Mubende Regional Referral Hospital in western Uganda is one of the 13 high-volume hospitals supported by the USAID Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project in Uganda with funding from PEPFAR. By December 2011, the hospital had 2,590 HIV-positive clients who were active on anti-retroviral therapy (ART) at the Mubende ART Clinic, and the team was overwhelmed by the growing number of HIV-positive clients visiting the clinic for care and treatment.
It was not clear why particular days within the week had heavier client loads than others; daily clinic attendance numbers ranged from 80 to 300 clients. On heavy days, the clinic would be forced to extend its operating time two additional hours (from closing at 5pm to 7pm) to make sure all clients were seen by the limited clinic staff.
“Every time I came back for my medicines, I would find even more clients waiting to see the doctors. Sometimes I failed to get where to sit and would stand in the scorching sun waiting for someone to leave so that i extend to the shade. Most of us spent the day without food or water. It was worse whenever the triage nurse called a client who was far from the triage table, it would take another person’s voice (from the crowd) for one to hear their name” said, John (not real name), a businessman who was initiated and started receiving care and treatment from Mubende ART clinic in 2009.
The long waiting times resulted in clients leaving the clinic without being served, thus affecting appointment keeping and treatment adherence. As a result, the clinic’s retention rate (the number of clients retained in care) was 65% in October–December 2011 and dropped even further to 61% in the subsequent quarter.
In April 2012, using quality improvement (QI) approaches with help from USAID-supported SUSTAIN project mentors, the ART Clinic team launched an investigation into the major cause of overcrowding on particular days. This was done through brainstorming sessions during weekly QI meetings which determined that due to the undefined appointment system, clinicians scheduled clients to return to the clinic randomly, including on known public holidays when the clinic was not open.
The team unanimously agreed to set a weekly clinic appointment limit and tasked clinicians to book a specific number of clients per day to evenly distribute clients throughout the week. The limit was determined by dividing the quarterly number of clients expected to visit the clinic by the total number of days in the quarter (excluding public holidays and weekends). The result was further divided by the number of clinicians to get a daily client appointment limit per clinician. To avoid missed opportunities, an estimated number of clients who missed appointments and were expected to return within the week were included on the daily limit. Each clinician was offered a diary where they would book clients for their next review using clinic-allocated client numbers on the individual cards.
Today, although the total number of clients active on ART at Mubende has risen to 4,010 (July–September 2014), the clinic attends to approximately 100 clients per day, and all clients are seen by clinicians by 3:00pm. The appointment limits and scheduling system has improved client appointment-keeping, which has remained above 90% since May 2012.
“The situation has changed. Now I spend utmost one hour in the clinic and get back to work on the farm. Because I take a short time at the clinic, six of my friends have also started getting their medicines at Mubende ART clinic,” John added.
After a year of monitoring the impact of the QI intervention, the change was adopted as a routine practice at Mubende hospital in March 2013. The practice has also resulted in increased client-clinician and client-counselor interaction time, allowing for the introduction of psychosocial assessment for every client attending the clinic to address client needs.
Written by; Julian Natukunda, Communications Specialist; Dr. Hillary Alima, HIV Care and Treatment Technical Advisor, with contributions from Jessica Ziegler, Knowledge Management Specialist at URC