| 4. In which ways is the initiative creative and innovative?
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The Institute for Health-care Improvement (IHI), Medecins Sans Frontiere (MSF), Cape Town City Health Department (CoCTCHD) and the Western Cape Provincial Department of Health (DoH) worked in collaboration to spread the ARV Adherence Club model to clinics throughout the Cape Town area. The Breakthrough Series Collaborative (BTS) program created ARV clubs at 14 major ARV facilities in the Cape Town Area. More than 300 clubs at these facilities were created and approximately 11,000 patients were accommodated. Facility members met every six months to attend daylong workshops (Learning Sessions). At the first Learning Session, all participating facilities agreed to have 30% of their ARV patients managed with ARV Clubs within 18 months. In order to accomplish this objective, they learned about the ARV club model from experienced MSF staff and developed an improvement methodology that encouraged facilities to start small and gradually test out new ideas. At the two subsequent Learning Sessions, faculty shared challenges and solutions. Between workshops, facilities were supported by mentors and were required to submit monthly data in order to track progress. In 2012, another 21 clinics were selected to create clubs. Participants from the first group were used to share their experiences with the new clinic faculty members. Today there are 950 clubs attending to around 28,000 patients.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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ARV Clubs had partnerships with the TB Association/Tutu Foundation, the Western Cape Department of Health (DoH), the Cape Town City Health Department (CoCTCHD), the Institute for Healthcare Improvement (IHI) and the Medicins San Frontieres (MSF) foundation. The program was initially piloted by MSF at the Khayelitsha clinic in South Africa. The program received support from a large number of clinics after successful efforts by the IHI in using the Breakthrough Series Collaborative (BTS) program to implement the club model in other Cape Town area clinics. The DoH and CoCTCHD worked in collaboration to design the project, select facilities, and mentors and create workshops.
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| 6. How was the strategy implemented and what resources were mobilized?
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The Institute for Healthcare Improvement (IHI) used a previous Impumelelo award of R25,000 as seed money to plan the project and facilitate workshops. Aspen Pharmaceutical and the Provincial Department of Health (DoH) provided refreshments for learning sessions. The UCT Medical School and the DoH provided free venues wherein workshops were conducted. Employees of the DoH, Medicins san Frontieres (MSF), TB/HIV Care and the IHI participated in the project.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The two most successful outputs were the ARV Adherence Club model and the Breakthrough Series Collaborative (BTS) model. These two models created a framework for patient treatment and care. The ARV Adherence Club model put patients in groups of 30 and streamlined the care process, which gave clinicians the opportunity to devote resources to taking care of new patients. The Breakthrough Series Collaborative (BTS) started ARV clubs in 14 clinics and effectively trained staff to implement and sustain ARV clubs. Staff were trained through a process of attending workshops, participating in collaborative efforts and working closely with mentors. Workshop groups created operating procedure that outlined the roles of club faculty members, methods of addressing problems and how to distribute pre-packaged medication.
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| 8. What were the most successful outputs and why was the initiative effective?
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The Institute for Healthcare Improvement (IHI) and the Department of Health (DoH) monitored and evaluated the implementation ARV clubs. Clubs initially reported data to the IHI coordinator monthly and later reported data directly to the DoH. This information was then reported directly to senior management. The Breakthrough Series Collaborative (BTS) provided members of the project with the ability to monitor the implementation of the club strategy and the tools to adjust the strategy when needed. It has been credited as a successful method of identifying and resolving problems regarding implementation.
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| 9. What were the main obstacles encountered and how were they overcome?
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Lack of space to conduct club meetings was an issue at many facilities. This problem was solved when staff used non-traditional spaces, such as the boardroom, the staff tearoom, the blood room, the waiting room, outbuildings and local libraries as venues in which to conduct meetings. The size of some clubs was also reduced in order to accommodate members in the available spaces. Additional obstacles included failing to quickly create support structures or replace mentors; failing to effectively use monthly data to identify and respond to clinics with inadequate performance. Clinics are now taught to slowly implement the club system and to use experienced mentors when creating new clubs. Additionally, as data collection has become systematic, it is becoming easier to identify and address issues of inadequate performance.
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