Providing “a beam of light to see the gaps”: determinants of implementation of the Systems Analysis and Improvement Approach applied to the pediatric and adolescent HIV cascade in Kenya

Abstract

Background Children and adolescents living with HIV have poorer rates of HIV testing, treatment, and virologic suppression than adults. Strategies that use a systems approach to optimize these multiple, linked steps simultaneously are critical to close these gaps. Methods The Systems Analysis and Improvement Approach (SAIA) was adapted and piloted for the pediatric and adolescent HIV care and treatment cascade (SAIA-PEDS) at 6 facilities in Kenya. SAIA-PEDS includes three tools: continuous quality improvement (CQI), flow mapping, and pediatric cascade analysis (PedCAT). A predominately qualitative evaluation utilizing focus group discussions (N = 6) and in-depth interviews (N = 19) was conducted with healthcare workers after implementation to identify determinants of implementation. Data collection and analysis were grounded in the Consolidated Framework for Implementation Research (CFIR). Results Overall, the adapted SAIA-PEDS strategy was acceptable, and the three tools complemented one another and provided a relative advantage over existing processes. The flow mapping and CQI tools were compatible with existing workflows and resonated with team priorities and goals while providing a structure for group problem solving that transcended a single department’s focus. The PedCAT was overly complex, making it difficult to use. Leadership and hierarchy were complex determinants. All teams reported supportive leadership, with some describing in detail how their leadership was engaged and enthusiastic about the SAIA-PEDS process, by providing recognition, time, and resources. Hierarchy was similarly complex: in some facilities, leadership stifled rapid innovation by insisting on approving each change, while at other facilities, leadership had strong and supportive oversight of processes, checking on the progress frequently and empowering teams to test innovative ideas. Conclusion CQI and flow mapping were core components of SAIA-PEDS, with high acceptability and consistent use, but the PedCAT was too complex. Leadership and hierarchy had a nuanced role in implementation. Future SAIA-PEDS testing should address PedCAT complexity and further explore the modifiability of leadership engagement to maximize implementation.

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health

“…As implemented to date, SAIA relies on an external facilitator to convene meetings and guide teams through SAIA implementation. Fidelity to SAIA facilitation is tracked through routine monitoring and its quality is assessed through periodic qualitative assessment using an implementation science determinants framework, such as the Consolidated Framework for Implementation Research (CFIR) [ 19 , 27 ]. The completed SAIA trials have been implemented by study nurses as facilitators.…”

“…Broader conversation across clinical areas highlighted commonalities and differences, clarifying the essential SAIA components, as well as broader linkages of this multi-component strategy to Proctor’s implementation outcomes [ 26 ]. Through consensus, the broader SAIA panel determined which Proctor implementation outcomes are effectively addressed through the use of the SAIA implementation strategy, a process that was informed by the published results of the various studies in peer reviewed journals [ 7 , 9 , 15 , 16 , 19 , 20 , 27 ] and conferences [ 24 , 28 ] as well as feedback from field-based research teams. For example, the more recent adaptation of SAIA to optimize community-based Naloxone distribution in Oakland, California, provided a different setting from the remaining SAIA studies which have been primarily health facility-based.…”

Assessing the sustainability of the Systems Analysis and Improvement Approach to increase HIV testing in family planning clinics in Mombasa, Kenya: results of a cluster randomized trial

“…In these contexts, flow mapping and continued quality improvement (CQI) cycles were considered core components of the intervention, while the cascade analysis tool was identified in some settings as being overly complex and nonessential in places with low HIV burden [ 31 ]. Similarly, a study that piloted SAIA to improve the pediatric and adolescent HIV care cascade in Kenya found that flow mapping and CQI were compatible with existing workflows, but that the cascade analysis was difficult to use [ 32 ]. Building on these findings, several SAIA studies are providing more detailed data on fidelity and adaptation to SAIA designs.…”

The Systems Analysis and Improvement Approach: Data-driven Quality Improvement

“…Broader conversation across clinical areas highlighted commonalities and differences, clarifying the essential SAIA components, as well as broader linkages of this multi-component strategy to Proctor's implementation outcomes. 19 Through consensus, the broader SAIA panel determined which Proctor implementation outcomes are effectively addressed through the use of the SAIA implementation strategy, a process that was informed by the published results of the various studies in peer reviewed journals [7][8][9]12,13,20,21 and conferences 17,22 as well as feedback from eld-based research teams. Implementation outcomes were considered for SAIA as a whole (not its individual components), as it is a multi-component strategy designed to be implemented holistically.…”