaother try?
• Plan and prepare for the next test cycle?

PLAN
• The team should state what they aim to achieve (Prediction) on implementation of the
proposed change idea
- What is the expected result following change idea implementation?
• The implementation plan should be developed to answer the below question with sharing
of tasks among the team members
- What will be done?
- When will it be done?
- Who will do it?
- Where will it be done?
- How will be done?
NB: A detailed work plan with activities, period, and the responsible person per activity by names

Table 8: Activity Plan Template

Objective Task Timeframe Responsible person Status of

(indicate names) implementation

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 • Plan for monitoring of the change idea to be implemented
- What will be measured? - A process indicator to measure the change idea; Define
the process indicator and describe what will be the numerator and the denominator
- Where will it be done? - Where will the data be collected (on excel sheet or existing
M&E tool)
- Who will do it? - Responsible person identified to carry out the specific tasks and
collect the data to monitor the process indicator
- When will it be done? - Defined time period, either daily weekly or monthly to at
least have 6-10 data points
- How will be done? – Clear description of task to be implemented

DO
Once the team develops their implementation plan, proceed to implement the change idea and
collect data as planned.
It is recommended that change ideas are tested within the shortest period possible for collection
of just enough data for learning. The testing period should be sufficient to collect 10 - 12 data
points as per the reporting frequency for the measurement indicator being tracked
Documentation should be done step by step during the implementation period.

STUDY
- Analyze the collected data for the defined period stated in the plan
- Small tests of changes (STOC) should be done using a run chart.
- Compare the analyzed data with your set prediction
- Is there an improvement? If yes, by how much?
- Is the process more difficult using new methods?

ACT
- Based on the data analysis, was the change successful?
- If yes, adopt the change and impliment it as part of the improvement process
- If not successful, review the change to determine reasons for poor performance, refine the
process, and plan another test cycle

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Table 9: PDSA Test Cycle Recording Template

PDSA Experiment Cycles Record

Date Target Condition (Aim/Problem Statement)

Process

PLAN DO STUDY ACT

Task Expectation What Happened What we learnt

NB: The PDSA cycle should be applied to each change idea individually. At the end of each
cycle, data analysis should guide on whether the change idea was successful, requiring scale-up/
sustaining or if it was not successful.

3. Community Based Implementation

Communities, households, and individuals are the central actors in primary health services
and are key in the quality improvement initiatives across the TB care cascade. Community-
level Work Improvement team members will be integrated into the facility WIT/QITs, this is to
enable identification and incorporation of relevant community activities that will help improve
implementation of the problems identified for Quality Improvement.

Suggested key community level-oriented efforts to drive ACF-PQE implementation;

1. Community-based health education
2. Finding people with TB symptoms within the community health units
3. Prevent the spread of TB and
4. Supporting access to diagnosis and treatment linkages
5. Providing community level DOTs services
6. Enabling patient-level engagement for improved quality of care.

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 Table 10: Community Level ACF care cascade activities

Activity Suggested steps

1 Investigation 1. HCW line-list contacts of index TB patients and give to CHVs
contacts of TB
patients 2. CHVs visit households of the patients to provide health
education and screen all contacts

3. CHV refer Contacts with TB symptoms to health facilities for further

investigations using MOH 100

4. CHVs refer all children under five years for initiation on

TB preventive therapy (TPT)

5. CHV work with HCW to ensure correct documentation

6. Other community members can also be trained to identify signs of TB

and how to refer possible TB patients to the appropriate facilities.

