1. Group 4 | Bolintiam, Cruz, Dela Cruz, Lu, Que, Rivera, Tai, Sioco, Valera, Veloso YL7 Integration Activity 1 GI, Pulmo, Nutrition, MBA, PH

2. The Clinical Case

3. Salient Features The patient is a 42 y/o female CC: colicky but bearable abdominal pain

4. Salient Features 2 yrs and 3/12 months PTA  Chronic cough  Loss of appetite  Weight loss  Feverish sensation  Body malaise  Diagnosed with Pulmonary TB  Enrolled in DOTS and claims to have continuously undergone the program for 6 months  Claims to have been cleared by the doctorr  No clear records available

5. Salient Features 8 months PTA  Colicky but tolerable abdominal pain (bloatedness)  Accompanied by abdominal distention that is relieved by passage of flatus or stool 4 weeks PTA  Vomiting of previously ingested food (1-2x/wk)  Progressed to intolerance of both solid and soft diet almost daily  Abdominal distention more frequent and severe  Colicky pain became localized in the RLQ  Lost 20-30% of weight in 1 month

6. Salient Features On Admission  Stable vital signs  Markedly hyposthenic  Evidence of fast muscle wasting  Has a high risk of pulmonary complications Nutrition  Decreased oral intake (short of starvation) due to vomiting  Only ate water,coffee and diluted bear brand.  Weak with poor hand grip

7. ToolsPatientInterpretation Anthropometrics Mid-arm Circumference, Mid-arm mass Circumference, Triceps Skin Fold Height150cm Actual Body Weight35kg BMI15.6Underweight IBW (Height in cm) – 100) - Frame Assume: patient is medium frame = 5% Or 105 lbs/5 ft + 5 lbs/inch over 5 ft. 49.95 = 50 kgPatient is just 35 kg. 15 kg below the IBW % IBW (ABW/IBW) x 100% 70%Moderate malnutrition

8. Radiologic Findings  Chest x-ray: Hazy infiltrates were seen on both upper lung fields, which is suggestive of active pulmonary TB. The heart is not enlarged.  Barium enema: Normal barium enema results but with irregularity in the ileocecal area

15. Psychosocial Factors  Unhealthy living conditions  Lack of ventilation  Substandard hygiene and sanitation  Population density  Financial difficulties  Financial constraints for hospitalization and treatment  Disruption of work or schooling  Adults won’t be able to work  Children may have to absent themselves  Stigma

16. Primary Impression Intestinal Obstruction Probably Due To GI TB With Suspected Concomitant Active Pulmonary TB

17. Intestinal Obstruction Probably Due To GI TB With Suspected Concomitant Active Pulmonary TB  Previous history of TB  No sputum AFB smear was done to see if the patient had really been cured  Possibility of a relapse, re infection or MDR-TB  Current symptoms and x-ray results  Symptoms of obstruction: abdominal pain, anorexia, nausea and vomiting

18. Pathophysiology

19. Primary Infection Mycobacterium tuberculosis Inhalation of droplet Invasion of alveoli by bacteria, macrophages react Formation of Ghon (Primary) complex Granulomatous reaction to prevent spread of infection

20. Active Pulmonary TB Patient becomes immunocompromised Reactivation of primary infection Destruction and caseous necrosis of lung tissue Scarring and cavitation

21. From the lungs to the GI system… Ingestion of infected sputum Hematogenously: via lymph nodes (LN) Local spread of infection Inflammation and fibrosis of bowel walls and regional LN Necrosis of Peyer’s patches and lymph follicles Ulceration of mucosa Fibrosis and thickening of bowel wall OBSTRUCTION

