Strengthening Laboratories in Uganda

Expediting the Roll-Out of TB and HIV/AIDS Programs

"I have learnt that a laboratory service is the engine oil that lubricates the 'mechanical system' of the hospital, without which the engine breaks down. As a leader, I will ensure that the oil is always available."

A participant in Uganda's Laboratory Performance Improvement Program used this metaphor to portray the power of laboratory management teams. These teams have broken through hospital barriers that hinder the roll-out of tuberculosis and HIV/AIDS programs. In two regional public hospitals, the management teams organized by the program have bridged a gap in understanding that long divided hospital administration, clinicians, and laboratories. Now they are working together to improve laboratory performance.

This breakthrough is an essential step in increasing the capacity of hospital laboratories to rapidly diagnose and carefully monitor TB, HIV/AIDS, and other health problems. Implementing the Laboratory Performance Improvement Program with funding from the President's Emergency Plan for AIDS Relief, Management Sciences for Health (MSH) came up with the idea of a multidisciplinary laboratory management team within each hospital. The team links the laboratory with the management support that it needs in order to improve and satisfy growing demand for its services. Traditionally, technical assistance for laboratories focuses on refresher technical training, supplies, and equipment. It overlooks the leadership capacity and management processes that hospitals must develop to routinely plan for and manage these inputs.

Working as teams, the administrators and clinicians soon realized that if they wanted timely test results, the laboratories needed a budget, so infrastructure could be improved, essential supplies could be ordered, and equipment could be maintained. And the laboratory staff recognized that the clinicians were internal clients who relied on their findings. As one participant commented, "Involving non-laboratory people in the affairs of the laboratory… was a great paradigm shift,… set to revolutionize laboratory operations in this country." Through increased productivity, the laboratories could provide "oil" essential to the roll-out of TB and HIV/AIDS treatment. At the same time, their work would benefit prevention and treatment of malaria, anemia, and other clinical conditions undermining community health.

Before the Program

In October 2004 when the Laboratory Performance Improvement Program was launched in two MOH regional hospitals, the hospitals' laboratories tended to be disorganized. Laboratory staff lacked motivation and support to deliver some basic services. They also lacked training in managing resources and people or in managing for results. Working in isolation, they had little regular communication with the hospital management or medical and nursing staff. Because of this, they were initially unrecognized as an essential part of the care team for TB, HIV/AIDS, and the antiretroviral treatment (ART) program that was being scaled up outside Kampala.

How the Program Worked

The Director of the Joint Clinical Research Centre (JCRC), a nonprofit AIDS research center and partner of the MOH, however, did understand the critical role of the regional hospital laboratories for ART expansion. To strengthen the capacity of these laboratories, MSH and the Ministry of Health (MOH) brought together a team of local staff from the Fort Portal Regional Hospital who had management responsibilities for laboratory services. They formed a similar team at the Mbale Regional Hospital. To each team, they added staff from the JCRC's TREAT Program, which is rolling out ART to more than 40 sites in Uganda. Each team included the hospital medical superintendent, hospital administrator, medical and nursing officers, and laboratory staff.

Through this public-private partnership, each team took on responsibility for improving laboratory performance, managing inputs, and developing effective work processes to produce quality test results. They improved their teamwork and leadership ability to initiate and implement change. During the program, these teams received support from a JCRC-TREAT-MOH team made up of JCRC coordinators, officers for purchasing, monitoring and evaluation, communications, training, logistics, data, nursing, and the MOH principal laboratory technologist at the central public health laboratory. This team continues to supervise and support the hospital laboratory management teams.

Together, the two hospital teams and JCRC-TREAT-MOH support team were introduced to leadership and management practices through a series of five workshops spread over a year. They learned how to apply the performance improvement process to narrow the gap between the specific results they desired and their actual results. They created a vision of how well their laboratory could operate in the future. They then committed themselves to realizing this vision through developing and implementing an action plan to address their challenges.

Of great importance were the activities that each team implemented between workshops to improve laboratory performance. Through onsite coaching and support, team members built up their problem-solving skills and developed actions to face the challenges they had identified. They implemented appropriate improvements, using already available resources.

Early in the program, MSH worked with the teams to develop a laboratory performance monitoring tool that fit their local needs. They used the tool at the beginning of the program, and again at the end of the program to review their progress and pinpoint remaining challenges. Along with the formation and strengthening of teams, the program participants rated this tool as "most useful."

Team Accomplishments

While team members had never been in the habit of talking together and planning their work, they now trust each other. They have learned how to work together on addressing their challenges, and as a result, report stronger dedication to their jobs. Their work climate and spirit of cooperation has improved markedly.

Both hospitals have new champions of laboratory change; in Fort Portal, this is the hospital medical superintendent, and in Mbale, the principal administrator.

The Fort Portal team reported they had not only improved their laboratory management skills, but also their ability to communicate, work plan, and problem solve. They praised their medical superintendent for his extraordinary leadership. During the program, he successfully negotiated to have a laboratory technologist appointed to head the laboratory despite staffing constraints. Broken equipment was also repaired and calibrated, so that test results will be available and reliable.

The Mbale team reported great enthusiasm for improving their laboratory services, and this enthusiasm is spreading to other laboratory staff. The staff reorganized their premises to maximize working space and foster better work practices. An air conditioner was installed to provide optimal conditions for operating the automated analyzers. Hospital management opened a separate room to provide safe working conditions for TB tests. Notices of hours, services, and standard operating procedures were developed and displayed. Staff also sent a written request to the Director of JCRC to obtain technical and financial support for in-service training in specific areas.

Both laboratories have become more skilled at keeping records and using data. They now keep a monthly roster of the duties assigned to staff members. Mbale reported improvements in keeping patient and specimen records and test registers. Through spot checks on staff attendance, that team has increased coverage and the number of tests performed. Fort Portal identified priority tests for managing major health problems and developed a system for monitoring workload and stock. They can target their purchases for these priority tests and estimate the monthly quantities of supplies required for their workload.

Through the partnership it has built with the MOH, JCRC-TREAT was also able to open a center of excellence in each of these hospitals to improve treatment and care for HIV-infected patients.

Although the last Laboratory Performance Improvement Program workshop was conducted in September 2005, each team committed itself to continue its performance improvement activities through a six-month action plan. They have begun to make important progress.

At the end of the program, the Director of JCRC stressed what the program had demonstrated:

"The laboratories are critical for the quality and safety of the TREAT Program. Without laboratories, it would be impossible to ensure sustainability of the [TREAT] Program as it defines best practices and delays emergence of resistance… There is such a huge need because the [Laboratory Performance Improvement] Program started almost from scratch as far as up-country laboratories were concerned. Only a tiny group of leaders and professionals were involved who almost unanimously expressed great appreciation for the importance of laboratory training, especially in management. It has exposed a big gap."