2 Integrated 1. HCWs and SCTLCs identify hotspots

community 2. Ride on existing outreaches for
outreaches
3. Link up with the county to organize targeted outreaches
4. CHVs support mobilization
5. CHV work with HCW to ensure correct documentation

3 Tracing patients 1. HCW identify any treatment interrupters from the TB4 register and
who interrupt the appointment diary.
TB treatment
2. HCW call all patients who miss appointments within 24 hours of
missing their scheduled appointment.
3. HCW give a list of treatment interrupters who are not reached
on phone and those who do not turn up on the date of the re-
scheduled appointment to the CHEWs/CHVs for physical tracing
and fill section A of the interrupters tracing form.
4. The CHV will trace the patient in the community and document the
outcome
5. CHV work with HCW to ensure correct documentation

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SECTION 4:
PERFORMANCE
MEASUREMENT
Overview
Performance measurement is the process of collecting, analyzing and reporting information
for purposes of tracking a process, project, system or organization, and is aimed at helping
organizations measure achievements of strategic goals and streamlining decision making. It is a
tool for identifying bottlenecks, gaps and tracking progress in quality improvement initiatives to
recommend improvement change ideas.

Data Review Guide

Purpose
This section describes the procedure for review and analysis of data duringthe implementation of
the TB quality improvement.

Scope of the data review guide

This guide is can be used by facility and community-based PQE teams to guide the following:-
- Data mining and summarizing.
- The review process and observations reporting.
- Observations trend analysis.
- Comparing achievements with targets (compliance to set project targets).

Frequency
The data review process will be conducted regularly (weekly, fortnightly, monthly) as agreed by
the WIT, depending on the area of focus. The process will be chaired by the WIT Team Lead.

Standard Recording and Reporting Tools to be used

1. MoH 204 A & B
2. MoH 705 A & B
3. Presumptive TB Register
4. Laboratory Register
5. TB Facility Register
6. Departmental and Facility Summary Tools e.g. ACF Facility Summary.

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 Standard Operation Procedure
Before the data review process, the WIT team need to:
1. Review the indicators discussed and agreed upon during goal setting.
2. Agree and document the method of tracking data e.g run charts/ graphs etc.

Procedure for Data mining and summarizing

1. Gather all data recording and reporting tools for the period under review
2. Assess tools for completeness and accuracy
3. Aggregate all the data from the various SDP tools against the relevant reporting indicators.

Observations trend analysis

1. Generate run charts/graphs on performance trends of key indicators during the period of
interest. If the facility is using physical tools plot data in the developed run charts/graphs
2. Highlight the peaks and dips for further detailed discussions.

Comparing achievements with targets (compliance to set QI targets)

1. Check for deviations against the set targets across all the indicators.
2. Brainstorm on the possible causes of the deviations
3. Develop an action plan on the issues identified.

Procedure for Data Review Process

1. The WIT to schedule a data review meeting with the facility staff.
2. Review the data that has been mined from the recording and reporting tools against the
set targets
3. For those areas that the target has been met, brainstorm on the best practices and areas
of sustenance
4. For those areas that the target has not been met, discuss the possible bottlenecks and
identify areas of improvement.
5. Objectively and realistically, identify the areas of focus for the next QI cycle
NB: Process indicator should be developed with defined Numerator and Denominator to track
the QI process implementation e.g.

Table 11: Indicator Reference Sheet Template

Process Indicator Numerator Denominator

The proportion of patients Number of clients screened Total number of clients visiting the
screened for TB using a using a TB symptoms screening health facility
screening checklist checklist at the SDPs

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Table 12: Data Abstraction Guide

QI Data Abstraction Tool: Indicator _____________________________________________________

Review Period: From__________________ To: __________________

INSTRUCTIONS: For every indicator, calculate the numerator and denominator based on the
definition. Sources vary depending on the indicator. Transfer the num/den values to your QI
Indicator Summary report.

Option: Instead of using this tool, the team could directly populate the indicator reference sheet,
using the preceding performance reports.

