Root Cause Analysis for Low Performance - Suggested Solutions - Case Studies along 4

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Root Cause Analysis for Low Performance - Suggested Solutions - Case Studies along 4

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Root Cause Analysis for Low Performance - Suggested Solutions - Case Studies along 4.

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Root Cause Analysis for Low Performance in Treatment Success Rate

Low performance in treatment success rate means the notified patients are not completing the treatment or cured of TB as desired.

Unsuccessful treatment outcomes are:

(a) Death

(b) Lost to follow-up

Analysing Ni-kshay data would give information on which among the unsuccessful outcomes requires attention. Analyse the data in terms of:

Who didn’t successfully complete the treatment (Person analysis)? - Was it high in TB cases notified from the public sector/ private sector? Those with co-morbidities/ addiction? Of any specific gender? Of any specific age group?
Are there specific geographies where the problems are more (Place analysis)? - Is the issue bigger in a particular TB Unit (TU)/ Peripheral Health Institute (PHI), in any population group residing in a specific area?
Is the low performance specific to any time period (Time analysis)? - Is the performance the same throughout the year or was it different in a particular time period?

Case to case audit of unsuccessful outcomes could provide insights into the reasons for the unsuccessful outcomes. Analysing audit reports could help to identify the underlying preventable cause if any.

Possible Causes	Suggested Approach to Data Analysis	Suggested Solutions to Minimise Poor Treatment Outcomes
Was there a delay in diagnosis leading to death?	Calculate the mean/ median time period between the date of onset of symptoms and the date of TB diagnosis. Date of onset to be obtained from death audit forms/ patient’s relative’s interview.	Strengthen case-finding efforts through Active Case Finding (ACF), Intensified Case Finding (ICF) and strengthening passive case finding Arrange for sensitisation if the delay is due to a training issue. Examine the diagnostic centre linkage and arrange for linkage if that is an issue.
Was there a delay in the initiation of treatment leading to death?	Calculate the mean/median time period between the date of diagnosis of TB and the date of treatment initiation (Both are available in Ni-kshay).	Explore the reasons for the delay in treatment initiation and address them. Arrange for sensitisation if the delay is due to a training issue. Examine the supply chain management and if there is a problem, solve it.
Was the treatment adherence poor? Was the lost to follow-up after treatment initiation high?	Monitor and analyse the adherence dashboards and Loss to Follow-up (LFU) rates from Ni-kshay. Analyse geography-wise/ gender-wise to see if it is poor in some specific areas/ there was a gender-based or age-based stigma.	Find out the further underlying cause and address it. Assess the counselling skills of the provider and sensitise if that is an issue. Check if the treatment supporter is monitoring the treatment adherence regularly. Solve if there is a problem. See if Additional Drug Requirements (ADRs) were timely addressed, and sensitise the stakeholders as applicable. Strengthen linkage to de-addiction services. Establish treatment support groups to address gender/ age-wise stigma in geographies with higher LFU.
Was there a delay in diagnosis of drug resistance leading to treatment failure/ death?	Calculate the mean/ median time period between the date of diagnosis of TB and the date of offering Rifampicin resistance testing/ Isoniazid resistance testing.	Explore the further underlying factors and address the same to minimise the delays Check if Universal Drug Susceptibility Testing (UDST) protocols were adhered to, and sensitise as appropriate. Check the linkage to the UDST facility, and arrange if there is a problem.
Were co-morbidity/ ADRs detected timely and managed properly?	Death audit reports/ patient’s relative’s interviews/ review of records.	Check if differentiated TB care is provided as per protocol, and sensitise as appropriate. Establish a system for differentiated TB care. Train treatment supporters for TB cases with ADR and comorbidity. Sensitise stakeholders for timely referral and clinical follow-up.
Is it due to the movement of TB cases from one place to another (e.g. migrants/ change in residence after marriage)?	Is it due to a lack of information about ‘transfer’ cases? Find out the areas from where the ‘out of area’ patients are there without treatment outcomes.	Establish a system for follow-up of transfer-out cases. Coordinate closely with the concerned TU/ district/ state to prevent duplicate entry and proper transfer systems through Ni-kshay.
Is the problem related to an information gap?	Is there a deficiency in reporting treatment outcomes from the private sector?	Sensitise/ train private providers, and establish systems for supporting private providers in recording treatment outcomes.

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Option 2

Option 3

Option 4

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Which of these is a false statement related to the poor performance in treatment success rate?

Poor management of ADR is a cause.

Delay in the initiation of treatment is a cause.

Death audits are not helpful to find out the cause.

Treatment support groups are helpful for treatment adherence.

Death audits are helpful in finding the cause of poor performance in treatment success rate.

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Root Cause Analysis for Low Performance - Suggested Solutions - Case Studies along 4

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