22. Differentials

23. Lymphoma of the distal ileum Rule InRule Out Bloating, abdominal pain, weight loss, vomiting, and occasional intestinal obstruction. It can also show symptoms of malabsorption Although partial small-bowel obstruction is the most common mode of presentation, 10% of patients with small-intestinal lymphoma present with bowel perforation. Contrast radiographs show stasis of the contrastCan also present with blood loss in vomitus or while defecating Primary intestinal lymphoma accounts for ~20% of malignancies of the small bowel History of malabsorptive conditions (e.g., celiac sprue), regional enteritis, and depressed immune function due to congenital immunodeficiency syndromes, prior organ transplantation, autoimmune disorders, or AIDS Periumbilical pain made worse by eating Patient’s radiographs do not show infiltration and thickening of the mucosal folds, mucosal nodules, or areas of irregular ulceration

24. Colon Cancer Rule InRule Out Rate and severity of weight loss, as well as the evidence of muscle wasting are suggestive of malignancy Rate at which the patient’s condition worsened may be too rapid to indicate a cancerous process Abdominal pain and intestinal obstruction are common clinical presentations Colorectal cancer usually develops in older patients aged around 65 Patient does not present with rectal bleeding, changes in bowel habits, a palpable abdominal mass, hepatomegaly or ascites

25. Lipoma of the Distal Ileum Rule InRule Out Common benign mesenchymal tumor, which frequently occurs in the distal ileum and at the ileocecal valve Condition is usually asymptomatic, but may cause fecal bleeding, which is absent in the patient Usually presents with generalized or colicky abdominal pain, vomiting, nausea and anorexia, which are all exhibited by the patient. Intussusception is usually produced rather than a plain obstruction

26. Crohn’s Disease Rule InRule Out Focal inflammation and fistula tract formation that eventually resolves by fibrosis and bowel stricturing  obstruction No reports of mucus, blood or pus in the patient’s stool; no fever or diarrhea Presentation of Crohn’s Disease may mimic colonic tuberculosis and vice versa Characteristic "cobblestone" appearance of CD was not exhibited on barium radiography Patient is not dehydrated, but she shows signs of severe malnutrition  Malabsorption in Crohn’s More common in Europe, the United Kingdom, and North America Chronic history of recurrent episodes of abdominal pain Patient does not fall within the usual age groups affected by the disease, which are those aged 15-30 and those aged 60-80, since the age of onset has a bimodal distribution Patient shows signs of obstruction

27. Diagnostics  Endoscopy  To visualize the intestinal tract in order to discover the exact nature of the abnormality  Obtain tissue sample for biopsy purposes

28. Diagnostics  Biopsy  Gold standard for GI-TB  Also opt to do a laparoscopic biopsy  Histological findings: Epitheliod cell granulomas with a peripheral rim of lymphocytes and plasma cells Langhan’s giant cells and central caseation Fibrosis and calcifications in healing infections

29. Diagnostics  Abdominal CT scan  To detect any abnormalities in the patient’s abdominal area  Features: irregular soft-tissue densities in the omentum low-attenuating masses surrounded by thick solid rims low-attenuating necrotic nodes disorganized appearance of soft-tissue densities multiloculated appearance after the intravenous administration of iodinated contrast material

30. Diagnostics: Lab Tests  AFB Smear and Sputum Culture  Classic and standard  Grade A Recommendation (PSMID, 2006)  Identify the exact pathogen  Useful in suspected cases of MDR TB

31. Diagnostics: Lab Tests  Tissue culture and drug sensitivity test  important in cases of relapse or of suspected MDR-TB  TC: identification of the exact identity of the infectious pathogen  DST: enables the determination of the kind of drug the pathogen is sensitive to

32. Diagnostics: Lab Tests  Complete blood count  To check for increased WBC titers which are indicative of an ongoing infection  To detect any other blood abnormalities such as anemia, thrombocytosis or leukopenia

33. Diagnostics: Lab Tests  Electrolytes and Serum albumin  The nature of the patient’s diet calls for an assessment of her nutritional status  ABGs

34. Clinical Management Plan

35. Stabilize the Patient  Airway  Breathing  Circulation *Patient should IDEALLY be placed in a negative pressure room, because she is highly infectious

36. Provide Initial Relief  Insert nasogastric tube  Decompress the stomach and keep it free from air and liquid  Relief of distension and vomiting  Replace the fluid and electrolyte loss, address the malnutrition

