Using CQI to Improve Cohort Retention at Keumbu Sub-County Hospital
A large challenge in HIV care and treatment is loss to follow up (LTFU) – patients who miss appointments for more than 30 days. As patients lapse in their medical care, they become harder to reach, which can lead to greater health complications in the future.
One hospital in Kisii County, Kenya sought to address this problem through CQI methodologies. Keumbu Sub-county Hospital (KSCH), located within Nyaribari Chache Sub-county, is a high-volume facility in the region and classified as a tier one site.
One metric to measure LTFU is cohort growth, which refers to the total number of clients on treatment at a particular point in time measured against the total number of clients who are expected to be on treatment. KSCH aimed to grow the total number of clients in treatment from 1,201 to 1,346, an increase of 145 over a 12-month period, or approximately eight or nine clients each month.
KSCH set out to improve several LTFU metrics over a six-month period in 2020. The facility created five CQI goals:
- Treat more than 95% of those expected to be in treatment (cohort growth)
- Increase the net new clients by 3% each week
- Reduce the weekly missed appointment rate to under 5% (compared to the baseline of 7%)
- Increase the proportion of clients brought back to care within a month who had previously missed appointments to 95% (compared to the baseline of 65%)
- Increase ratio of clients who returned to care (RTC) versus LTFU from less than 1:1 to more than 2:1
Developing a CQI approach
Through routine data review and client audits, KSCH analyzed the reasons behind low cohort growth using a LTFU audit tool and tree map. A driver diagram helped to determine the root causes and develop counter measures.
The audit studied the circumstances around 41 LTFU clients. The largest reason for LTFU was 18 clients who had relocated, and the second-largest reason for LTFU was 11 clients who declined care. Of the 41 total LTFU clients, four had returned to care, two were transferred to continue care, and two had died, so the true LTFU total was 33.
Further analysis through the tree map found that the biggest reason for LTFU was that clients could not be contacted. This applied to 22 of the 33 LTFU clients, or 67%.
Through the driver diagram, KSCH developed a three-pronged client-centered case management approach: staff would administer client exit interviews, implement client-centered bookings to allow the clients more autonomy in selecting days and times for appointments, and structure defaulter management to involve peer educators who follow up with specific clients.
Results of CQI implementation
Twenty-two randomly selected clients were interviewed between March and April 2020 to understand the challenges from the patient perspective. Although the majority of clients were happy with the overall services from KSCH, there was also several areas to improve:
- Long waiting time at the appointment desk
- Clients not involved in scheduling appointments
- Consent for contacting treatment supporter
After implementing the three changes, the CQI team met three of its five goals by the end of the study period. The missed appointment rate dropped from 7% to 3%, the ratio of RTC to LTFU clients improved from 1:2 to 3:1, and the percent of cohort growth rose from 93% to 95%.
Future areas to prioritize
Although several objectives were met, there is still further improvement needed in other areas. The weekly cohort target growth of 3% was met from March to June 2020, although growth slowed down afterwards, partly due to the COVID-19 pandemic.
The other objective not met was the tracing rate. The proportion of clients missing appointments who came back within the reporting weekdays grew from 65% to 74%, but the facility goal is to reach 95%.
Overall, the three-pronged client case management approach resulted in improved LTFU outcomes. An exit interview helped to design a targeted, patient-centered approach, and CQI initiatives at all stages of care improved patient management. This led to successes of lowering the missed appointment rate to under 5%, improving the ratio of RTC to LTFU clients, and growing the cohort of clients actively receiving treatment.