MINISTRY OF HEALTH LIP-H PROGRAM

A Capstone Project on Improving Turnaround Time For MDR-TB Culture Result

Delivery At The Hawassa Regional Laboratory

By
Sidama RHB and SPHI Team

1. Mrs. Roza Nasir

2. Mr. Temesgen Tadele

3. Dr. Afensha Amelo

4. Mr. Ashagre Beyene

5. Mr. Muluken Bekele

6. Dr. Hiwot Abebe

Table of Contents

Acknowledgement...........................................................................................................................5
Chapter 1: Background:...................................................................................................................5
Organizational Description..........................................................................................................5
Introduction..................................................................................................................................6
Problem Statement.......................................................................................................................7
Significance of the Study.............................................................................................................7
Chapter 2: Objectives......................................................................................................................7
General Objective........................................................................................................................7
Chapter 3: Root Cause Analysis......................................................................................................7
Chapter 4: Literature Review...........................................................................................................9
Chapter 5: Methods and Materials.................................................................................................11
Study Area and Period...............................................................................................................11
Study Design..............................................................................................................................11
Population..................................................................................................................................11
Sample Size and Sampling Technique.......................................................................................11
Data Collection Procedures........................................................................................................11
Study Variables..........................................................................................................................11
Operational Definition...............................................................................................................11
Data Analysis Procedure............................................................................................................12
Chapter 6: Select Best Interventions..........................................................................................12
References......................................................................................................................................13
Acknowledgement
We would like to thank the facilitators of LIP-H 7th cohort, Mrs. Nurhan Tofik and Dr.
Bereketeab Mulugeta and others for their advice, support, and guidance. We also thank the
IPHCE for supporting this training. Special thanks go to the management of Sidama Public
Health Institute, as well as the regional laboratory staff members, for their assistance in obtaining
the necessary data for this project.
Chapter 1: Background:
The Sidama National Regional State, located in southern Ethiopia, covers an area of 6,806
square kilometers and has an estimated population of 4,774,480, with over 80% residing in rural
areas. The region features diverse agro-ecological zones and a predominantly rural population. It
is divided into 4 zones, 30 Woreda administrations, and 6 town administrations, with a total of
636 kebeles (547 rural, 89 urban). This administrative structure facilitates effective governance
and tailored service delivery to meet the needs of both urban and rural communities.

The Sidama region has a comprehensive healthcare system, including 26 hospitals (21
government-run, 1 specialized, 21 primary, 5 general) and 137 health centers (133 government, 2
police, 2 NGO), ensuring quality and accessible services for the people.

Organizational Description
The Sidama Public Health Institute (SPHI) was established in 2021 with the vision to improve
public health outcomes through emergency management, innovative research, data management,
and quality laboratory services. SPHI's efforts aim to promote evidence-based decision-making
and enhance the effectiveness of health interventions across the region.

The Sidama Public Health Institute Regional Laboratory is one of the directorates of Sidama
Public health Institute it has a clear and ambitious vision - to become a leading public health
problem-solving institute laboratory in Ethiopia. This aspiration is underpinned by the institute's
mission to provide high-quality public health laboratory services to the inhabitants of the Sidama
region. The ultimate goal is to reduce morbidity and mortality due to communicable diseases and
other health problems affecting the local population.

To achieve this mission, the regional laboratory has outlined several key objectives that guide its
operations. Firstly, the institute is committed to facilitating patient testing by delivering
diagnostic services of the highest standards. Secondly, it aims to educate the public on critical
matters of health and disease, empowering the community with essential knowledge. Thirdly, to
dedicated to fostering a mutually respectful and safe work environment for its staff. Finally, the
institute emphasizes the effective management of resources required to accomplish its ambitious
goals, ensuring efficient and sustainable operations.

Sidama Regional Public Health Institute Laboratory (Hawassa)

Introduction
Multidrug-Resistant Tuberculosis (MDR-TB) is a pressing public health issue in many countries,
including the Sidama region of southern Ethiopia. In this region, the MDR-TB Treatment
Initiation Center (TIC) at Yirgalem Hospital has taken a leading role, identifying and beginning
treatment for 73 MDR-TB cases in 2024. Integral to these efforts is the Hawassa Regional
Laboratory, which receives samples for MDR-TB culture testing from 11 TIC sites across
Sidama and other regions. This lab provides vital diagnostic services, including bacteriological
tests, TB Culture and Sensitivity, Gene Xpert, and TB Line Probe Assay, enhancing the region's
capacity to manage and treat MDR-TB effectively.