S.No. Performance Definition: Numerator Definition: Num Den %

Measure (Source) Denominator
(Source)
1.0 Rate of facility Number of the Number of patients
presumptive presumptive TB cases screened for TB in
case accurately filled during the facility during
identification the review period the review period
(Presumptive Register) (204 A&B Register)

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SECTION 5:
SELECTED QI
TOOLS SAMPLE
Table 13: Tools description

Tool Purpose Location Responsible

Person
MoH 204 A & B A facility tool for recording TB screening OPD Clinician
data (number screened for TB)
MoH 705 A & B Provides the monthly facility workload Health records Facility HRIO
office
Presumptive A tool used in the facility to record people SDPs Clinician
register who are presumed to have TB
Facility/ dept ACF Summarizes TB case finding data along the SDPs and Health Department
summary tools care cascade records office In-charge
Lab Register Collects data of people who have Lab Laboratory
investigated for TB disease among the Technologist
presumptive
TB4 facility Collects data on people who are being Chest Clinic TB Clinician
register initiated on TB treatment
Data review guide Provides a step by step process of mining QI Office Work
data from the various tools to measure the Improvement
achievement Teams
WIT/QIT Meeting To provide a structured approach to WIT/QIT Folder WIT Team
Template documenting team discussions Scribe
WIT/QIT Work Provides a team with a guide on key WIT/QIT Folder WIT Team
planning Template elements for consideration in the Scribe
development of the activity work plan
Run Chart Enables a team to monitor progress WIT/QIT Folder, WIT Team
and visualize achievement through the Project corner/ Scribe
implementation cycle of a QI project wall display
QI Project Enables the team to track progress in the WIT/QIT Folder WIT Team
Checklist course of implementing a QI project. Not Scribe
every QI cycle will necessarily include every
step
WIT QI Project Used to document the improvement WIT/QIT Folder WIT Team
Template journey and develop a presentation that Scribe
can be used during dissemination or to
document lessons learned if an intervention
was not successful

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 Table 14: QI Tools and Usage

Root
Problem Activity Performance Sustenance/
QI Tool / Usage Cause
Identification Planning Measurement Maintenance
Analysis
Bar graph, Pie Chart,
1 X
Histogram
2 Brainstorming X X
Cause & Effect/Fishbone
3 X
Diagram
Client Focused Group
4 X
Discussion
5 Decision Matrix X X
6 Driver Diagram X
7 Flow Chart/Process Map X X
8 Pareto Chart X X X
Run Chart/Time Series
9 X X
Chart
Statistical Process
10 X X
Control Chart
‘6S’ tools – Tags, Colour
11 X X
Codes, 6S Corner/Board
12 5 Why Template X
QI Team meeting
13 X X X X X
template
QI Activity work-planning
14 X X X X X
template
QI Project
15 X X X X X
Implementation Checklist
QI Project Summary
16 X
Sheet

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ANNEXES:
SAMPLE OPERATIONAL
& QI TOOLS
Table 15: Data Review Guide Template

ACF care Standard Standard Under- Review Baseline Target Achieve- Com-
cascade performance recording standing data (col- (Current (What ment ments
measure- and report- of the data late from status) Target (Achieved (Challeng-
ments ing tools collection all SDPs did you results es, best
tools us- and check set for based on practices.
age against ex- this QI the indica- Lessons
pectation) project) tors) learnt)
Screening 100% of the MoH 204 A
workload &B
MoH 705 A
&B
TPT / ICF
cards
Identifica- 10-15% 0f all Presumptive
tion of pre- screened register
sumptive Facility and
departmen-
tal summary
Testing 100% of all Lab register/
presumptive Presumptive
should be register
linked to
testing
Testing 10% of all Lab register/
yield tested should TB4 register
be TB posi-
tive
Care and 100% 0f all TB4 Register
Treatment those diag-
nosed should
be linked to
treatment
Other
cross-cut-
ting issues
e.g. infra-
structure,
training

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 Driver Diagram (Adapted from Agency for Healthcare Research and Quality)

Improvement focus: Active Case Finding

Aim Primary Drivers Secondary Drivers Change Concepts

Primary • System components • Elements of the associated • Small Tests of Change

which will contribute primary driver – used to (PDSA Cycles)
Outcome
to moving the aim create projects/tests of • Tasks/Action Plans
• Outcome Measure(s) change that will affect the
• Measures
primary driver
• Process Measure(s)

