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Root Cause Analysis of Low Performance in Percentage of Rifampicin-resistant (RR)/ Multidrug-resistant (MDR)-TB Cases Initiated on Treatment out of the Total Diagnosed

 

Low performance means the diagnosed cases of MDR/ RR-TB cases are not started on treatment as desired.

Obtain the data from the Programmatic Management of Drug-resistant TB (PMDT) quarterly report and Ni-kshay and analyse in terms of:

  • Who was not initiated on treatment? (Person Analysis) - Patients from the public sector or private sector, of any specific age group (elderly or paediatric), of any specific gender.
  • Whether the problem is more in a specific geography? (Place Analysis) - Patients from a particular TB Unit (TU)/ Peripheral Health Institute (PHI)? Patients staying in specific geographical areas (difficult to access areas).

Once this is done, analyse at the process level. The process is:

  1. Patient diagnosed as RR/ MDR-TB in the lab and data entered in Ni-kshay
  2. Patient should be traced (at PHI/ private hospital) and information disclosed
  3. Pretreatment evaluation
  4. Initiation of treatment

Case to case audit can be done to find the cause against each patient.

Discussion with patients, treatment supporters and verification of source records may be done to get more information.

Examine if there is a pattern - e.g., only patients from one particular place (may be hard to reach area) are not initiated on treatment.

There may not be a single pattern. Then examine the most common patterns.

Understanding the underlying cause is important to address the problem in an efficient manner.

  Possible Causes Suggested Solutions
Is there any problem in patient tracing and contact at PHI/ private hospital level?
  • Contact information not available in Ni-kshay
  • Incorrect address
  • No contact number
  • Assign one Drug-resistant TB (DR-TB) coordinator for the patient and entrust him for the follow-up.
  • Ensure correct data entry in Ni-kshay. Double check the address with id at Ni-kshay entry. Proper training and capacity building of the staff for the same.
  • Procure more than one contact number.
  • Seek the help of a Local Self Government (LSG) representative.
  • If the patient has moved out of the area, take measures to trace and transfer out to the respective area.
Patient resistance
  • Fear
  • Apprehension
  • Lack of family support 
  • No bystanders
  • Proper counselling of the patient and the immediate relative at the time of disclosure of the result is very important.
  • Counselling should be provided at each stage.
  • An immediate relative can be counselled and trained to be a treatment supporter of the patient. 
  • Seek cooperation from Non-government Organisations (NGOs)/ volunteers.
Is there any issue in pretreatment evaluation?
  • Distance to the testing facility
  • Cost of evaluation
  • Multiple visits needed
  • Delay in getting the reports
  • Transportation issues
  • Arrange for patient-centric quality services at a government facility to avoid patient discomfort.
  • Outsource in a partnership model in areas where facilities are not available. 
  • Arrange for transportation or refund of travel expenses.
Is there a delay in the initiation of treatment?
  • Patient resistance
  • Delay in results of pretreatment evaluation
  • Distance from the treatment centre
  • Counselling 
  • Fast-tracking the report
  • OPD-based treatment
  • Setting up a decentralized treatment facility
  • Arranging for transportation or reimbursement for travel
Do the patients from the private sector have issues in starting treatment?
  • Patient wants to continue the clinical services from the private provider, but drugs are not available.
  • Patient wants to change the treatment to a public health facility.
  • Coordinate with the hospital management and provide the drugs and necessary support.
  • Linkage through Public Private Partnership (PPP) 
  • Arrange for the patient transfer to a public health facility.
Other causes
  • Duplication of data entry leading to an inflated denominator (total diagnosed cases)
  • Issues with data entry in Ni-kshay
  • Proper monitoring to avoid duplication 
  • Training, monitoring of staff
  • Sort out internet connectivity issues

 

Note: This page describes only an approach for analysis of low performance and has not captured the entire list of problems or solutions. The root cause analysis may be modified according to the local context.

 

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Assessment

Question Option1 Option 2 Option 3 Option 4 Correct answer Explanation Page id Pretest Post-test
Which of the following does not minimise the delay in treatment initiation/ treatment not initiated for MDR-TB cases? Timely tracing of the patient Proper counselling of the patient A trained treatment provider  Not offering drugs to private patients  4 Timely tracing of the patient. proper counselling of the patient, a trained treatment provider will help minimise the delay in treatment initiation.      

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