The Sidama Regional Laboratory not only supports patient testing but also plays a pivotal role in
public health education, staff welfare, and resource management. It is dedicated to delivering
diagnostic services of the highest standard, educating the community on critical health matters,
fostering a safe and respectful work environment, and efficiently managing resources to achieve
its ambitious goals.

Turnaround time (TAT), which measures the elapsed time between various stages of the
laboratory testing process, is a critical benchmark for assessing the lab's performance. Timely
diagnostic services are crucial, as delays can lead to prolonged treatment times, increased
hospital stays, and higher costs. Regulatory and accrediting bodies emphasize the importance of
targeting TAT as part of a continual improvement process. Identifying the root causes of high
 TAT using evidence-based methods is essential for ensuring quality improvements and better
health outcomes.

Problem Statement
Prolonged Turnaround Time (TAT) for Culture Result Delivery in MDR TB Patients at
Hawassa Regional Laboratory

Significance of the Study

Improving the turnaround time for culture result delivery is crucial for timely diagnosis and
treatment of MDR-TB patients. This study aims to identify the root causes of delays and
recommend solutions to enhance the efficiency of the laboratory processes, ultimately improving
patient outcomes.

Chapter 2: Objectives
General Objective
 To reduce the turnaround time for culture result delivery from 57% to 90% by the end of
December 2024 at Hawassa Regional Laboratory.

Chapter 3: Root Cause Analysis

The root cause analysis identified several contributing factors to the prolonged TAT, categorized
under people, equipment/material, environment, and policy/procedure. The analysis utilized tools
such as fishbone diagrams, structured questionnaires, record reviews, and tally methods to
validate each potential root cause. The main root causes are thermalized as shown below by fish
bone diagram
 People
Currier awareness gap.
Staff shortage. Policy/Procedure
Turnover of curriers at post office Poor adherence to SOP.
Incompetency. result reporting system is manual
Lack of training Poor sample result tracking.

Turnaroun
Prolonged
(TAT)
d time
Equipment/Material Environment
prolonged Equipment dawn time Sample transportation delay at TIC.
Shortage of supply(TP). Delay on lab for Sample processing
Inappropriate temperature for sample
transportation
Power interruption

Figure 1. The fishbone diagram which illustrates the main root causes of TAT for culture
result delivery in MDR-TB patients at Hawassa Regional Laboratory

A list of root causes was identified and verified using a standard checklist and observations to
determine the actual root cause. The detailed verification results are shown in the table below.

Table 1 Root cause verification

Possible Root Cause Verification methods Decision

  Currier awareness gap. Structured questionnaires reject
 Staff shortage.(Biomedical, culture) Institute standard HR reject
People  Turnover of curriers at post office Structured questionnaires reject
 Incompetency Record review reject
 Lack of training Record review reject

Equipment/  prolonged Equipment dawn time Tally reject

Material  Shortage of supply. Tally reject
 Sample transportation delay at TIC. Record review accept
 Delay on Sample processing at lab Record review accept
Environment Inappropriate Temperature for sample Observation reject
transportation
Power interruption Tally reject

 Poor adherence to SOP. Observation reject

 result reporting system is manual Interview and Observation accept

Policy/Procedure
Record review and reject
 Poor sample result tracking
observation

Chapter 4: Literature Review

Turnaround time (TAT) is a crucial quality metric in laboratory medicine, reflecting the
efficiency and effectiveness of laboratory services. The International Organization for
Standardization (ISO) underscores the need for laboratories to establish and regularly evaluate
TAT benchmarks that align with clinical needs. Delays in TAT can severely impact patient care,
leading to treatment delays, prolonged hospital stays, and increased healthcare costs.

A study conducted by Shiferaw and Yismaw (2019) at the Amhara Public Health Institute
(APHI) in Bahir Dar, Ethiopia, revealed significant delays in the TAT for critical tests such as
HIV viral load, Exposed Infant Diagnosis (EID) for HIV, and TB Genexpert tests. The study
found that 76.5% of HIV viral load tests, 68.1% of EID tests, and 53.8% of TB Genexpert tests
exceeded the established TAT targets. These delays were attributed to factors including reagent
stockouts, high workloads, overlapping activities, and staff turnover, which are consistent with
challenges identified in similar settings.

The negative consequences of delayed TAT are especially pronounced in infectious diseases like
HIV and TB, where timely diagnosis and treatment are critical. Delays in viral load testing can
hinder the timely adjustment of antiretroviral therapy (ART) in HIV patients, increasing the risk
of treatment failure, drug resistance, and mortality. Similarly, delays in TB testing can prevent
early treatment initiation, exacerbating the risk of transmission and poor health outcomes.

