TABLE 2.

PDSA cycle in SWEEP-TB Daru implementation, May–December 2023.

Cycle	Plan	Do	Study	Act
0: Pre-implementation (May 2023)	Trial implementation	Pilot implementation conducted: November 2022	Use of unique identifiers (ID, image-based) for participants trialled but not considered user-friendly by participants or for health information system Trialled screening with Daru Provincial Hospital (DPH) staff households but low uptake	Switch to a more user-friendly numerical SWEEP ID for participants. Planned for regular SWEEP education and awareness sessions and updates for healthcare workers at DGH
	Test tools and process in trial implementation	Version 1 of tools and SOP used in trial implementation	Used previous household mapping but was outdated Reviewed tools and SOP Need to reduce prolonged visits and improve screening flow	Full household mapping planned. Updated SOP and tools Updated database for data capturing (Bahmni) Revised and documented screening flow in SOP
	Team recruitment, training, and orientation	33 new staff recruited, total SWEEP-TB staff (n = 45); SWEEP-TB staff trained and orientated	Staff assessed after training and orientation for sub-team allocation as per organogram	Allocated in sub-teams to focus on specific activities/tasks
	Staff screening in preparation for full implementation in the community	57 staff screened in May 2023	Revised process and tools with team	Refresher training on specific areas for improved practice Prepare logistics of community implementation
1: Start implementation (1 June–22 August 2023)	Full implementation by ward: sequence: Ward 1 > Ward 2 > Ward 3 > Ward 4	Ward 1: Community engagement resumed on 10 May 2023 Household mapping commenced on 10 May 2023 Community screening commenced on 13 June 2023	Mismatch, 3 screening teams vs. 1 clinical team Slow screening pace, projected to not reach targets Discrepancies in Screening & Diagnostic Form identified Data entry to the EMRS lagging – being done at the office and not field Stock out of drugs (isoniazid 100 mg) and consumables (Xpert Ultra cartridges) PPD cold-chain breach Security threat: team verbally assaulted/ threatened during community awareness and mapping activities	Reassess staffing requirements to increase clinical teams - TB fellows recruited and planned for additional HEO and CHWs Monitoring screening reports of the number screened and refused per team. Increased screening frequency from 3 days/week to 5 days/week Explore options for increasing data entry pace: field data entry through a VPN connection; explore hiring additional DEOs, and bi-weekly data cleaning reports for data and screening/clinical teams Close monitoring of drugs and consumables stock through the hospital and consider a backup plan/parallel system for drugs and consumables CAG/community leaders/community reps to be involved in the initial week of screening at a new location to encourage community participation and mitigate security risks
2: Implementation (23 August–7 November 2023)	Progress implementation with recommended actions from Cycle 1	Continued screening and TPT in Ward 1	CAG provided feedback on community education and engagement materials, including consent Main challenges were with CXR and CAD4TB connections, PPD stockouts, and duplicate screening Challenges with the referral pathway and links with TBDC SWEEP-TB staffing complement still not optimum, impacting operations at the screening station Data entry still lagging with data quality concerns Staff wellbeing at community/screening site concerns	Verbal consent for screening is to be obtained from the household head. Increase age of consent from 16 to 18 years. Human resources: TB Fellows x2 commenced and rotated to support SWEEP-TB 2x CHW replacements recruited to fill vacancies from resignations Mapping team absorbed into screening/clinical team to increase HR capacity Additional data entry officer recruited Data: Weekly follow-up day (Thursday) to complete pending screening activities and pending data entries in the tracker Monthly data cleaning day to complete quality checks and data entries/updates in EMRS CXR: Observe the systematic approach of switching on/off CXR and CAD4TB UPS for backup power Repair van CXR machine Expedite purchase of ultraportable CXR machine Staff wellbeing: Trailer for storage and mobilisation of current mobile CXR machine with generator set Bicycles for participant follow-ups in the community Temporary screening and TPT shelters to supplement gazebos Staff toilet, wash and break station
3: Implementation (8 November–15 December 2023)	Continue and progress implementation with recommended actions from Cycle 2	Progressed screening in Ward 1	Main challenges included TPT drug (levofloxacin) shortage resulting in treatment interruptions and increased backlog of pending initiations, and screening delays or disruptions due to numerous factors, e.g. lack of communication or coordination across other teams Persisting challenges were lag in data entries, prolonged waiting time at screening stations as the number screened increased, delays in screening site preparations Other challenges included duplicate screening, increase in the number of participants pending screening outcome, incorrect nutritional assessment, gaps in routine TPT referral, and concerns for confidentiality	Escalated issue of levofloxacin shortage for decisions on the way forward for both supply and patient care. Raised issue of poor communication or coordination with respective teams concerned to prevent/mitigate delays or disruptions in screening Strengthen weekly follow-up and monthly data cleaning days to clear backlogs of screening outcome pending and EMRS data entry Plan for refresher training on gaps identified or areas to improve, meanwhile conduct on-the-job training/refreshers for nutritional assessment, routine TPT referrals, and maintaining confidentiality of participants Identified options to mitigate duplicate screening

PDSA = plan-do-study-act; SWEEP-TB = Systematic Island-Wide Engagement & Elimination Project for TB; DGH = Daru General Hospital SOP = standard operating procedure; EMRS = Electronic Medical Record System; HEO = Health Extension Officer; CHW = Community Health Worker; VPN = virtual private network; DEO = Data Entry Officer PPD = purified protein derivative; CAG = Community Advisory Group; UPS = uninterruptible power supply; CXR = chest X-ray; CAD4TB = computer-aided diagnostics for TB; TBDC = TB Diagnostic Centre; TPT = TB preventive therapy.