37. TOTAL ENERGY ALLOWANCE (Inpatient) Actual body weight x caloric factor Elective surgery caloric needs= 28-30 kcal/kg/day 35kg x 30kcal/kg= 1050 kcal/day

38. FLUID NEEDS Patient’s Weight: 35 kg 100cc/kg for the first 10kg100cc/kg x 10kg= 1000cc 50cc/kg for the second 10kg50cc/kg x 10kg= 500cc 20cc/kg for each additional kg 20cc/kg x 15kg= 300cc 1000 cc + 500 cc + 300 cc = 1800 cc 1800 cc/day

39. PROTEIN NEEDS Protein Requirement: 2.5 kg/due to protein losses Weight x 2.5 g/kg/day 35kg x 2.5g/kg= 87.5 g Protein/day Using 10% amino acid solution (100g protein/L) 87.7/X ml= 100g/1000mL X= 875ml Give 875 cc of 10% amino acid solution per day

40. PROTEIN NEEDS Protein Requirement: 2.5 kg/due to protein losses Weight x 2.5 g/kg/day 35kg x 2.5g/kg= 87.5 g Protein/day Using 10% amino acid solution (100g protein/L) 87.7/X ml= 100g/1000mL X= 875ml Give 875 cc of 10% amino acid solution per day

41. FAT NEEDS Essential Fatty Acids Requirement: 2-4% Caloric Fat Needs: 1050 kcal/day x 0.04 = 42kcal Fat needed (in grams) 35kg x 2.5g fat/kg = 87.5g fat 588 kcal/week / 286 kcal fat = 2.06 bottles of 10% fat emulsion = 1000cc of 10% fat emulsion Give 1000 cc of 10% fat emulsion

42. CARBOHYDRATE NEEDS Carbohydrate Requirements: 658 kcal / day CHO given as dextrose monohydrate (3.4kcal/g) 658 kcal/ 3.4kcal/g = 194 g dextrose Using D50W as starting solution: 194 g/ X ml= 500g/ 1000mlL X = 387cc Give 387 cc of D50W per day as starting solution

43. PARENTERAL NUTRITIONDAILY NEEDS TOTAL CALORIC REQUIREMENT: 1050 CAL 1800cc fluid 10% amino acid solution of 875cc D50W dextrose 562cc 10% intralipid 750cc Add 70-150cc of fluid electrolytes, vitamins and additives Total volume = 2300cc TOTAL CALORIC REQUIREMENT: 1050 CAL Protein: 140 Cal 25 g Carbohydrate: 239 g 637 Cal Fats: 30.3g 273 Cal

44. Medical  Active TB  Consider the possibility that patient now has a drug resistant strain (Patient was already treated with TB before which was allegedly resolved according to a chest xray  sometimes show clear findings even with infection)  Provide pre – treatment before surgery (3 months)  Re – enroll patient into the TB – DOTS program and refer to TB – DOTS plus if MDR-TB

45. Empiric treatment while awaiting laboratory results DurationDrugsDosage 56 days 2 months Isoniazid175 mg OD Rifampicin350 mg OD Pyrazinamide875 mg OD Ethambutol700 mg OD Streptomycin525 mg OD 28 days 1 month Isoniazid175 mg OD Rifampicin350 mg OD Pyrazinamide875 mg OD Ethambutol700 mg OD 140 days 5 months Isoniazid175 mg OD Rifampicin350 mg OD Ethambutol700 mg OD * Give Pyridoxine 875mg OD at night for patients with peripheral neuropathies

46. Surgical  Laparotomy  Surgical resection of the affected segments (possibly the ileocecal segment)

47. Monitoring and follow-up  The patient’s nutritional status should be constantly monitored  Continuously assess whether oral feeding could already be reintroduced and tolerated  Function of the intestine should be assessed  Patient’s intake of TB medications should be monitored

48. TOTAL ENERGY ALLOWANCE (Outpatient) Actual body weight x caloric factor Caloric factor= 30 kcal/kg/day 35kg x 30kcal/kg= 1050 kcal/day