To strengthen Structured Availability of PQE Develop PQE implementation tool kit

& improve the approach to implementation tools
implementation PQE and ACF Develop ACF fliers out of the toolkit
of ACF by implementation Availability of ACF
mainstreaming across the country implementation toolkit Disseminate tools to the health facilities
Program Quality
and Efficiency
Establishment of PQE Train teams on PQE
approach for TB
case finding. PQE teams in Health Facilities
implementation Pair PQE teams with coaches/mentors
teams Reactivate & strengthen
dormant existing PQE Provide routine Technical Assistance
teams
Task schedules and responsibility allocation
ACF activity PQE Activity work plan
implementation Monitor implementation progress
based on PQE Implementation
approach resources/inputs Rationalize and optimize available resources

A driver diagram enables a team to conceptualise a problem, determine its system components
and create a pathway to get to the goal

Figure 6: Run Chart Sample

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Figure 7:Fishbone Template

ENVIRONMENT EQUIPMENT

Power fluctuations Higher module GXpert

machines

Networked lab out Down time – interruptions EFFECT

of range
Long turn-
around time for
lab results
Unnecessary lab No one available to
processes process specimen
Cartridge stock-outs

No FIFO in place Clinician not

Sputum
relaying results
containers

MATERIALS PROCEDURES PEOPLE

Figure 8: 5 WHYs Template – Adapted from Agency for Healthcare Research and Quality
DEFINE
THE Define problem here
PROBLEM

WHY IS PRIMARY CAUSE

THIS A Why is it happening?
PROBLEM? 1 - It is happening because
Why is that?
2 - It is happening because
Why is that?
3 - It is happening because
Why is that?
4 - It is happening because
Why is that? ROOT CAUSE
NOTE: If the final “Why”
has no controllable
solution, return to the 5 - It is happening because
previous “Why.”

CORRECTIVE CORRECTIVE ACTION PARTY RESPONSIBLE

ACTION TO
TAKE
DATE ACTION TO BEGIN
Describe action here

DATE TO COMPLETE

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 Flow Chart / Process Map (Basic Shapes & Sample)

Basic Instructions;
Start & End of Task / Activity
Process 1. Have the “right” people on the
table (persons with the best
knowledge of the process)
2. Define the 1st and last step in the
process
3. Fill in the steps “as is” (Not the
Decision Point
desired) – take note of parallel steps
(Yes / No)
Flow Connector 4. Review for accuracy/completeness
5. Assign tasks/action items to team
members for respective steps
(assures accuracy)
6. Analyse the complete chart – pick
action areas/improvement ideas &
update where necessary

Figure 9: Sample Case Finding Flow Chart

Screen for YES Further Clinical

Triage Desk Resp.
Respiratory Assessment
Symptoms
symptoms

NO

NO
Discharge / Routine Care Presumptive
Transfer for TB

YES

Initiate TB Tx & YES Investigate –

Bact Dx Sputum/CXR
Notify

NO

Further Clinical
Assessment

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QI TEAM MEETING TEMPLATE

Facility: MFL Code: Department:

WIT Unit: Date Venue:

Members present:

Apologies:

Agenda: (Sample)
1. Review previous meeting minutes
2. Status Report on previous action points
3. Discuss current performance data and QI projects progress.
4. Way forward
5. AOB.

Meeting Minutes: (Main points of discussion during the meeting)

Action Points:

SN Tasks Responsible Due Date Status

Party
1
2
3

Ownership:
WIT T/L: Date: Sign:
WIT Scribe: Date: Sign:
WIT Member: Date: Sign:
WIT Sponsor: Date: Sign:

NB: Meeting minutes to be shared with all members of the team after each meeting with a copy
filed in the WIT document folder.

