TB Program Lead South Africa at The Bill and Melinda Gates Foundation and former Chief Operations Officer at the South African Tuberculosis Vaccine Initiative (SATVI), Dr Zameer Brey, talks about doing more with existing resources to drive quality improvement and efficiency.
After you qualified as a doctor what attracted you to moving away from patient care to focus more on research and data analysis?
While I had great admiration for the clinical work that my colleagues were involved in I had a yearning to do something on a bigger scale and something that would have a bigger impact. While I recognised that there is a need for more professionals in the system to look after individual patients, my passion was always about how to change the system to improve patient outcomes. After I got my medical degree, I obtained a few other degrees that helped to develop my skill set around how to change systems to harness the talent and commitment of its people because even with the best intentions, a system can only do what it’s designed for.
I think the binding thread of my career thus far has been on identifying the levers within a given system and what can be done to improve both the efficiency and effectiveness of the system. It’s really about figuring out how to do more with less. I’m not saying that South Africa has adequate resources by any means but we can do better with what we have.
Your experience as an Analyst in the Western Cape Department of Health (WC DoH) must have been in line with the premise of doing more with less? Tell us about your role there.
My work with the WC DoH started as a seed project to test whether we could improve the efficiency of how we do things in the public service. I had great support from Norman Faull from the Lean Institute Africa (LIA) in looking at a couple of hospital systems, outpatient pharmacies, emergency units and some surgical theatres to answer our fundamental question of how to maximise existing resources.
The first improvement project we undertook was phenomenal because it threw me into the deep end – exactly what I like. We started in the outpatient pharmacy because it was a hotpot in the hospital. It had the longest waiting times, the highest number of patient complaints, and the highest staff turnover. On average patients were waiting four hours to collect a packet of pills that could be 10 Panados. It was often so bad that people would have to come back the next day to get their medication. Can you imagine the huge inconvenience, the economic impact and the deep sense of frustration the patients must have gone through? There was something fundamentally flawed about that system and we didn’t have the resources to just get more staff.
But within three months we managed to reduce waiting times by 75%. Patients’ complaints shifted to compliments. So much so that the pharmacy team went on to compete with the Clicks pharmacy down the road because they believed they could achieve and maintain a 25 minute turnaround time down from three to four hours. The pharmacy team went on to win the Western Cape Premiere’s Service Excellence award in 2008 not because they were working harder, but because the process was fundamentally different, so the outcomes were different.
That work, which became a springboard for much greater things for me, demonstrated to us that even in an environment where resources were constrained, we were able to improve efficiency with great results.
There’s still a gap in the public sector in using digital systems in conjunction with these highly skilled people to deliver consistently better outcomes at every interaction with the health system. What’s your take on it?
When I started my PhD in Lean, I realised that Lean is a very simple tool to implement. I could walk into a pharmacy or an emergency room and explain to the staff that it’s as simple as moving a desk, moving a person or getting that person to come in at a particular time. While the Lean element brings the tools and the innovative thinking, all change in healthcare is still about people. If you don’t get people on-board changing the process is virtually impossible.
I think that leveraging Lean together with technology is happening at a slower pace than what it could be, considering that South Africa is not short of health tech solutions that address pertinent inefficiencies within our health system. Vula Mobile is an outstanding example of how tech can positively impact waiting times on a macro level. By supporting rural doctors and health workers, patient waiting times are going down and more patients are getting the right kind of help without continuing to overburden the system. Those kinds of technological advances are transformational. Lean is incremental, it’s very good, very necessary for every process but there is room to expand it in a broader context of the different tools available to us.
You went from a management role within a public hospital to COO at the South African Tuberculosis Vaccine Initiative (SATVI) at UCT. How were you able to fulfil some of your mandate to do more with less in that role?
Throughout my career, I’ve been fortunate enough to see the impact of the work I’ve been doing for myself. To see the surprise on patients’ faces as a result of the process analysis work in the Western Cape was gratifying. But my work moved on from micro systems within institutions to a broader spectrum. Ultimately I ended up as an organisational turnaround specialist. I worked for the South African Medical Association (SAMA) to facilitate a turnaround strategy at the executive level and then I was asked to assist at SATVI, UCT with a similar mandate. SATVI had already developed a strong global reputation as a leading TB vaccine trial site, but other aspects of the organisational structures needed more focus and strategy led reform. In the three years that I was there, my role involved the development of systems, improving efficiencies and fine-tuning the operational team.
The strategy refresh we did led the organisation to do some deep introspection about the TB vaccine space, where that was going and the need to think about a TB vaccine in a different way. Even though I’m no longer there, I can say that they’ve successfully managed to do that. They are currently working on a prognostic tool which is phenomenal. Basically, they’ve analysed the mass of data that they’ve accrued over many years and discovered a potentially ground-breaking gene signature which can be used to predict the development of the TB disease in an individual 12 months in advance. SATVI’s currently carrying out a trial funded by the Gates Foundation to validate that exact finding and they continue to be a good example of a South African research institute that has the magic triad for world class research, which includes deep expertise, cutting edge infrastructure and proximity to high burden populations. They are going to do great things.