49. PROTEIN NEEDS Protein Requirement: 1.0 g/kg/day (Weight x 1.0 g/kg/day) = 35 g Protein in grams x 4 calories = 140 Calories 35 g Protein 140 Calories

50. CARBOHYDRATE NEEDS Carbohydrate Requirement: (60% to 70% of non-protein calories) (1050 – 140 Cal) x 0.7 =637 calories 637 calories/4 = 159.25 or 239 g CHO 239g Carbohydrates 637 Calories

51. FAT NEEDS Fat Requirement: (30% to 40% of non-protein calories) (1050 – 140 Cal) x 0.3 = 273 calories 273 calories/9 = 30.3 g Fats 30.3 g Fats 273 Calories

52. PARENTERAL NUTRITIONDAILY NEEDS TOTAL CALORIC REQUIREMENT: 1050 CAL 1800cc fluid 10% amino acid solution of 875cc D50W dextrose387cc 10% intralipid 750cc Add 70-150cc of fluid electrolytes, vitamins, and additives Total volume 2162cc TOTAL CALORIC REQUIREMENT: 1050 CAL Protein: 140 Cal 25 g Carbohydrate: 239 g 637 Cal Fats: 30.3g 273 Cal

53. Prevention  As an extension of the DOTS strategy, contract tracing should be done  To detect other cases and prevent further spread of TB infection  Targeted contact tracing among family members and close contacts of the patient  Patient education including the family

54. Prognosis  If patient is not treated with surgery and TB medications…  Prognosis is poor  If patient is treated with surgery and TB medications…  Prognosis may improve if surgery is done to relieve the obstruction allowing the patient to tolerate food again thus improving her nutritional status  Drug resistant TB can be resolved with TB – DOTS plus

55. The Public Health Aspect

56. Knut Lonnroth*, Ernesto Jaramillo, Brian G. Williams, Christopher Dye, Mario Raviglione. Drivers of tuberculosis epidemics: The role of risk factors and social determinants. Soc Sci Med 68 (2009) 2240–2246

57. Phil. Plan of Action to Control TB 2010-2015  Reduce TB prevalence of all forms of TB from 799 per to less than 400 per 100,000 in 2015

58.  Practitioners showed that TB was diagnosed mainly through X-ray (87.9%) and usually treated with inappropriate regimens of anti-TB drugs (89.3%)  The PPs did not follow-up their TB patients, did not trace the defaulters (97.9%), and did not identify contacts (91.4%)

59. DOTS center26.7 Public hospital or clinic26.4 Private physician21.7 Private hospital16.0 NGO clinic1.5 Outreach clinic1.1 More than a third (37.7%) were being managed by the private practitioners and private hospitals. A worrisome development was those who went to hospitals (both public and private), 42.2% in 2007, since most hospitals had not adopted DOTS

60. Misconceptions The 2003 NDHS revealed that 53% of respondents did not consult since they perceived TB as harmless The most common reasons given for going to a government health center were: proximity (46%), cost (28%), and service (18%). On the other hand, reasons given for going to a private doctor were: service (65%), proximity (14%), and quality of drugs (10%)

61.  Using layman terms to address stigma  this practice encourages self-treatment with anti-TB drugs that are considered "vitamins for the lungs" and can lead to drug resistance

62. The TB-DOTS program  Government commitment  Case detection by DSSM (Direct Sputum Smear Microscopy) among symptomatic patients self- reporting to health services  Standard short-course chemotherapy; complete drug taking supervised by DOTS facility workers during the whole course of treatment for all smear positive cases

63. Requires:  A regular, uninterrupted supply of all essential anti- tuberculosis drugs and other materials  A standard recording and reporting system that allows assessment of case finding and treatment The TB-DOTS program

64. Access to drugs  Barangay health workers (BHWs) should be mobilized in far flung areas  BHWs as treatment partners who conduct visits to the patients’ homes

