Scaling up implementation of ART: Organizational culture and early mortality of patients initiated on ART in Nairobi, Kenya

Background Scaling up the antiretroviral (ART) program in Kenya has involved a strategy of using clinical guidelines coupled with decentralization of treatment sites. However decentralization pushes clinical responsibility downwards to health facilities run by lower cadre staff. Whether the organizational culture in health facilities affects the outcomes despite the use of clinical guidelines has not been explored. This study aimed to demonstrate the relationship between organizational culture and early mortality and those lost to follow up (LTFU) among patients enrolled for HIV care. Methods and materials A stratified sample of 31 health facilities in Nairobi County offering ART services were surveyed. Data of patients enrolled on ART and LTFU for the 12 months ending 30th June 2013 were abstracted. Mortality and LTFU were determined and used to rank health facilities. In the facilities with the lowest and highest mortality and LTFU key informant interviews were conducted using a tool adapted from team climate assessment measurement questionnaire and competing value framework tool to assess organizational culture. The strength of association between early mortality, LTFU and organizational culture was tested. Results Half (51.8%) of the 5,808 patients enrolled into care in 31 health facilities over the 12-month study period were started on ART. Of these 48 (1.6% 95% CI 0.8%-2.4%) died within three months of starting treatment, while a further 125 (4.2% 95% CI 2.1%-6.6%) were LTFU giving an attrition rate of 5.7% (95% CI 3.3%-8.6%). Tuberculosis was the most common comorbidity associated with high early mortality and high LTFU. Organizational culture, specifically an adhocratic type was found to be associated with low early mortality and low LTFU of patients enrolled for HIV care (P = 0.034). Conclusion The use of ART clinical guidelines in a decentralized health systems are not sufficient to achieve required service delivery outcomes. The attrition rate above would mean 85,000 Kenyans missing care based on current HIV disease burden figures. Deliberate efforts to improve individual health facility leadership and inculcate an adhocratic culture may lower mortality and morbidity associated with initiating ART.

• the 'Template for the TCAM Report' Word file.
Enter the response scores for each team member into the 'Template for Scoring TCAM' Excel file. The spreadsheet will automatically calculate the scores for the 11 Dimensions, and the Patient Safety components.
Enter the 'Team' scores from the 'Template for Scoring TCAM' Excel file into the relevant sections in the 'Template for the TCAM Report' Word file to produce the TCAM report.
• If you are producing the final TCAM Report, enter the initial scores in italics and the final scores in bold to enable team members to see the difference. There is high turnover of staff in the team.
There is low turnover of staff in the team.

Effective Leadership
Leadership of the team is not clear and Team Members do not share leadership. There is little peer coaching within the team.
Leadership of the team is clear and shared. There is a good deal of peer coaching within the team.

Regular Contact
There is very little regular formal or informal contact between Team Members.
Team Members meet regularly and frequently, both formally and informally.

Patient Safety Component
There is very little discussion about patient safety issues. Meetings about patient safety or adverse incident management rarely take place.
Team Members frequently discuss patient safety issues and adverse incident management, both formally and informally.

Team Efficacy
The team goal is either not achievable with the skills available, or unreasonable time or effort is required to achieve the team's goal.
The team has the skills to achieve its goals with ease.

Patient Safety Component
The team cannot achieve high standards of patient safety with the current skills, time or resources available to it.
The team has the skills, time and resources available to achieve high standards of patient care with ease.

Task Reflexivity
The team rarely reviews team objectives, processes or effectiveness.
The team regularly takes time out to formally review team objectives, processes and effectiveness.

Patient Safety Component
The team rarely reflects upon adverse incident management or patient safety issues.
The team regularly reviews adverse incident management and patient safety issues.

Patient Safety Component
Team Members find it difficult to discuss concerns about patient safety. Reporting of such concerns or problems is not encouraged.
Team Members find it easy to discuss concerns about patient safety. Reporting of such concerns and problems is actively encouraged.

Mutual Trust
There is little trust, friendliness, support, cooperation, helpfulness or empathy between Team Members.
There is a good deal of trust, friendliness, mutual support, helpfulness, co-operation and empathy between Team Members.

Patient Safety Component
Team Members do not feel confident that they will receive support and co-operation from colleagues in relation to patient safety issues and adverse incident management.
Team Members are confident that they will be supported by team colleagues in matters related to patient safety and adverse incident management.
8 Inter-professional Credibility Team Members have low or inaccurate perceptions of the skills and expertise of others.
Team Members value and rely on the skills and expertise of others and their assessments are accurate.

Patient Safety Component
Team Members have little faith in the ability of others to ensure patient safety. Junior members of the team are not listened to when they express concern about patient safety issues.
Team Members have faith in the ability of others to ensure patient safety. The views of junior members of the team in relation to patient care and safety issues are valued.
There is little practical support given to enable individual development. Team Members do not feel that their creativity or learning activities are supported or valued.
Team Members' creativity and learning activities are actively supported and they are provided with useful ideas and practical support to optimise learning opportunities.

Patient Safety Component
Team Members do not pay attention to the behaviour of others that could affect patient safety.
Team Members pay attention to each other's patient safety-related behaviour and provide support to enable improvement.
10 Team Learning Behaviour Team Members are discouraged from reviewing work processes and seldom make comments or seek information to inform important changes. There is little sharing of information between Team Members.
Team Members regularly review work processes and frequently seek information from others outside the team to inform change and improve team performance. Team Members share valuable information.

Patient Safety Component
Information from adverse incident reports is very rarely used to bring about improvements in patient safety.
Information from adverse incident reports is always used to bring about improvements in patient safety.

Inter-professional Learning
There is conflict, distrust and little collaboration and individual learning across professional groups. Team Members rarely show interest in the work of those in different professional groups.
There is constructive debate, exchange and collaboration across professional groups. Each profession pays attention to the work of others and there is a good deal of support for individual learning between professional groups.

Patient Safety Component
There is little constructive debate about patient safety issues between professional groups and there is often conflict about how best to ensure patient safety.
There is a good deal of constructive debate between professional groups, leading to improved levels of patient care and safety.