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

Abstract

Background Healthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline providers are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages providers in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the USA. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches and thus improve reproducibility, guide future adaptations, and lay the groundwork to define its 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 recommendations for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects. Results Based on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies: facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modeling and simulation of change. Process mapping matched to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change, and purposefully re-examining the implementation process. Conclusions Specifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.

Systems analysis and improvement approach to optimize tuberculosis (SAIA-TB) screening, treatment, and prevention in South Africa: a stepped-wedge cluster randomized trial

“…SAIA-TB is similar to previously described SAIA applications [ 44 , 48 , 49 ]. The facility-based, five-step iterative process is designed to guide clinic staff and managers in understanding and improving their TB services and optimizing MOH-defined evidence-based interventions, namely, TB screening, prevention, and treatment protocols in order to improve patient outcomes through clinic teams’ delivery of these protocols.…”

“…The resultant TB cascade analysis tool (TCAT) will be refined as part of the SAIA-TB implementation strategy to aid frontline healthcare workers and managers to optimize cascade performance. In addition to the TCAT which is specifically tailored to the TB care cascade in our proposed study setting, SAIA-TB will also employ monthly process flow mapping and continuous quality improvement cycles with clinic-led discussions to implement clinic-identified micro-interventions to optimize the TB care delivery for patients as each of these components are core to the SAIA strategy [ 48 ].…”

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

“…The intervention led to 3.3-fold greater improvement in antiretroviral uptake for HIV-infected pregnant women (13.3% vs 4.1%; increase to 77.7% in intervention and 65.9% in control facilities) and over 17fold greater improvement in early infant diagnosis in HIV-exposed infants (11.6% vs 0.7%; increase to 46.1% in intervention and 32.0% in control facilities) [7]. " Following the publication of the original article [1] the authors requested to update the "Competing interests" section as follows:…”

“…Following publication of the original article [ 1 ], an error was identified in the Background section.…”

“…Following the publication of the original article [ 1 ] the authors requested to update the “Competing interests” section as follows:…”