65.  Patients perceive health care workers’ attitudes as harsh  Develop good rapport, learn to befriend patients and take the time to explain to them the importance of taking their medications regularly Strengthen Patient and Healthcare Workers Relationship

66.  Inform patients that improvement of their symptoms does not necessarily mean that they are totally free from infection  Explain that they must take the whole set of drugs and get a negative reading in the sputum smear exam before they are considered completely free of the disease Strengthen Patient and Healthcare Workers Relationship

67. Partnership with Private Practitioners  The inappropriate use and non standard of anti-TB drugs has also contributed to the development of MDR and XDR-TB  All practitioners must refer all suspected and diagnosed TB patients to the DOTS program as recommended in the guidelines

68. Partnership with Private Practitioners  Create a referral system, which would assure that the physician who referred the patient to the nearest DOTS center would still remain the patient’s primary attending physician  Private practitioners must also be trained

69. Restricting the availability of drugs  Low quality drugs and the over availability of drugs has also resulted in the development of MDR- TB  Self medication and prescription sharing  Restrict over the counter selling

70. Improve Compliance If family members are also not educated about the disease, then they would not be able to assist in reinforcing positive behavior like treatment compliance and lifestyle modifications. Widespread non-compliance to treatment and lack of education about tuberculosis could be major factors leading to low cure rates of the DOTS program.

71. Improve Compliance  Provide transportation  Proper education of the patients and their families through a widespread, comprehensive, proper education program involving the whole country

72. Diagnosis and Proper Treatment  Misdiagnosis of the condition or misclassification of the specific type of TB  Receiving inappropriate treatment leads to treatment failure and greater drug resistance

73. MDR-TB  Resistant to both rifampicin and isoniazid  Failure of completion of treatment leads to an increased incidence of MDR-TB or could even lead to the development of even more resistant strains of the bacteria, which would lead to higher rates of treatment failure

74. Poor Case Reporting  Leads to inaccurate and incomplete data and statistics = lack of preparedness  Strategy: Increase the health seeking behavior of people  Proper education

75. Improving the quality of the DOTS program  Personnel need further training  Lack of workers in the centers causes other employees get burnt out and tired easily  Give more incentives or more health benefits  Volunteers  Build partnerships with other organizations  Invest in research

76. Ethics  Just: Free drugs for all patients  Utility: For the greater good  Care: Proper monitoring  Very permissive and not coercive

77. Management

78. The Mckinsey 7S and Gap Analysis GOAL: Control the TB burden in the Philippines

79. Strategy  Striving towards high-quality DOTS expansion and enhancement  Address TB-HIV, MDR-TB and the needs of poor and vulnerable populations  Contribute to health system strengthening based on primary health care  Engage all health care providers  Empower communities through partnership  Enable and promote research

80. Strategy  STANDARDIZED TREATMENT  with an individual touch  Flexible and adaptable  Patient treatment cards

81. Strategy NOW:  People still unaware of TB DOTS  No good health seeking behavior  Self medication and treatment outside of DOTS

82. Strategy PLAN: Mobilize media to educate and inform people: – facts about TB and its treatment – Diagnosis and treatment are FREE!!! Lobby for policies to address the factors associated w/ TB – poverty – lack of education – poor living conditions

83. Strategy NOW: Noncompliant private health providers PLAN: Continuous education and retraining of the private sector Better reimbursements from Philhealth Expansion of existing programs

84. Strategy NOW:  No research and development PLAN:  Form a research and development committee/team  Secure more funds for research and development

85. Structure DOHLGU DOTS Clinic LGU DOTS Clinic

86. Structure  DOH  Provides standardized training  Central control  Where everyone reports to  LGUs  Report to DOH  Inspect DOTS clinics

87. Structure  DOTS Clinics  Provide treatment and follow-up  TBDC (TB Diagnostic Committee)  Quarterly reports  The centralization of the DOTS program is essential to their success  Explicit lines of communication

88. Structures NOW:  Different management styles therefore differing levels of performance among DOTS clinics PLAN:  Better communication and sharing of management techniques