To mitigate these challenges, the adoption of digital methods and automation for reporting
laboratory results is highly recommended in future studies. Digital reporting systems can
significantly reduce TAT by enabling real-time data transfer between laboratories and clinicians,
thus expediting decision-making and improving patient outcomes. For instance, implementing an
automated system to send patient reports digitally can eliminate delays associated with manual
processes, reduce errors, and enhance the overall efficiency of laboratory operations. Moreover,
digital solutions can facilitate better tracking of samples and results, ensuring that clinicians
receive timely and accurate information necessary for patient management.

In conclusion, while addressing issues such as stock management, workload optimization, and
staff retention remains crucial, integrating digital reporting systems into laboratory practices
represents a forward-looking approach that can further enhance the timeliness and quality of
laboratory services.

Chapter 5: Methods and Materials

Study Area and Period
This study will be conducted at the Hawassa Regional Laboratory from July to December
2024.

Study Design
A cross-sectional study design will be employed, incorporating both qualitative and
quantitative methods to gather comprehensive data on the factors affecting TAT.
 Population
The study population includes laboratory staff, curriers, and MDR-TB patients whose
samples are processed at the Hawassa Regional Laboratory.

Sample Size and Sampling Technique

A retrospective cross sectional study was carried out from 01 January to 31 June 2024. Each
patient sample was considered as a study unit. Six months data were extracted from the
register.

Data Collection Procedures

Instrument: Structured questionnaires, interviews, and observation checklists.
Personnel: Laboratory staff, curriers, and supervisors.
Technique: Surveys, record reviews, and direct observation.

Study Variables
Independent Variables: Sample processing time, transportation delays, equipment
downtime.

Dependent Variable: Turnaround time for culture result delivery.

Operational Definition
Turnaround Time (TAT): is defined as the total elapsed time between two specific points
in the laboratory testing process: from the placement of a test order to the delivery of the
final results to the clinician. TAT is a critical quality metric used to evaluate the efficiency of
laboratory services, including pre-examination, examination, and post-examination phases.

Multidrug-Resistant Tuberculosis (MDR-TB):MDR-TB refers to a form of tuberculosis

(TB) infection caused by Mycobacterium tuberculosis strains that are resistant to at least
isoniazid and rifampicin, the two most potent anti-TB drugs. This resistance makes MDR-TB
treatment more complex, requiring longer and more expensive treatment regimens.

Culture Testing Methods: involve growing microorganisms from a patient’s sample in a

controlled environment to identify the presence of infectious agents, such as bacteria or
fungi. In the context of tuberculosis, TB culture methods are used to confirm the diagnosis by
allowing the slow-growing TB bacteria to proliferate, typically requiring several weeks for
conclusive results.

GeneXpert: GeneXpert is a molecular test that detects Mycobacterium tuberculosis and

resistance to rifampicin, a key anti-TB drug, directly from sputum samples. It is a rapid
diagnostic test that provides results within two hours and is crucial for the timely initiation of
TB treatment.
 Laboratory Information System (LIS): is a software platform used by laboratories to
manage patient data, track samples, process test results, and facilitate communication with
healthcare providers. The LIS ensures efficient workflow and data management, reducing
errors and improving the accuracy of laboratory services.

Data Analysis Procedure

Data will be analyzed using statistical software, with results presented in tables, charts, and
graphs. Comparative analysis will be used to evaluate the effectiveness of different
interventions.

Chapter 6: Select Best Interventions

• Based on the root cause analysis and comparative analysis of alternatives, the best
intervention is to automate the result reporting system. This intervention scores highest in
impact, cost, feasibility, and time efficiency, making it the most practical and effective
solution for reducing TAT.

Table 2: Comparative Analysis of Alternatives Comparison

Alternative Impact Cost Feasibility Time Total Score

 Improve Sample processing 2 4 4 4 14

time at lab
 Result reporting system 5 5 5 4 19
automated
 Improve Sample 2 3 2 3 10
transportation time at TIC.
References

 Shiferaw, M. B., & Yismaw, G. (2019). Magnitude of delayed turnaround time of

laboratory results in Amhara Public Health Institute, Bahir Dar, Ethiopia. BMC Health
Services Research, 19(240). https://doi.org/10.1186/s12913-019-4077-2.
 International Organization for Standardization (ISO). (2012). ISO 15189:2012: Medical
laboratories - Requirements for quality and competence. Geneva: ISO.
 Hawkins, R. C. (2007). Laboratory turnaround time. Clinical Biochemistry Review, 28(4),
179-184.
 Ialongo, C., Porzio, O., Giambini, I., & Bernardini, S. (2016). Total automation for the
core laboratory: Improving the turnaround time helps to reduce the volume of ordered
STAT tests. Journal of Laboratory Automation, 21(3), 451-458.