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

Abstract

Background: The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages service providers in the use of routinely-available service data to optimize service delivery cascades and promote systems-level thinking. SAIA was originally developed to address bottlenecks in HIV care in low-and middle-income countries, but has since been adapted and applied to a variety of care systems including: cervical cancer screening, mental health treatment, hypertension management, family planning, and community-based naloxone distribution. These projects have been implemented across a variety of settings in sub-Saharan Africa and the United States. Given the diversity of implementation experience, our consortium aimed to define the core elements of SAIA, to improve reproducibility, guide future adaptations, and lay the groundwork to evaluate mechanisms of action. Methods: Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA researchers, implementing agents and stakeholders, using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor’s recommendation for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects.Results: The four components of the SAIA strategy: (1) SAIA strategy meetings; (2) cascade analysis; (3) process mapping; and (4) continuous quality improvement, mapped to 13 distinct ERIC strategies. The SAIA strategy meetings component mapped to external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to facilitating relay of clinical data to providers, use of audit and feedback, and modelling and simulation of change. Process mapping tied to local needs assessment, local consensus discussions, and assessment of readiness and identification of barriers and facilitators. Continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change and purposefully re-examining the implementation process.Conclusions: Formally specifying the core components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings. Furthermore, this work provides a structured framework to examine potential mechanisms of SAIA and its component implementation strategies.

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

“…One limitation of this analysis is the lack of more granular measures of fidelity, such as adherence to each step of SAIA, adaptations made, and reasons for adaptations. Studies in other contexts provide more detailed insight into SAIA fidelity, as well as the core components of SAIA and how clinics may adapt the strategy [7]. The original SAIA trial was conducted in Mozambique, Kenya, and Cote d'Ivoire to improve PMTCT of HIV.…”

“…SAIA is an evidenced-based multicomponent implementation strategy that is applied at the facility level to provide staff with tools aimed at improving care cascades. Through a five-step process (described below) SAIA provides a system-wide view of a healthcare cascade and uses small tests of change to address context-specific bottlenecks and barriers to care delivery [7]. Using this method, SAIA provides healthcare teams with tools to collaboratively identify problems, prioritize areas of improvement, implement changes, and evaluate those changes [8,9].…”