Effects of a performance and quality improvement intervention on the work environment in HIV-related care: a quasi-experimental evaluation in Zambia

Abstract

BackgroundHuman resource shortages and reforms in HIV-related care make it challenging for frontline health care providers in southern Africa to deliver high-quality services. At health facilities of the Zambian Defence Forces, a performance and quality improvement approach was implemented to improve HIV-related care and was evaluated in 2010/2011. Changes in providers’ work environment and perceived quality of HIV-related care were assessed to complement data of provider performance.MethodsThe intervention involved on-site training, supportive supervision, and action planning focusing on detailed service delivery standards. The quasi-experimental evaluation collected pre- and post-intervention data from eight intervention and comparison facilities matched on defence force branch and baseline client volume. Overall, 101 providers responded to a 24-item questionnaire on the work environment, covering topics of drugs, supplies, and equipment; training, feedback, and supervision; compensation; staffing; safety; fulfilment; and HIV services quality. In bivariate analysis and multivariate analyses, we assessed changes within each study group and between the two groups.ResultsIn the bivariate analysis, the intervention group providers reported improvements in the work environment on adequacy of equipment, feeling safe from harm, confidence in clinical skills, and reduced isolation, while the comparison group reported worsening of the work environment on supplies, training, safety, and departmental morale.In the multivariate analysis, the intervention group’s improvement and the comparison group’s decline were significant on perceived adequacy of drugs, supplies, and equipment; constructive feedback received from supervisor and co-workers; and feeling safe from physical harm (all P <0.01, except P <0.04 for equipment). Further, the item “provider lacks confidence in some clinical skills” declined in the intervention group but increased in the comparison group (P = –0.005). In multivariate analysis, changes in perceived quality of HIV care did not differ between study groups. Provider perceptions were congruent with observations of preparing drugs, supplies, equipment, and in service delivery of prevention of mother-to-child transmission of HIV and antiretroviral therapy follow-up care.ConclusionsThe performance and quality improvement intervention implemented at Zambian Defence Forces’ health facilities was associated with improvements in providers’ perceptions of work environment consistent with the intervention’s focus on commodities, skills acquisition, and receipt of constructive feedback.

Efficiency of HIV services in Nigeria: Determinants of unit cost variation of HIV counseling and testing and prevention of mother-to-child transmission interventions

“…Similar to previous studies, we observed evidence of economies of scale [ 23 , 24 ]. However, we also found evidence consistent with economies of scope—integrating HIV services—for which previous studies have found inconclusive evidence [ 25 ].…”

A standards-based approach to quality improvement for HIV services at Zambia Defence Force facilities

“…For example, staff teams at ZDF facilities coped with staff shortages by reorganizing work schedules and recruiting community workers to assume some nonclinical tasks [13]. In practice, however, teams also have been able to use the results of facility assessments to lobby for external support to resolve critical barriers to the quality of services [22].…”

“…A brief summary of the methods is presented here. For a full description of the study design, sampling, and data collection, see the articles by Kim et al [11,12] and Bazant et al [13].…”

“…Researchers conducted a separate analysis of data on the work environment at intervention and comparison sites [13]. At intervention sites, in-service training on ART and PMTCT, and regular supervision all increased sharply by 20-39 percentage points (Fig.…”

“…A 2012 evaluation of SBM-R's effectiveness examined facilities' readiness to offer goodquality HIV-related services and the actual quality of the services offered. Previous articles have reported the evaluation's findings on ART services [11]; antenatal care (ANC), including PMTCT, services [12]; and the work environment [13]. This study presents selected data from those articles and synthesizes the findings to provide a fuller picture of the SBM-R approach to quality improvement at ZDF facilities, its effects, and the lessons learned.…”