Usin ing the CFIR IR to Evaluate Systems Analysis & Im Improvement proje jects in in resource lim limited settings: Experiences from the SAIA IA tria ial Sarah Gimbel, RN, PhD, MPH Assistant Professor Departments of Family & Child Nursing, Global Health University of Washington sgimbel@uw.edu
CFIR use in LMIC increasing • Vietnam • Implementing tobacco use treatment guidelines in community health centers in Vietnam • Implementation Science 2015 • Donna, S., VanDevanter, N., Nguyen, N., Cleland, C. • Mozambique, Rwanda, Zambia • Creating resilient health systems through data quality improvement across 3 African countries using the CFIR: Results from the African Health Initiative • HSR 2016, Submitted to BMC-Health Services Research • Gimbel, S., Mwanza, M., Michel, C., Nisingizwe, M.P., Hirschhorn, L. • Cote d’Ivoire, Kenya, Mozambique • Evaluation of a systems analysis and improvement approach to optimize PMTCT of HIV using the CFIR • JAIDS 2016 • Gimbel, S., Rustagi, A, Robinson, J., Kouyate, S., Coutinho, J., Nduati, R., Pfeiffer, J., Gloyd, S., Sherr, K. • Many studies in the pipeline • GAVI, DDCF, NIH supported studies
CFIR application Evaluation Typology Label Formative Research Pre-implementation Diagnostic systems-level assessment info prior to developing study Formative Evaluation/ Pre-implementation Assess best practices Developmental Evaluation assessment & adaptation /determinants, barriers to implementation, buy-in Formative Evaluation/ Concurrent implementation Improve likelihood of Implementation-focused assessment and adaptation leading to change (barriers, evaluation facilitators) Formative Evaluation/ Concurrent implementation Optimize intervention/ Progress-focused progress reinforce progress evaluation (feedback) Formative Evaluation/ Post-implementation Explain success or failure Interpretive evaluation retrospective evaluation Summative Evaluation Post-implementation Determine degree of success Source: Stetler CB, Legro MW, Wallace CM, et al. The Role of Formative Evaluation in Implementation Research and the QUERI Experience. Journal of General Internal Medicine . 2006;21(Suppl 2):S1-S8. http://www.cfirguide.org/overview.html 3
pMTCT HIV IV Care Cascade Antenatal care • ANC attendance • HIV counseling & testing • CD4 testing • Provision of ARV prophylaxis/ HAART to mother Birth • Safe delivery • Provision of prophylaxis to infant • Education on safe infant feeding and care Postpartum care • Safe infant feeding • Infant follow up care and HIV testing • Family planning • Linkages to long-term HIV care and treatment 4
World Health Organization, Towards Universal Access; Scaling up Priority HIV/AIDS Interventions in the Health Sector . Progress Report 2011. Joint United Nations Programme on HIV/AIDS, Together We Will End AIDS , 2012 5
Providing health workers & managers with a systems view = Novel, iterative approaches to improve pMTCT 6
Systems Analysis and Improvement Approach Im (SAIA) Trial (R01HD075057) I. pMTCT Cascade • Aim 2: Evaluate the Analysis Tool impact of a 5-step systems analysis tool on pMTCT services • Cluster randomized trial III. Continuous • Cote d’Ivoire, Kenya and Quality II. Process Mapping Mozambique Improvement Sherr, K., Gimbel, S, Rustagi, A, et al. Systems analysis and improvement to optimize pMTCT (SAIA): a cluster randomized trial. Implementation Science. 2014
I. I. pMTCT Cascade Analysis Tool (P (PCAT) 8
II. II. Process Mapping • A method for health care teams to jointly describe their facility’s patient care pathway • Builds common understanding • Improved communication/ problem solving
II III. . Continuous Quality Im Improvement • Step 3: Identify, define, and implement facility- specific workflow adaptations to eliminate modifiable bottlenecks • Step 4: Monitor changes in routine performance data and initiate additional iterations • Step 5: Repeat analysis and improvement cycle
CFIR SAIA Study Aims Using the CFIR as a lens we 1. Defined core and adaptable components of the SAIA intervention • Endline meeting with country teams 2. Explained the heterogeneity in SAIA’s success between facilities • 6 FGD @ 6 HF (1 high, 1 low performing per country) • Interviews with study staff and health system managers • “Outer setting” domain collected prospectively via Damschroder, L., Lowery, J.C. Evaluation of a large-scale weight management program using the CFIR. secular events monitoring Implementation Sci. 2013
Scoring Sheet Low performers High performers Mozambiq II. INNER SETTING Mozambique Kenya Cote d'Ivoire ue Kenya Cote d'Ivoire Structural Characteristics 2.a +2 M -2 M M M m Networks and Communication 2.b +1 +1 -1 +1 +2 +1 ** Culture 2.c +2 +1 M +2 +2 +1 Implementation Climate 2.d Tension for Change 2.d.1 0 -2 +1 +1 0 +2 * Compatability 2.d.2 +1 M M +2 +1 M m Relative Priority 2.d.3 -1 -1 +1 +2 M X * Organizational Incentives and Rewards 2.d.4 M M M M M M m Goals and Feedback 2.d.5 +1 M X +2 M +1 * Learning Climate 2.d.6 +2 M M +2 +1 +1 m Readiness for Implementation 2.e Leadership Engagement 2.e.1 +1 +2 +1 +1 +2 +2 Available Resources 2.e.2 -2 -2 -2 +1 -1 -1 ** Access to Knowledge and Information 2.e.3 +2 +1 X +2 +1 X
Results • Core Components • Flow mapping • Sustainable • Team building • Uncovered discrepancies in service delivery • CQI • Defined methodology • Ensured critical space for discussion • Coordination across sectors • Adaptable periphery • PCAT • Computer literacy • Computer access • Less relevant in low disease burden settings • Cote d’Ivoire
Results • Strongly distinguishing constructs • Networks and communication • Roles & tasks clearly communicated • In poor performing sites not enough staff to be feasible • Available resources • Perennial issue • Interventions that address logistical issues prioritized in high performers • External change agents • Strong study staff (experienced, well known, respected) • Support work on the ground before meetings • Executing • Participation/buy in • Get the right nurses to support during roll out • Majority of nurses engaged • Reflecting and evaluation • Built into the “systems view”=strengthening of the intervention • Flow maps • Cascade analysis
Considerations of f applying CFIR in LMIC settings • CFIR was useful in assessing implementation across multiple countries and contexts • Some issues in implementation • Prospective use with Likert, did not hold together • Explore binary scales • New, need to reinforce the added value of the CFIR framework to participants prior to use • Due to time, HR restraints, intent — use parts of the CFIR most relevant to intended application
Obrigada, merci, thanks
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