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 QI PROJECT PLANNING TEMPLATE

County/Sub County: Team Lead: Team Members: Project Title: Reducing

sputum sample rejection
by 30% in the next 3
months
Facility: Project Champion: Project Period:

Department: Project Sponsor:

Task List – From the Driver Dia- Process Measure Goal

gram Change Ideas
1. Patient education

2. Specimen collection support

3.

Task Change Tasks to PDSA Responsible Timeline (T=Test; I=Implement; S=Spread)

List Idea prepare Person
No. for Test Week

1 2 3 4 5 6 7 8 9 10 11 12
1 Provide Avail The James & T T
fliers with enough clinician Rita
sputum fliers at will hand
collection SDPs the flier
with a
specimen
bottle

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Figure 10: PDSA Cycle Short Form – Adapted from Institute for Healthcare Improvement

PDSA Worksheet for Testing Change

Aim: (the overall goal you wish to achieve)

Every goal will require multiple smaller tests of change

Describe your first (or next) test of change: Person When to Where to be
responsible be done done

Plan:

List the tasks needed to set up this test of change Person When to Where to be
responsible be done done

Predict what will happen when the test is carried out Measures to determine if prediction
succeeds

Do: Describe what happened when you ran the test

Study: Describe the measured results and how they compared to the predictions
Act: Describe what modifications to the plan will be made for the next cycle from what you
learned

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 Figure 11: QI Project Summary Sheet/A3 Template

County/Sub County: Team Lead: Team Members: Project Title:

Facility: Project Champion: Project Period:

Department: Project Sponsor:

Problem Statement: Description of the Countermeasures: Action plan and findings of tested
problem and its effect solutions (PDSA-Plans, Do)

Root Test of Responsible Due Findings

Cause Change Date

Situation Analysis: Depiction of the cur-

rent state, its processes, and problem(s)
(Baseline Run Chart, Pareto Chart)
DO: Description of the change ideas selected for test

Performance Measures: Summary of the solutions’

results, overall goal success, and any supporting
Aim/Goal Statement: How will we know metrics (Project Run Chart)
the project is successful; standard/basis
for comparison

Goal & Metrics Baseline Target Achievement

Goal
Supporting
Root Cause Analysis: Investigation Metric
depicting the problems’ root causes (Fish-
bone & 5Ys Chart) Supporting Data

Act: Action taken as a result of the Check, and the

plan to sustain results (SOPs Developed as a result of
the QI Project)

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List of Reviewers
Mburu Muiyuro NASCOP
Zacheus Muiruri KCCB

List of Contributors
Name Organization

1 Drusilla Nyaboke DNTLD-P

2 Lilian Kerubo DNTLD-P

3 Jeremiah Ogoro DNTLD-P

4 Dr. Stephen Macharia DNTLD-P

5 Martin Githiomi DNTLD-P

6 Wesley Tomno DNTLD-P

7 Dr. Jacklyn Kisia DNTLD-P

8 Joyce Kiarie DNTLD-P

9 Aiban Rono DNTLD-P

10 Wendy Nkirote DNTLD-P

11 Felix Mbetera DNTLD-P

12 Oduor Otieno SYSTEMS Evaluation Ltd.

13 John Mungai Amref Kenya

14 Benson Ulo Amref Kenya

15 Anne Munene Amref Kenya

16 Christine Mwamsidu Amref Kenya

17 Maero Lutta KCCB

18 Dr. Sam Muga KCCB

19 Dr. Stephene Wanjala CHS TB ARC II

20 Dr. Simon Wachira CHS TB ARC II

21 Idah Ombura MOH - DHSQAR

22 Mburu Muiyuro NASCOP

23 Frankline Ochieng’ Kenya Red Cross

24 Linet Okoth LVCT

25 Eunice Kanana Meru County

26 Dr. Job Okemwa Turkana County

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34 PROGRAM QUALITY AND EFFICIENCY
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