89. Style  Overall leadership: DOH  Trains everyone  Everyone reports to them  Dedication and teamwork

90. Style No Gaps  Good leadership by the DOH

91. Shared values  Dedication  Team-work

92. Shared Values NOW:  No written core values PLAN:  Explicitly state core values of the program

93. Systems  Main: DOH  Supplies drugs and equipment  Provides training  Implements rules

94. Systems NOW:  Unaddressed needs and issues of employees PLAN:  Stronger human resource system be developed

95. Systems NOW:  Poor documentation (slow) and communication PLAN:  Use of technology for reporting and evaluation

96. Systems NOW:  Insufficient networking between physicians and their DOTS referred patients PLAN:  A program where physicians may be able to network and follow up their referrals in DOTS clinics

97. Skills  Technical skills  DOH training  Procedural competency

98. Skills NOW: Limitation of employee knowledge (training is in English) Poor patient relationship skills PLAN: Retraining and continuing medical education among the employees  should be done in context of the staff members Invest on human resources Evaluation of staff by patients (external customer satisfaction survey)

99. Staff  Nurses and medical technicians  Trained by the DOH  Dedication  Teamwork  Underpaid

100. Staff NOW:  Poor attitude of staff towards patients PLAN:  Invest in human resource through better pay and benefits  Evaluation by patients

101. Financial Analysis  More cost efficient to treat people early  514,000 DALYs lost due to illness and premature death each year (Peabody et al. based on 1997 Philippine population data)  P 8 Billion of income lost per year (1998 APIS data)

102. Pulmonary TB Treatment Generic DrugPrice per tabletTotal (8 months) Myrin P forte Dosage: (Ethambutol(275mg), Rifampicin (150mg), Isoniazid (75mg), Pyrazinamide (400mg)) P11.24P8,304 MyrinP-P15 (Rimstar) Dosage: (Ethambutol 275mg, Rifampicin 150mg, Isoniazid 75mg, Pyrazinamide 400mg) P11.75P5,640

103. Gastrointestinal TB Treatment  Surgical  Open Surgery (Excision) – P120,000-P150,000  Laparoscopic – P220,000  Medical  Pre-operation treatment (3 mos) - P2,115  Post-operation treatment (12 mos) - P8,460

104. Strategic Measure Performance measure Unit of MeasureBaselineTargetActualInitiative FINANCIAL INDICATORS Increase sources of funding Quarterly budget reports Number of new major benefactors Current number of major benefactors Find enough benefactors whose total donations amount P360M in the span of 1 year Grant from the Global Fund is currently suspended Increase global awareness about the TB situation in the Philippines and network more in the international scene Secure more funding from the DOH Drug and equipment acquisition Amount of drugs and equipment supplied by the DOH Current procedure about drug and equipment Increased quality and quantity of drug and equipment grants Old drugs and equipment Awareness that their facilities are not at par with the other countries; Lobby for more funding and formalize it through legislation Increase self sustainability of the program Financial statements Income generated by fund raising Relies more on external funding Develop enough self-sustainability to detach itself from external funding Started charging minimal fees to patients Sustain current self-sustainability programs Ensure that the funds are being used appropriately and maximally NTP monitoring indicators Inventory and case reports Current distribution of funds Optimal allocation of funds The funds that DOTS clinics receive go mostly to salaries and administrative fees None

