Is there room for improvement? Intervening at facility and district level to improve access and quality of care in a well-performing TB Control Programme: the Cape Town experience

Abstract

Objectives. To use a quality improvement approach to improve access to and quality of tuberculosis (TB) diagnosis and care in Cape Town. Methods. Five HIV/AIDS/sexually transmitted infections/TB (HAST) evaluations were conducted from 2008 to 2010, with interviews with 99 facility managers and a folder review of over 850 client records per evaluation cycle. The data were used in a local quality improvement process: sub-district workshops identified key weaknesses and facility managers drew up action plans. Lessons learnt and successful strategies were shared at quarterly districtwide HIV/TB meetings. Results. Geographical access was good, but there were delays in treatment commencement times. Access for high-risk clients improved significantly with intensified TB case finding made routine in both the HIV counselling and testing and antiretroviral treatment (ART) services (p<0.01 for both). Access for children in contact with an infectious case has improved but is still low (42% investigated and treated). Quality of care was mostly high at baseline (adherence to treatment protocols 95%). Measurement of body mass index improved from 20% to 62%. The assessment of contraception improved from 27% to 58%. Care for co-infected clients showed improved use of customised HIV stationery and increased assessment for ART eligibility. Conclusions. The HAST audit contributed to the improved TB cure rates by supplementing routine information and involving sub-district managers, facility managers and facility staff in a quality improvement process that identified local opportunities for programme strengthening.