Tell us about your role now and how data is being used and can be used to plot a course for the improvement of healthcare.
When I took up my role as TB Program Lead for South Africa at the Gates Foundation about 18 months ago, my instinct was to look at the TB data to understand the epidemic in as much detail as possible. I learned that we don’t have the data at our finger tips to understand TB better, so what we did was to look at the TB burden in South Africa in terms of how many people get appropriately screened, tested and diagnosed with TB. And how many of those who test positive for TB get treatment and actually complete it. That analysis, which had never been done before, revealed that only 5 in 10 South Africans with TB complete treatment successfully. That’s enlightening and sobering information because it means not only are we losing people to a treatable disease but we are allowing the transmission of people we know have TB to other people. It’s estimated that every person with TB will transmit to another 10-13 each year that they are not treated.
As we developed an in-depth understanding of the data we also realised that a one-size-fits-all approach to the TB epidemic in the country will have limited impact. From the data, we know that 29 districts in South Africa constitute 80% of the TB burden. The disease profile was different in different geographies and therefore required targeted interventions. I’m not saying we shouldn’t consistently engage in TB control in all provinces, I’m saying we could markedly slow the rate of infection if we focused really hard on the concentrated sources of the disease.
Beyond the Gates Foundation and our use of data, I have to acknowledge the team that’s working on the new National Strategic Plan (NSP) for HIV, TB and STIs. One of the key requirements to effectively implement this plan is data availability at a granular level. A TB facility in Madwaleni might struggle to find the cases because people live far from the facility, whereas in Hillbrow they can find the cases but can’t get people to complete their treatment. Having this one size fits all approach just doesn’t work when looking at the context of specific regions and patient populations. We can throw the new, next-generation gene expert diagnostics at them but if we don’t understand the psycho-social issues and challenges that face communities, we’ll only get so far.
Can you expand on the Gates Foundation’s investment in improving TB care locally?
The Gates Foundation has made a significant investment in strengthening data systems for HIV and TB in South Africa together with the NDoH, s UCT and implementing. This investment aims to accelerate the roll out of the unique patient ID b in the public health service in South Africa. The NDoH embarked on this project and continues to lead it, with some support from the Foundation and other donors. The second part of this investment is trying to bring together disparate clinical data systems with the laboratory system. And then the last part of what we hope the investment will achieve is the generation of care cascades for both TB and HIV so that we develop a better understanding of where patients are dropping off during screening, testing, treatment access and retention in care. Our role in this project is in keeping with the way the Gates Foundation usually functions, as a catalyst for system wide, locally led, impactful projects.
A second major investment, we have made, is to use data to drive improvement through a national quality improvement project focussed on TB and TB/HIV coinfection. This project is also led by the NDoH and is supported by several important partners including the Global Fund and other donors and implementing partners. This project will rely on the healthcare workers experience and knowledge to help close gaps in the care cascades. Early signs form this initiative are really positive.
What would you say we could do better in trying to improve health systems?
I think there’s a temptation to just focus on the methodology or the technology but there’s still a huge vacuum around the change management that needs to go hand in hand with this kind of system overhaul. Because healthcare is so complex, we sometimes gloss over the realities that this is going to take a lot of work, time, effort, training, support and hand holding to make sure that people feel that they are part of the process and aligned to the overall goal of transformation.
Implementing any new system comes with teething problems where patients who were waiting for two hours are now waiting for three, for example, but once we get it right patients are going to wait for just minutes. I don’t think we spend enough time communicating planned changes and why change is necessary. Our system isn’t designed around patients or people for that matter.
What’s the starting point for people-centred care?
I think it starts with the principle that leaders should constantly put themselves in the shoes of the customer. One example that comes to mind is a pharmacy that I worked at 10 years ago. When I started at the hospital there were plans being drafted to knock down the audiologist room to make the waiting area for the pharmacy bigger. They were addressing the fact that patients had to stand while waiting. I asked them to give me a little bit of time to find a solution to the problem because I didn’t think the patients’ problem was that they needed to sit while they wait, the problem was that they were waiting for too long.
Patient-centred or people-centred care isn’t usually the most linear, logical answer we can come up with. It’s about innovation that actually makes a positive impact on the people we are trying to serve. System overhaul isn’t about huge, far reaching often clumsy changes all at once but rather incremental improvements; most often it’s small but meaningful changes that make the biggest difference to patients.
The Lean Healthcare Summit 2017: Empowering Healthcare Professionals Through Continuous Improvement will be taking place on 7th September 2017 at The Forum, Johannesburg. The one-day event will inspire the South African healthcare community by demonstrating the benefits of using lean management in healthcare, and motivate those already adopting lean management. More information about the event can be found here.