105. INTERNAL BUSINESS PROCESS Improve competence in laboratory procedures Accurate detection and diagnosis Detection rates and number of true positive cases 80% detection rateAchieve a diagnostic accuracy and detection rate of 95% 80% detection rateImprove TB screening and surveillance systems, proper training of personnel and ensure consistency of diagnostic criteria used by the TBDC Provide standardized treatment, supervision and support Number of patients who completed treatment Patient treatment card 88.5% success rate95% success rate in 5 years Lots of drop-out cases Improve TB screening and surveillance systems, proper training of personnel and ensure consistency of diagnostic criteria used by the TBDC Ensure constant drug supply and delivery to all DOTS centers Regularity of delivery and completeness of each shipment Quarterly reportsInformation unavailable 100% regularity of delivery and completeness of each shipment Information unavailable due to faulty reporting Create a separate body for evaluation of equipment and drug supply quantities Improvement of communication between referring physicians and DOTS clinics Decrease in number of cases lost to follow up Number of referred cases with actual follow up Poor communication between referring physicians and DOTS clinics 100% follow-up of referred cases Poor communication between referring physicians and DOTS clinics Increase the involvement of physicians in the DOTS program and vice-versa Develop new diagnostics, drugs and vaccines through research Development of improved technology and techniques Number of breakthroughs NoneFaster and more accurate detection and improved cure rates; Develop a vaccine for prevention NoneStart a program on research and development

106. CUSTOMER PERSPECTIVE Increase public awareness and knowledge about the TB- DOTS Program Activities and programs established for public awareness Number of activities, programs, and local campaign conducted in 1 year Existing awareness and advocacy programs by PHILCAT 12 activities/ programs/ campaign per year Plan well- organized acitivities and come up with more creative yet feasible projects Improve patients’ satisfaction in services offered by TB-DOTS Loyalty and regularity of patients Percentage of new patients from the beginning of the year until the end of the year who are enrolled that year At least 70 % retention of patients At least 80 % retention At least 70 % retention Foster a better relationship between the DOTS staff and the patients.Encourag e patient feedback Ensure all TB- DOTS patients enrolled complete their treatment Patients who complete their treatment Percentage of patients from the start to end of treatment and were pronounced treated within the given period of time At least 80 % completed their treatment At least 70 % completed their treatment Aggressive interventions should be done to ensure that the patient will be adherent to all of his medications, that s/he will be expected to come back in the clinic, and assure that he was informed well about his treatment, since completion should be the main objective.

107. LEARNING AND GROWTH Recruit A highly competent and skilled workforce Promotion rate for the new employees who are working in the program for less than 2 years Percentage of new employees hired at the beginning of the previous year over the total number of employees hired within the two years At least 5 % within 2 years At least 7 % within 2 years At least 5 % within 2 years Promotion rate should be ideally improving annually. In addition to recruiting quality employees, proper identification of what specific field the employees are good and comfortable with is necessary. Retain asset employees Turnover rate of the employees working in TB-DOTS programs Percentage of retained employees over the total number of employees for the period of 1 year Will not exceed 20 % of the total number of employees Turnover rate of not greater than 20 % could be acceptable Retention of quality employees determines the success of the program, since they are the cornerstone in having the patients adhere to and complete the treatment. Giving incentives and setting good morale in the workfield could address this issue. Ensure organizational learning and application based in the guidelines and standards of TB-DOTS Track all external trainings, conferences and meetings attended by the employees Average number of activies an employee attend for 1 year At least 12 activities such as conferences attended for the period of 1 year At least 15 activities such as conferences attended for the period of 1 year At least 12 activities such as conferences attended for the period of 1 year Ensure that every employee attends conferences, talks, meeting, lectures regularly to remind them of the standards set, and to keep them updated

108. Financial Indicators  Lacks funding  Sustain optimization of funds usage  Needs to get more benefactors or implement a self- sustainability program  Progress can be measured by quarterly reports  Started to implement self-sustainability programs

109. Internal Business Process  Maintain standardization of the program  Needs to update current equipment and technologies used  No research and development department  Improve communication between physicians and nurses  Eliminate loss of referrals and follow-up

110. Customer Perspective  Improve patient satisfaction  Needs patient feedback  Can help reduce number of lost cases  Ensure that all patients complete their treatment

111. Learning and Growth  Ensure the competency of the staff  Retention of quality employees  Gap: Research and development  For advancement

112. Summary: Merits of the Program  Structured and standardized  Everyone has a clear idea of what they’re supposed to do  Trained employees  Successful

113. Summary: Gaps  Lack of funding  No patient evaluation  Need to improve feedback mechanisms  RESEARCH AND DEVELOPMENT